Every finding on record at Maplecrest Nursing and Hta

Based on observation, record review, interview, and facility policy review, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of pressure ulcers, timely identify new pressure ulcers and perform wound care using appropriate infection control practices. This affected one resident (#43) of one resident reviewed for pressure ulcers. This had the potential to affect four residents (#4, #9, #17, and #43) identified by the facility with pressure ulcers. Actual Harm occurred on 01/29/25 when Resident #43, who was dependent on staff assistance for most all activities of daily living (ADL) including toileting, and transfers, and required substantial to maximum assistance with rolling left and right in bed, was found to have an in-house acquired unstageable (full thickness tissue loss in which the actual depth of the ulcer was obscured by slough/ dead skin) pressure ulcer to his right gluteal fold (horizontal crease between the buttocks ad posterior upper thigh) per Registered Nurse (RN)/ Wound Nurse #449 as the wound bed contained 90 percent (%) slough. The facility failed to provide documented evidence of effective, comprehensive, and adequate interventions being in place to prevent the development of the pressure ulcer and to ensure the pressure ulcer was identified before being found as unstageable. Findings included: Review of the medical record for Resident #43 revealed an admitted [DATE] and diagnoses including acute kidney failure, hypertension, osteoarthritis, and muscle wasting with atrophy. Review of care plan dated 12/10/24 revealed Resident #43 was at risk for impaired skin integrity. Interventions included assess skin on admission, quarterly, annually and upon significant change, encourage and assist in turning and repositioning every two hours and as indicated, encourage nutrition and hydration supplements as ordered, incontinence care with barrier cream, keep linen clean, dry, and wrinkle free, keep skin clean and dry, treatments and dressings as ordered by the physician and pressure relieving cushion to wheelchair. Review of the re-admission Braden Scale (assesses risk for developing pressure ulcers) dated 12/27/24 and completed by Licensed Practical Nurse (LPN) #446 revealed Resident #43 was at high risk for developing pressure ulcers because his sensory perception was very limited, he was occasionally moist, he was bedfast, he had inadequate nutrition, he was very limited on mobility and had a problem with friction and shearing as he required moderate to maximum assistance with moving. Review of the Admission/ Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had impaired cognition and was dependent on toileting hygiene. The MDS assessment revealed during the assessment period rolling left and right and transfers were not attempted due to medical condition. He was at risk for pressure ulcers and had one unstageable pressure ulcer that was present on admission. Review of the nursing note dated 01/28/25 timed 4:36 A.M. and completed by RN #414 revealed Resident #43 had a new area to his right gluteal fold. There was no staging classification, description, and/or measurements noted per the nursing note or any other assessment form. Review of the Weekly Wound Observation Tool (documented as first observation in the note section) completed by RN/ Wound Nurse #449 and dated 01/29/25 revealed Resident #43 was found to have an unstageable pressure ulcer to his right gluteal fold that measured a length of 3.4 centimeters (cm), width of 2.0 cm and 0.2 cm in depth. The wound bed contained 90 percent slough and 10 percent granulated tissue with moderate serosanguinous (combination of clear and blood) drainage. Primary Care Physician (PCP) #482 was notified and ordered to cleanse the wound with normal saline, pat dry, apply calcium alginate (a highly absorbent wound dressing), cover with foam dressing twice a day. The assessment revealed the pressure ulcer was present on admission. Review of an Outside Wound Clinic progress note dated 01/29/25 and completed by Wound Physician #483 revealed Resident #43 was seen in the clinic and new orders were received for the right posterior thigh (the facility identified as right gluteal fold) to cleanse with vashe (super-oxidized solution formulated to combat bacteria and facilitate wound healing), apply silver alginate (absorbent dressing with antimicrobial properties) and cover with silicone border dressing every day. Resident #43 was also seen for the pressure ulcer to his coccyx that was present on admission and a wound culture was taken of this area. There were no details including measurements or classification of the wounds in the progress note. Review of the Wound Culture completed on Resident #43's coccyx pressure ulcer obtained on 01/29/25 and resulted on 02/01/25 revealed mixed gram-negative organisms (bacteria) and rare gram-positive cocci (unique group of bacteria that cause various infections) in pairs. Review of an Outside Wound Clinic progress note dated 01/29/25 and completed by Wound Physician #483 revealed he reviewed the wound culture results for Resident #43 and ordered doxycycline (antibiotic) 100 milligram (mg) by mouth every 12 hours. The progress note revealed to continue same treatment to the right posterior thigh: cleanse with vashe, apply silver alginate and cover with silicone border dressing every day. The progress note revealed the treatment order for the coccyx remained the same: cleanse with vashe, pack with silver alginate rope, and cover with silicone border. Review of the Wound Culture completed on Resident #43's coccyx pressure ulcer obtained on 02/27/25 and resulted on 03/01/25 revealed corynebacterium striatum (opportunistic bacteria that can infect tissues, complicate wound healing and often was resistant to various antibiotics) and granulicatella adiacens (gram positive bacteria) was identified in the wound. Review of Infection Control Physician #484's progress note dated 03/02/25 revealed Resident #43's coccyx wound culture was reviewed and Ceftriaxone (antibiotic) 2,000 mg intravenously (IV) every 24 hours for 42 doses was ordered. Review of the Outside Wound Clinic progress note dated 03/13/25 and completed by Wound Physician #483 revealed Resident #43's wound care orders for his right posterior thigh was to cleanse wound with vashe, apply black foam to wound bed, cover with drape, and apply wound vacuum (negative pressure suction to help bring the wound edges together and remove fluid and dead tissue) at 125 millimeters of mercury (mmHg). The note revealed to continue IV antibiotic Ceftriaxone as ordered per Infection Control Physician #484. There were no details including measurements of the wound in the progress noted. Review of the Medicare five-day MDS assessment dated [DATE] revealed Resident #43 had impaired cognition and was dependent on staff assistance with toileting hygiene and transfers. He required substantial to maximum assistance with dressing, rolling left and right and showers. He was at risk for developing pressure ulcers and had two unstageable pressure ulcers with one being present on admission. Review of the Weekly Wound Observation completed by RN/ Wound Nurse #449 and dated 04/07/25 revealed Resident #43's pressure ulcer to his right gluteal fold was now a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer that measured 3.4 cm in length, 5.2 cm in width and 4.6 cm in depth. The wound area contained 25 % necrosis, 75 % slough and moderate serosanguinous drainage. The treatment was for a wound vacuum at 125 mmHg to the pressure area and change every Monday, Wednesday and Friday. Interview on 04/08/25 at 10:59 A.M. with RN/ Wound Nurse #449 revealed she incorrectly placed on the Weekly Wound Observation Tool dated 01/29/25 that Resident #43 was admitted with the pressure ulcer to his right gluteal fold and verified the wound was in-house acquired. RN/Wound Nurse #449 also verified the nursing note dated 01/28/25 indicated Resident #43 had a new area to his right gluteal fold but there was no documentation of staging, description or measurements per the nursing note or any other assessment form until she completed the Weekly Wound Observation Tool dated 01/29/25 and it was classified as unstageable. RN/Wound Nurse #449 revealed the pressure ulcer to Resident #43's right gluteal fold contained 90% white slough to the wound bed and she did not know why the wound was not found at an earlier stage especially with already formed slough inside the wound bed. RN/Wound Nurse #449 revealed she was aware Resident #43 refused to turn once and that after she educated him to her knowledge, he did not refuse any further. RN/Wound Nurse #449 had not relayed to LPN/ MDS #419 that Resident #43 had refused because in her opinion it was an isolated event and the education provided was effective, and he refused no longer. Interview on 04/08/25 at 11:49 A.M. and 12:34 P.M. with LPN/ MDS #419 verified on the Admission/ Medicare five-day MDS assessment dated [DATE] she had marked that rolling left and right and/or transfers were not attempted for Resident #43 due to medical condition. LPN/MDS #419 revealed she was unsure why she had marked that as she could not think of the medical condition that would have prevented Resident #43 from being turned. She revealed nobody had communicated anything to her regarding Resident #43 refusing care including turning as she would have documented that in his care plan. LPN/MDS #419 verified there was nothing in Resident #43's care plan regarding being noncompliant with care including turning and repositioning. Interview on 04/08/25 at 12:12 P.M. and 12:38 P.M. with the Director of Nursing (DON) verified Resident #43's right gluteal fold was found at an unstageable pressure ulcer with 90 % slough inside the wound bed. The DON also verified that there was no medical condition that prevented Resident #43 from being turned and the MDS assessment dated [DATE] was marked incorrectly as he was dependent on staff assistance with bed mobility and transfers. Review of the Outside Wound Clinic progress note dated 04/09/25 completed by Wound Physician #483 revealed to place wound vacuum on hold and change treatment order to cleanse the right posterior thigh with vashe, apply silver alginate and cover with silicone border. The treatment to Resident #43's coccyx was changed to cleanse with vashe, pack with silver alginate rope and cover with silicone border. The progress note revealed to continue to follow with Infection Control Physician #484. Observation of wound care on 04/10/25 at 10:26 A.M. with RN/Wound Nurse #449 and Certified Nursing Assistant (CNA) #478 revealed Resident #43 was dependent on staff assistance to turn to his side. RN/ Wound Nurse #449 had performed hand hygiene and applied gloves, gown and mask as Resident #43 was on enhanced barrier precautions. RN/Wound Nurse #449 proceeded to remove the dressings from the right gluteal fold and coccyx and disposed of them. RN/Wound Nurse #449 changed her gloves but did not wash her hands. She proceeded to pour vashe wound solution inside each wound and then took an unsterile gauze four by four and cleansed the inside of the coccyx wound and then with the same gloved hand took another unsterile gauze four by four and cleansed the inside of the right gluteal fold wound. Then, she took a sterile four by four and wiped the inside of the coccyx wound and then took a sterile four by four and wiped the inside of the right gluteal fold wound with the same gloved hands that had come in contact with both wounds. RN/Wound Nurse #449 described the right gluteal fold as a Stage IV with 90 percent necrotic tissue and 10 percent slough. RN/Wound Nurse #449 described the coccyx wound as also a Stage IV and only having 10 percent granulated tissue as majority of the wound bed contained slough. Both wounds had moderate yellow drainage with a foul smell. RN/Wound Nurse #449 proceeded with the same gloved hands to pack the coccyx wound with silver calcium rope gauze and then packed the right gluteal fold. She then took Skin Prep and wiped around both wounds (right gluteal fold and coccyx) with same gloved hand, then covered each wound with silicone border dressing. RN/Wound Nurse #449 then proceeded to doff and wash her hands. Interview on 04/10/25 at 10:49 A.M. with RN/Wound Nurse #449 verified Resident #43 had a wound culture completed of his coccyx area that indicated it was infected, and he was started on IV antibiotics on 03/02/25 for 42 doses that continued at this time. RN/Wound Nurse #449 verified the right gluteal fold had not been cultured and to her knowledge there was nothing documented that the right gluteal had an infection. RN/Wound Nurse #449 verified she had removed both dressings at the same time, changed her gloves and did not wash her hands. She verified she had cleansed each wound with the same gloved hands with vashe wound care solution and then packed each wound with the same gloved hands without washing her hands and/or changing her gloves. She verified that she then applied Skin Prep to the skin surrounding the wounds and applied the silicone border dressing with the same gloved hands. RN/Wound Nurse #449 verified there was the potential to cross contaminate the already known wound infection to the coccyx wound to the right gluteal fold wound. RN/Wound Nurse #449 verified she should have completed each wound dressing separately including cleaning the wound, packing the wound, and covering the wound and not with the same gloved hands as well as washing her hands after removing the old dressings before applying new gloves. Interview on 04/10/25 at 11:49 A.M. with the DON verified Resident #43's coccyx wound culture had come back positive indicating he had an infection and was on IV antibiotics. She verified RN/ Wound Nurse #449 should have washed her hands after removing the old dressings. The DON also verified RN/ Wound Nurse #449 should not have cleansed, packed and covered the coccyx and right gluteal fold wounds with the same gloved hands as there was a potential for cross contamination of infection especially since the coccyx wound already had a known infection. Review of the undated facility policy labeled, Pressure Injury Prevention revealed the purpose of the policy was to ensure the safety and well-being of the residents by minimizing the risk of pressure injuries and promote skin integrity. The policy revealed if a Braden Scale for Predicting Pressure Sore Risk was 18 or lower than preventative orders would be implemented such as turning and repositioning and elevating heels. The policy revealed proper lifting and transferring techniques would be utilized to minimize shearing and skin damage, appropriate support surfaces such as mattresses and cushions would be used to redistribute pressure and ongoing education to all staff members on pressure ulcer prevention and management. Review of the undated facility policy, Wound Care and Dressing Change revealed the purpose of the policy was to ensure consistent, safe and effective wound care to reduce the risk of infection and promote wound healing. The policy revealed the dressing change process included to perform hand hygiene and don gloves, remove old dressing carefully noting any drainage or odor, remove gloves and perform hand hygiene. The nurse was to don new gloves, cleanse wound per orders, apply new dressing as prescribed and secure dressing. There was nothing in the policy regarding the process the nurse should follow when there was more than one wound.

Based on interview, record review and review of facility policy the facility failed to ensure Resident #43's advance directives were accurate in the physician orders and care plan. This affected one resident (Resident #43) out of one resident (Resident #43) reviewed for advance directives. The facility census was 46. Findings included: Review of the medical record for Resident #43 revealed an admitted [DATE] and diagnoses including acute kidney failure, hypertension, osteoarthritis, and muscle wasting with atrophy. Review of the care plan dated 12/10/24 revealed Resident #43's advance directives indicated he was a full code. Review of the Do Not Resuscitate (DNR) Comfort Care form in Resident #43's medical record revealed on 12/13/24 Primary Care Physician (PCP) #482 signed the form indicating Resident #43 was a DNR comfort care- arrest. Review of the DNR Comfort Care form in Resident #43's medical record revealed on 12/26/24 PCP #482 changed Resident #43's advance directives from a DNR comfort care- arrest to a DNR comfort care. Review of Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had impaired cognition. Review of the April 2025 physician orders revealed Resident #43 had an advanced directive order dated 12/27/24 for a DNR comfort care- arrest. Interview on 04/08/25 at 11:49 A.M. and 12:34 P.M. with Licensed Practical Nurse (LPN)/ MDS #419 verified Resident #43's care plan was inaccurate as the care plan had identified Resident #43 as a full code and that he should have been a DNR comfort care. She also verified the physician order of DNR comfort care- arrest in the electronic medical record was also inaccurate as the physician order did not match the DNR Comfort Care form that indicated Resident #43 was to be a DNR-comfort care. Interview on 04/08/25 at 12:12 P.M. and 12:38 P.M. with the Director of Nursing (DON) verified the advanced directives were inaccurate in the care plan and physician orders. The DON verified the care plan indicated Resident #43 was a full code, the physician order in the electronic medical record indicated Resident #43 was a DNR comfort care- arrest and the DNR Comfort Care form in Resident #43's medical record indicated he was to be a DNR comfort care. The DON verified Resident #43 should have been a DNR comfort care. Review of the facility policy labeled, Advanced Directives dated January 2015 revealed advanced directives would be respected in accordance with state and facility policy. The policy revealed prior to admission the admissions coordinator, or the social service designee would provide written information regarding the right to formulate advanced directives. Any changes of an advance directive would be submitted in writing to the Administrator and/or Director of Nursing who would submit the changes to the care plan team for adjustments to the care plan. The Director of Nursing or designee would notify the attending physician of the advanced directives so that appropriate orders would be documented in the medical record and care plan.

Based on observation, record review, interview and review of facility policy the facility failed to ensure Resident #43's peripherally inserted central catheter (PICC) line (a long flexible tube usually inserted into the vein in the upper arm and passed through a larger vein near the heart to administer medications and other treatments) dressing was changed as ordered. This affected one resident (Resident #43) out of one resident (Resident #43) reviewed for intravenous (IV) therapy. Findings included: Review of medical record for Resident #43 revealed an admitted [DATE] and diagnoses including acute kidney failure, hypertension, osteoarthritis, and muscle wasting with atrophy. Review of undated care plan revealed Resident #43 had intravenous (IV) medications. Interventions included IV dressing change as ordered, and monitor, document and report as needed signs and symptoms of infection at the site including drainage, inflammation, swelling, redness and warmth. Review of March and April 2025 physician orders revealed the following orders all dated 03/06/25: monitor PICC line to right upper extremity for any signs of infection or infiltration every shift, Ceftriaxone (antibiotic) 2,000 milligram (mg) intravenously (IV) every 24 hours for 42 doses due to wound infection, change PICC line dressing to right upper extremity every week (Thursday), and flush PICC line to right upper extremity before and after every antibiotic administration using the SASH method (a guideline for flushing and delivering medication to IV lines, that stands for administration of saline, medication, saline, and then heparin (blood thinner) to prevent complications and ensure safe IV line maintenance). Review of the March 2025 Treatment Administration Record (TAR) revealed the order to change Resident #43's PICC line dressing to his right upper extremity every week was not documented as completed as ordered on 03/20/25 as it was blank. There was no documentation the PICC line dressing was changed from 03/13/25 until 03/27/25. Review of Medicare five-day MDS assessment dated [DATE] revealed Resident #43 had impaired cognition and received intravenous antibiotics. Review of the April 2025 TAR revealed Resident #43's order to change the PICC line dressing to Resident #43's right upper extremity every week was documented as completed on 04/03/25 by Licensed Practical Nurse (LPN) #446. Observation on 04/09/25 at 8:35 A.M. revealed Resident #43's right upper extremity PICC line was intact with a dressing covering the PICC line dated 03/27/25. The dressing was loose to the lower left as it was peeling and folding upward. Interview and observation on 04/09/25 at 8:56 A.M. with LPN #446 verified Resident #43's right upper extremity PICC line dressing was dated 03/27/25. LPN #446 verified the dressing was supposed to be completed once a week and was scheduled to be changed 04/03/25. LPN #446 verified she had signed off in the TAR that the dressing was changed on 04/03/25 and that she did not change the dressing. LPN #446 revealed she had been sick and all the days run together so she did not know why she had documented that she had changed the dressing when she had not. LPN #446 verified the right upper extremity PICC line dressing was loose and the lower left corner of the dressing was peeling and folding upward. Interview on 04/09/25 at 9:10 A.M. with the Director of Nursing (DON) verified PICC line dressings were to be changed once a week. The DON also verified Resident #43 was the only resident currently receiving IV therapy. Review of undated facility policy labeled, PICC Line revealed the dressing over the PICC line should be changed every seven days or sooner if the dressing became wet, soiled or loose. The nurse was to document the dressing change procedure including date and any observations regarding the site including signs of infection, and condition of catheter.

Based on medical record review and staff interview, the facility failed to ensure pharmacy recommendations were reviewed and responded to timely from the physician. This affected one resident (#29) of five residents reviewed for unnecessary medications. The current census was 46. Findings included: Review of Resident #29 record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #29 included cerebral infarction, schizoaffective disorder, major depression, hemiplegia, anxiety disorder and chronic pain syndrome. Review of Resident #29's Minimum Data Set ( MDS) 3.0 quarterly assessment dated [DATE] revealed the resident had good cognition and was receiving antipsychotic, antidepressant, diuretic, and antiplatelet medication during the assessment period. Review of the physician order dated 10/28/24 revealed Risperidone oral tablet one milligram by mouth at bed time for schizoaffective disorder. Review of Resident #29's Pharmacy Drug Regimen Review sheet with dates of 04/17/24 through 03/12/25 revealed a recommendation was made to the physician on 02/18/25. Review of the Physician's Communication Form dated 02/18/25 revealed a pharmacy recommendation for a dose reduction for the psychoactive medication Risperidone one milligram tablet. Further review of Resident #29's medication record, treatment records, progress notes, and physician orders revealed there was no documentation of a response from the physician to the pharmacy or facility staff until the physician response dated 04/07/25 indicating not to reduce Risperidone. Interview on 04/08/25 at 3:04 P.M. with the Director of Nursing ( DON) verified a recommendation was made by the pharmacist on 02/18/25 and the response was not timely since the psychiatrist was in the building every six weeks and the nurse practitioner more often. Review of facility policy Tapering Medications and Gradual Drug Dose Reduction, revised April 2007, revealed after medication was ordered for a resident, the staff and practitioner would seek an appropriate does and duration for each medication that also minimized the risk of adverse consequences.

Based on interview, observation, and policy review the facility failed to ensure physician ordered diet modification texture was followed as required. This affected one resident (#5) of three residents reviewed for diet texture. The facility census was 46. Findings included: Review of the medical record for Resident #5 revealed an admitted [DATE]. Diagnoses included but were not limited to gastrointestinal hemorrhage, chronic kidney disease, neoplasm of parotid gland, dysphagia and cognitive communication deficit. Review of the Care Plan dated 03/10/25 revealed Resident #5 had swallowing problems related to swallowing assessment results per Modified Barium Swallow (MBS) study. Resident #5 had a potential risk of aspiration. Interventions included monitor dietary intake. Monitor, document, report as needed dysphagia such as pocketing, choking, coughing, drooling, holding food in mouth, and several attempts to swallow. Aid with meals as needed to encourage intake. Refer to speech therapist for swallowing evaluation. Resident to eat only with supervision. Review of the physician order dated 03/10/25 for Resident #5 revealed a diet order for regular diet, puree texture, and honey thick consistency for liquids. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #5 revealed a Brief Interview of Mental Status (BIMS) score of eight which indicated moderate cognitive impairment. Resident #5 received a mechanically altered therapeutic diet, and required moderate assistance for eating meals. Review of the Speech Therapy Note dated 04/03/25 revealed Resident #5 had limited insight into current physical impairment. Resident #5 consumed honey thick liquids with no signs and symptoms of aspiration. Intervention included honey thick drinks and puree consistencies. Observation on 04/08/25 at 8:19 A.M. of the Activities Dining Room revealed Resident #5 was feeding himself breakfast that consisted of apple juice that was thick, cream of wheat, puree banana, pancakes that were of a minced consistency, sausage that was of a minced consistency, and milk that was thick. Resident #5 was observed to chew his food upon feeding himself. Interview on 04/08/25 at 8:26 A.M. with the Director of Nursing (DON), who was in the Activities Dining Room, confirmed Resident #5 was to receive puree food. Interview on 04/08/25 at 8:28 A.M. with Dietary Manager #401 verified Resident #5's breakfast was minced/chopped and not smooth. Interview on 04/08/25 at 8:29 A.M. with Resident #5 revealed he was a poor historian. Interview on 04/08/25 at 12:49 P.M. with Speech Therapist #481 revealed Resident #5 was evaluated by speech therapy and was ordered a puree diet consistency and honey thick liquid consistency after a Modified Barium Swallow (MBS) test was done on 03/08/24. The puree consistency honey thick liquids was deemed the safest diet at that time to reduce the risk of choking and aspiration. Interview on 04/09/25 at 9:00 A.M. with Registered Dietitian (RD) #454 revealed Resident #5 was ordered a puree food consistency because Resident #5 was at high risk for aspiration. Review of the facility's undated policy Food Textures revealed puree diet texture was smooth, lump free and did not require chewing.

Based on observation, record review, interview, and facility policy review, the facility failed to perform wound care using appropriate infection control practices. This affected one resident (#43) of one resident observed for wound care. This had the potential to affect six Residents (#4, #9, #17, #18, #31 and #43) identified by the facility with wounds requiring dressing changes. Findings included: Review of medical record for Resident #43 revealed an admitted [DATE] and diagnoses including acute kidney failure, hypertension, osteoarthritis, and muscle wasting with atrophy. Review of the care plan dated 12/10/24 revealed Resident #43 was at risk for impaired skin integrity. Interventions included skin assessment on admission, quarterly, annually and upon significant change, encourage and assist in turning and repositioning every two hours and as indicated, and treatments and dressings as ordered by the physician. Review of the Outside Wound Clinic progress note dated 01/29/25 and completed by Wound Physician #483 revealed Resident #43 was seen in the clinic and new orders were received for the right posterior thigh (the facility identified as right gluteal fold) to cleanse with vashe (super-oxidized solution formulated to combat bacteria and facilitate wound healing), apply silver alginate (a wound care absorbent dressing with antimicrobial properties) and cover with silicone border dressing every day. Resident #43 was also seen for a pressure ulcer to his coccyx that was present on admission and a wound culture was taken of this area. There were no details including measurements, description or classification of the wounds noted in the progress note. Review of the Wound Culture completed on Resident #43's coccyx pressure ulcer obtained on 01/29/25 and resulted on 02/01/25 revealed mixed gram-negative organisms (bacteria) and rare gram-positive cocci (unique group of bacteria that cause various infections) in pairs. Review of the Wound Culture completed on Resident #43's coccyx pressure ulcer obtained on 02/27/25 and resulted on 03/01/25 revealed corynebacterium striatum (opportunistic bacteria that can infect tissues, complicate wound healing and often was resistant to various antibiotics) and granulicatella adiacens (gram positive bacteria) was identified in the wound. Review of Infection Control Physician #484's progress note dated 03/02/25 revealed Resident #43's coccyx wound culture was reviewed and Ceftriaxone (antibiotic) 2,000 mg intravenously (IV) every 24 hours for 42 doses was ordered. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had impaired cognition and had two unstageable (full thickness tissue loss in which the actual depth of the ulcer was obscured by slough/ dead skin) pressure ulcers. Review of the Weekly Wound Observation completed by Registered Nurse (RN)/ Wound Nurse #449 and dated 04/07/25 revealed Resident #43's pressure ulcer to his right gluteal fold was now a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer that measured 3.4 centimeter (cm) in length, 5.2 cm in width and 4.6 cm in depth. The wound area contained 25 percent necrosis, 75 percent slough and moderate serosanguinous drainage. The treatment was for a wound vacuum (negative pressure suction to help bring the wound edges together and remove fluid and dead tissue) at 125 millimeters of mercury and change every Monday, Wednesday and Friday. Review of the Outside Wound Clinic progress note dated 04/09/25 and completed by Wound Physician #483 revealed to place wound vacuum on hold and change treatment order to cleanse the right posterior thigh with vashe, apply silver alginate and cover with silicone border. The treatment to Resident #43's coccyx was changed to cleanse with vashe, pack with silver alginate rope and cover with silicone border. The progress note revealed to continue to follow with Infection Control Physician #484. Observation of wound care on 04/10/25 at 10:26 A.M. with RN/Wound Nurse #449 and Certified Nursing Assistant (CNA) #478 revealed Resident #43 was dependent on staff assistance to turn to his side. RN/ Wound Nurse #449 had performed hand hygiene and applied gloves, gown and mask as Resident #43 was on enhanced barrier precautions. RN/Wound Nurse #449 proceeded to remove the dressings to the right gluteal fold and coccyx and disposed of them. RN/Wound Nurse #449 changed her gloves but did not wash her hands. She proceeded to pour vashe wound solution inside each wound and then took an unsterile gauze four by four and cleansed the inside of the coccyx wound and then with the same gloved hand took another unsterile gauze four by four and cleansed the inside of the right gluteal fold wound. Then, she took a sterile four by four and wiped the inside of the coccyx wound and then took a sterile four by four and wiped the inside of the right gluteal fold wound with the same gloved hands that had come in contact with both wounds. RN/Wound Nurse #449 described the right gluteal fold as a Stage IV with 90 percent necrotic tissue and 10 percent slough. RN/Wound Nurse #449 described the coccyx wound as a Stage IV and only having 10 percent granulated tissue as majority of the wound bed contained slough. Both wounds had moderate yellow drainage with a foul smell. RN/Wound Nurse #449 proceeded with the same gloved hand and packed the coccyx wound with silver calcium rope gauze and then packed the right gluteal fold. RN/Wound Nurse #449 then took Skin Prep and wiped around the right gluteal fold and coccyx with same gloved hand. RN/Wound Nurse #449 then covered each wound with silicone border dressing and proceeded to doff and wash her hands. Interview on 04/10/25 at 10:49 A.M. with RN/Wound Nurse #449 verified Resident #43 had a wound culture completed of his coccyx area that indicated it was infected, and he was started on IV antibiotics on 03/02/25 for 42 doses that continued at this time. RN/Wound Nurse #449 verified the right gluteal fold was not cultured and to her knowledge there was nothing documented that the right gluteal had an infection. RN/Wound Nurse #449 verified she had removed both dressings at the same time, changed her gloves and did not wash her hands. She verified she had cleansed each wound with the same gloved hands with vashe wound care solution and then packed each wound with the same gloved hands without washing her hands and/or changing her gloves. RN Wound Nurse #449 verified that she then applied Skin Prep to the skin surrounding the wounds and applied the silicone border dressing with the same gloved hands. RN/Wound Nurse #449 verified there was the potential to cross contaminate the already known wound infection to the coccyx wound to the right gluteal fold. RN/Wound Nurse #449 verified she should have completed each wound dressing separately including cleaning the wound, packing the wound, and covering the wound and not with the same gloved hands as well as washing her hands after removing the old dressings before applying new gloves. Interview on 04/10/25 at 11:49 A.M. with Director of Nursing (DON) verified Resident #43's coccyx wound culture had come back positive indicating he had an infection and was on an IV antibiotic. The DON verified RN/ Wound Nurse #449 should have washed her hands after removing the old dressings. The DON also verified RN/ Wound Nurse #449 should not have cleansed, packed and covered the coccyx and right gluteal fold wounds with the same gloved hands as there was a potential for cross contamination of infection especially since the coccyx wound already had a known infection. Review of undated facility policy, Wound Care and Dressing Change revealed the purpose of the policy was to ensure consistent, safe and effective wound care to reduce the risk of infection and promote wound healing. The policy revealed the dressing change process included to perform hand hygiene and don gloves, remove old dressing carefully noting any drainage or odor, remove gloves and perform hand hygiene. The nurse was to don new gloves, cleanse wound per orders, apply new dressing as prescribed and secure dressing. There was nothing in the policy regarding the process the nurse should follow when there was more than one wound.

Based on record review and interview the facility failed to provide single rooms with at least 100 square feet of living space in each room. This affected six residents ( #2, #13, #16, #22, #38, and #41) of 46 residents residing in the facility. Findings included: On 04/08/25 at 8:30 A.M. an interview with the Administrator confirmed the facility had six single rooms with less than the required 100 square footage of living space. Six of the six rooms were occupied by residents at the time of the survey. Review of the space/occupancy certification waiver, dated 11/22/22, revealed Resident #2, #13, #22, #38, and #41 were in single rooms that measured less than the required 100 square feet of living space. The room measurements and residents affected were as follows. room [ROOM NUMBER] (Resident #41) 96.47 square feet. room [ROOM NUMBER] (Resident #2) 93.15 square feet. room [ROOM NUMBER] (Resident #38) 96.46 square feet. room [ROOM NUMBER] (Resident #13) 93.55 square feet. room [ROOM NUMBER] (Resident #16) 97.75 square feet. room [ROOM NUMBER] (Resident #22) 91.50 square feet.

Based on observation, interview and record review the facility failed to assess the skin underneath Resident #28's right lower extremity hinged brace resulting in an in-house acquired stage II pressure ulcer under the brace. This affected one resident (#28) of three residents reviewed for pressure ulcers. The facility census was 52. Findings include: Review of the medical record for Resident #28 revealed an admitted [DATE]. Diagnoses included displaced comminuted fracture of the shaft of the right femur, chronic atrial fibrillation, and cerebral infarction. Review of the physician's order dated 04/26/24 revealed Resident #28 had an order for a right lower extremity hinged brace which was to remain intact and only to be removed for personal hygiene. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had moderate cognitive impairment. Resident #28 required substantial/maximal assistance for eating, oral hygiene, upper body dressing, and showering/bathing. Resident #28 was dependent for toileting, lower body dressing, and putting on and taking off footwear. Resident #28 was frequently incontinent of urine and bowel. Resident #28 had no pressure ulcers on admission and was at risk of developing pressure ulcers. Review of the care plan for Resident #28 dated 05/08/24 revealed she was at risk for skin breakdown. Interventions included to assess skin weekly and turn and reposition every two hours. Review of the nursing progress note dated 05/18/24 for Resident #28 revealed an area was found on her right outer lower extremity under the hinged brace. The physician and her family were notified. Review of the skin incident/accident witness statement dated 05/18/24 authored by Licensed Practical Nurse (LPN) #530 revealed she was called to Resident #28's room by a state tested nurse aide (STNA) and observed the area to the right outer lower leg. Review of the skin incident/accident witness statement dated 05/18/24 by STNA #522 revealed she was doing care for Resident #28 when she complained of pain in her right lower leg. The STNA #522 got a mirror and looked inside her brace and found a new skin area and notified the nurse. There was no documented evidence that treatment orders were implemented until 05/20/24. Review of weekly skin assessment dated [DATE] revealed family was notified of the wound on 05/18/24. The lateral right lower extremity was found to have a stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough, may also present as an intact or open/ruptured serum filled blister) identified on 05/18/24. The wound bed was epithelial tissue, slough, and was moist. There was a scant amount of serosanguinous drainage with no odors. The wound measured 28 millimeters (mm) length by 6 mm width, by 1 mm depth. The surrounding skin was dry and intact erythematous. An order to clean with normal saline, apply optical AG and cover with a foam dressing. The comment section revealed it was from her hinged brace to her right lower extremity, per surgeon it may only be removed for hygiene purposes. A treatment order was put into place to assess skin every shift under the brace. Review of physician orders revealed on 05/20/24 orders for low air loss mattress to bed and check function every shift. Prosource (supplement) 30 milliliters (ml) by mouth twice a day for wound healing. Check placement of hinged brace to right lower extremity and assess skin integrity under the brace every shift. The resident was to have a protective boot to the left lower extremity at all times and a heel protector to the right lower extremity while in bed for skin integrity. Interview on 06/07/24 at 8:15 A.M. with Resident #28 confirmed she had a wound on her right lower extremity that was caused by the brace she must wear. She reported the staff was caring for it and it is healing. Interview on 06/07/24 at 8:49 A.M. with Wound Care Registered Nurse (RN) #548 confirmed that Resident #28 was admitted with a hinged brace to her right lower extremity. She reported staff informed her that they were checking underneath the brace but there was no documented evidence of it until an area was identified on 05/18/24. She confirmed when she returned to work on 05/20/24 she assessed Resident #28's wound with the wound care team. They put treatments in place including for the staff to check residents' skin under the brace every shift. She also completed an in-service with the staff to educate them on the new changes for when a resident is admitted with a brace. RN #548 also confirmed that residents were assessed with no new findings. Review of the in-service completed on 05/20/24 revealed eleven nurses signed the sign in sheet. Observation on 06/07/24 at 9:44 A.M. of wound care for Resident #28 with STNA #530 and Wound Care RN #548 revealed the area was clean and the edges were dry. There was moderate amount of serosanguineous drainage with no odor. Good hand hygiene and resident privacy was maintained during the observation. This deficiency represents noncompliance investigated under Complaint Number OH00154076.

Based on record review and interview, the facility did not ensure Resident #51 was not verbally abused by a nurse. This affected one resident (#51) of three residents reviewed for abuse. The facility census was 53. Findings include: Review of the medical record for Resident #51 revealed an admitted [DATE] with diagnoses including cerebral infarction, chronic obstructive pulmonary disease, atherosclerotic heart disease, chronic systolic congestive heart failure, cerebral aneurism non ruptured and hyperlipidemia. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 12/26/23, revealed the resident had a Brief Mental Status score of 15 out of 15 indicating intact cognition. Resident #51 had no behavioral problems, hallucinations, or delusions. Review of the Self Reported Incident (SRI), dated 01/28/24, revealed on 01/27/24, the daughter of Resident #51 reported to the facility Licensed Practical Nurse (LPN) on duty that she was very upset by the way her mother had been spoken to by LPN #105 on 01/26/24. Resident #51's daughter stated her mother, Resident #51, reported to her she had been called stupid and ignorant by LPN#105 upon receiving her evening medications. The LPN who received the allegation immediately notified the Director of Nursing (DON) who reported the incident to the facility Administrator. The facility Administrator submitted a Self Reported Incident on 01/28/2024. LPN #105 was not on duty at the time of the allegation and was not scheduled to work again until 01/29/24 at 2:00 P.M. The facility Administrator, DON, and Assistant DON interviewed Resident #51 on 01/29/24 at 9:40 A.M. During the interview, Resident #51 stated she had asked LPN #105 if her Klonopin medication was included with her medication administration and the responce from LPN#105 was Are you just stupid? Resident #51 stated she asked why she would say that and LPN #105 responded are you just dumb or retarded? You have asked me this before and I have told you that you get this medication routinely. Resident #51 stated sometimes I forget things, I have dementia. Resident #51 stated LPN #105 then went on to care for her roommate. LPN #105 later returned, got into her face and told her you don't have dementia, I looked it up. She then stated LPN #105 began questioning her why she was getting so much pain medication which Resident #51 did not understand why she was being asked this. The facility Administrator, DON, and Assistant DON then interviewed Resident #51's daughter on 1/29/24 at 10:30 A.M. who reported her mother informed her while she was visiting on 01/27/24 LPN #105 had called her stupid and retarded when she asked a question about her medications and the nurse was not very nice. Resident #51's daughter then explained the nurse had been rude to her on the day of her mother's admission to the facility. The daughter requested to speak to the facility nurse directly and was informed by administration they would be investigating and would address LPN #105. The facility requested the daughter provide a written statement which she did. The facility Administrator, DON, and Assistant DON interviewed LPN#105 on 01/29/24 at approximately 11:00 A.M. LPN #105 denied making any of the alleged statements or having any wrongdoing in this matter. LPN #105 stated she did not know of any reason why this resident would make up this allegation and has not had any negative interactions with the resident. When LPN #105 was asked if she had ever made a comment about or referred to a resident as retarded, she did admit she had said this in the presence of other staff members. LPN #105 was informed she was being suspended pending full investigation of the incident. A written statement regarding the incident was requested from and provided by LPN #105. Resident #51's roomate, Resident #29, when interviewed by staff reported she did hear LPN #105 call Resident #51 stupid and ask her about pain medications. Review of the written statement taken from Resident #51 after the incident revealed LPN #105 was giving medications to her and she asked LPN #105 about her pain medication Klonopin and if it was included in the medications she was receiving at this time. LPN #105 responded Are you just stupid? Resident #51 responded why? LPN #105 then responded, Are you just dumb or retarded? You have asked me this before and I have told you that you get this medication routinely Resident #51 responded sometimes I forget things, I have dementia. LPN #105 then went to another resident's room to care for her. LPN #105 then came back to Resident #51's room a few minutes later, got down close to her face, and said you don't have dementia, I looked it up than began questioning why Resident #51 was getting so much pain medication, which Resident #51 did not understand why LPN #105 was asking her this. The facility substantiated the allegation of abuse after the investigation was verified by evidence. The facility terminated LPN #105's employment while she remained on suspension during the investigation. Further review of the facility investigation and follow-up actions to the incident revealed a list of 72 staff members of which 53 had evidence via staff signatures and/or written acknowledgment of on-line training on the topic Elder Abuse: what you need to know or F600 Freedom from abuse, neglect and exploitation for the date range of training completion 01/31/24 through 02/13/24. Two of the 72 staff members were marked as on leave of absence at the time of the training and one was marked as no longer employed at the facility. In addition to the interviews with Resident #51 and #29, the facility staff interviewed 20 additional interviewable residents with no findings of verbal abuse. There was no evidence in the facility investigation that non-interviewable residents had skin assessments performed on them to ensure no form of abuse had occured with them. On 02/05/24, as part of a quality assurance audit, 19 interviewable residents were interviewed for concerns or instances of verbal abuse and no issues were identified during the interviews. An interview was conducted on 02/13/24 at 2:45 P.M., with Resident #51 who confirmed the statement she gave to the facility. Resident #51 verified she felt she was verbally abused when LPN #150 asked her if she was stupid, dumb or retarded. An interview with LPN #150 was unable to be completed, as she could not be reached for comment. An interview was conducted on 02/13/24 at 3:01 P.M. with the Administrator who verified LPN #150 was terminated from the facility due to substantiated verbal abuse of Resident #51. The Administrator verified he had submitted all evidence of corrective actions taken to the surveyor for review as of 02/13/24. Review of facility policy titled Abuse Policy and Procedure, undated, stated the facility will not condone resident abuse by anyone, including staff members and described verbal abuse as any use of oral, written or gestured language that includes disparaging and derogatory terms to the resident or their families or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability. This deficiency represents non-compliance investigated under Complaint Number OH00150429.

Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #40's advance directives were accurately reflected in the resident's medical record (the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one resident (#40) of one resident reviewed for advance directives. Findings include: Review of medical record for Resident #40 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of comprehensive care plan, dated 10/31/21 revealed Resident #40 wished to have her advanced directives honored as she was a Full Code. Review of a Do Not Resuscitate (DNR) form for Resident #40 located in her medical record revealed on 11/30/21 Primary Care Physician (PCP) #900 signed a DNR Comfort Care- Arrest advance directive form for the resident. No other DNR forms were noted in the resident's medical record. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 06/14/22 revealed Resident #40 was rarely or never understood. Review of the September 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/07/22 at 1:48 P.M. interview with the Director of Nursing (DON) revealed Resident #40 had a DNR form in her medical record that identified her advance directive status as DNR Comfort Care- Arrest. She indicated Resident #40's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON also verified Resident #40's care plan identified Resident #40 had a Full Code status which was also inaccurate. On 09/07/22 at 2:06 P.M. interview with the Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Coordinator verified the comprehensive care plan for Resident #40 was inaccurate as her advance directives should have been a DNR Comfort Care- Arrest not a Full Code. Review of facility policy titled Advance Directives Policy Statement, dated January 2015 revealed any changes of an advance directive must be submitted in writing to the Administrator and/or Director of Nursing who would submit the changes to the care plan team for adjustments to the resident's Minimum Data Set (MDS) and care plan. The policy also revealed the Director of Nursing and/or designee would notify the attending physician of the advance directives so that appropriate orders were documented in the medical record and care plan.

Based on closed record review and interview the facility failed to notify Resident #43's representative in writing of a discharge to the hospital. This affected one resident (#43) of one resident reviewed for hospitalization . Findings include: Review of Resident #43's closed medical record revealed an initial admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a progress note indicated Resident #43 was discharged to the hospital on 07/02/22 for acute [CONDITION(S)], gastrointestinal bleed and [CONDITION(S)]. Resident #43 was then discharged from the hospital to a different facility closer to her family. Review of Resident #43's medical record revealed no evidence the resident's representative was provided in writing a transfer/discharge notice indicating the reasons for the discharge, the effective date of the discharge, the location where Resident #43 was sent, a statement of Resident #43's appeal rights, and the name/address/phone number of the Office of the State Long Term Care Ombudsman; all in writing and in a language and manner they understand. On 09/07/22 at 1:02 P.M. interview with the Director of Nursing (DON) and Business Office Manager #510 verified the facility did not notify the resident's representative of the discharge. The DON indicated the facility had not provided written discharge notices for any residents discharged from the facility in the last year.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #34, who was identified as being at moderate risk for wandering/elopement had a care plan specifying this risk with individualized interventions. This affected one resident (#34) of one resident reviewed for wandering/elopement. Findings include: Review of the medical record for Resident #34 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of an Admission Wandering Assessment, dated 04/08/22 and completed by Registered Nurse (RN) #502 revealed Resident #34 was at moderate risk for wandering. The assessment revealed Resident #34 was disoriented, forgetful, had a short attention span and she did not understand her surroundings. Review of the comprehensive care plan, with a date of initiation of 04/11/22 revealed Resident #34 did not have a care plan that identified Resident #34 the risk for wandering/elopement. Review of a quarterly Wander Assessment, dated 07/26/22 and completed by Licensed Practical Nurse (LPN) #536 revealed Resident #34 remained at moderate risk for wandering. The assessment revealed Resident #34 was forgetful, had a short attention span and did not understand what was being said due to cognition. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/14/22 revealed Resident #34 was rarely or never understood. The assessment revealed the resident was non-ambulatory and required staff supervision with one-person physical assist for locomotion on and off the unit. This assessment indicated the resident had no wandering behaviors identified. Review of a nursing note, dated 08/25/22 at 7:04 P.M. and completed by LPN #528 revealed Resident #34 was exit seeking and confused. The nursing note revealed one on one (supervision) was effective. Review of a nursing note, dated 09/01/22 at 9:15 P.M. and completed by LPN #531 revealed Resident #34 was propelling all over the facility in her wheelchair continually asking everyone where her purse and shoes were. Review of a nursing note, dated 09/03/22 at 7:49 P.M. and completed by LPN #528 revealed Resident #34 was in her wheelchair wandering asking staff, do you see my shoes? and when staff attempted to redirect, resident cursed. Review of a nursing note, dated 09/05/22 at 4:04 P.M. and completed by LPN #528 revealed Resident #34 was exit seeking and wandering. The nursing note revealed Resident #34 was verbally aggressive and swearing at staff when redirected. On 09/07/22 at 1:27 P.M. and 3:23 P.M. Resident #34 was observed self-propelling her manual wheelchair throughout the facility including into the lobby area. On 09/07/22 at 2:06 P.M. interview with LPN/MDS Coordinator #523 verified on 04/08/22 and 7/26/22 Resident #34 was assessed at moderate risk for wandering. She also verified in the nursing notes on 08/25/22, 09/01/22, 09/03/22 and 09/05/22 Resident #34 was wandering and/or exit seeking. LPN/MDS Coordinator #523 verified the facility had not developed a comprehensive and individualized care plan for Resident #34's wandering and/or exit seeking behavior. Review of undated and untitled State tested Nursing Aide (STNA) report sheet revealed Resident #34 was at risk for wandering. Review of an undated facility policy titled Elopement Policy and Procedure revealed confused residents that appear to have a tendency towards elopement would be targeted to wear a wander guard bracelet. The policy did not include anything regarding ensuring a care plan was initiated when a resident was assessed at moderate to high risk for wandering and/ or elopement.

Based on record review, facility policy and procedure review and interview the facility failed to ensure fall risk assessments were completed timely following falls and failed to ensure fall care plan updates were completed timely to include all interventions in place. This affected three residents (#14, #20 and #39) of three residents reviewed for falls. Findings include: 1. Review of the medical record for Resident #39 revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction, [CONDITION(S)] and [CONDITION(S)] affecting right dominant side and [CONDITION(S)]. Review of the assessments revealed on 12/30/21 a fall assessment was completed following a significant change in condition and Resident #39 was determined to be at high risk for falls. Review of the plan of care, dated 01/14/22 revealed Resident #39 was at risk for falls related to injuries. Interventions included one person assist for transfers with wheelchair, assess need for safety measures and fall interventions as needed (call light in reach, provide verbal reminders to call when needing assistance, place all personal items within reach). On 08/24/22 a care plan intervention included a pressure alarm to wheelchair as ordered and indicated to alert nursing of attempt to rise from chair. Review of the nursing progress notes dated 01/24/22 at 1:15 P.M. revealed a nurse was called to Resident #39's room and the resident was observed on the floor between the bed and his wheelchair. Vital signs were temperature 97.6; pulse 70; respirations 18; blood pressure 108/58; pulse oximetry was 94%; range of motion within normal limits, no injuries noted. Resident denied hitting his head. The physician was notified, pressure alarm was placed to wheelchair. The resident was assisted to bed with two person assistance. On 01/24/22 at 1:15 P.M., a nurse documented initiated neurological assessments; On 01/24/22 at 9:59 P.M. a nurse documented resident had no complaint of discomfort or pain from fall; On 01/25/22 at 12:42 P.M. a nurse documented the resident was alert and oriented, vital signs stable, no behaviors or complaints of pain or discomfort from previous fall. Chair alarm in place and functioning properly. On 01/26/22 at 4:45 P.M., a nurse documented the physician acknowledges notification of resident fall from wheelchair on 01/24/22. On 01/24/22, 01/25/22, 01/26/22 and 01/27/22 neurological assessments of Resident #39 were documented in the resident's records related to a fall. On 04/05/22 a quarterly fall assessment was completed and the resident was determined to be at a high risk for falls. On 04/06/22 at 11:54 P.M. a nurse documented a care plan meeting was held, resident declined attendance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/17/22 revealed Resident #39 had mild cognitive impairment. The assessment revealed Resident #39 required extensive one person assistance for bed mobility, transfers, toilet use and personal hygiene. The MDS also noted Resident #39 had no falls since admission. The resident was ordered an antidepressant and a diuretic medication. On 09/02/22 at 12:55 A.M., a nurse documented being called to the resident's room and observing Resident #39 sitting on the floor next to the bed. Resident stated that he was trying to get up out of bed and get some clothes out of his drawer and his feet slid forward and he lowered himself down next to his bed and put his call light on for help. Resident said he did not hit his head and had no voiced complaints of pain. Range of motion and vital signs are all within normal limits for this resident. Blood pressure 134/74; temperature 97.8; pulse 76; respirations 18; pulse oximetry 96%. Resident was assisted up with two person assist back into bed and Neuro checks started. Physician notified and message left for the residents' family. Staffing will continue to monitor the resident. On 09/02/22, 09/03/22, 09/04/22 and 09/05/22 neurological assessments for Resident #39 were documented in the resident's records related a falls. Review of the physician's orders revealed one person assist with transfers with wheeled walker, occupational therapy consult, pressure alarm to wheelchair (initiated 01/24/22). The resident also received medications including [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], Losartan and [MEDICATION(S)]. On 09/07/22 at 3:45 P.M. interview with the Director of Nursing (DON) revealed there were no fall assessments completed for Resident #39 subsequent to the falls experienced on 01/24/22 and 09/02/22 and there should have been. The DON verified there should have been a fall assessment documented after the falls. The DON revealed staff performed a fall investigation on 01/24/22 with a recommendation for a seat alarm on the resident's wheelchair, but the recommendation for the seat alarm was not included with the resident's care plans until 08/24/22 and a fall investigation was completed on 09/02/22 with a referral to physical therapy for safe measures to independently obtain personal items. Review of the facility undated Fall Management policy revealed when a fall occurs with no injuries, the attending physician and family would be notified in an appropriate time frame, recommendations would be made and a safety nurse would follow through with an investigation. Review of the facility undated Fall Prevention Policy revealed upon admission and quarterly in correlation with the Minimum Data Set (MDS) assessment, a falls assessment would be completed on the resident with a fall risk score. 2. Review of medical record for Resident #20 revealed the resident was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], heart failure, and hypertension. Review of the plan of care, dated 04/08/22 revealed Resident #20 was at risk for falls related to previous falls. Interventions included one person assist with front wheeled walker for transfers and gait, assess need for safety measures, fall interventions as needed, call light in reach, provide verbal reminders to call for assistance when needed. Review of the fall assessment, dated 04/08/22 revealed Resident #20 was at moderate risk for falls. On 05/21/22, 05/22/22, 05/23/22 and 05/24/22 neurological assessments were documented subsequent to a resident fall. Review of a nurse progress note, dated 05/21/22 at 5:45 P.M. revealed a nurse documented Resident #20 was observed sitting on the floor on his bathroom with his feet towards commode. Resident stated after toileting, he was trying to adjust his pants and slid out of the wheelchair onto his buttocks. Back brace in place. Denies pain or injury. Resident was returned to bed with two person assistance and family was notified. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/21/22 revealed the resident had intact cognition and required limited one person assistance for bed mobility, extensive two person assistance for transfers and toilet use and extensive one person assistance for dressing and personal hygiene. The assessment revealed Resident #20 was always continent of bowel and bladder and was prescribed an antidepressant and an anticoagulant. Review of the physician's orders revealed the resident required one assist with front wheeled walker for transfer and gait, up in wheelchair daily, bilateral grab bars up at all times when in bed and received the medications [MEDICATION(S)] and [MEDICATION(S)]. On 09/07/22 at 3:45 P.M. interview with the Director of Nursing (DON) revealed there were no fall assessments completed for Resident #20 subsequent to the fall experienced on 05/21/22 and there should have been. The DON verified there should have been a fall assessment documented after the falls. Review of the facility undated Fall Management policy revealed when a fall occurs with no injuries, the attending physician and family would be notified in an appropriate time frame, recommendations would be made and a safety nurse would follow through with an investigation. Review of the facility undated Fall Prevention Policy revealed upon admission and quarterly in correlation with the Minimum Data Set (MDS) assessment, a falls assessment would be completed on the resident with a fall risk score. 3. Review of medical record for Resident #14 revealed an admitted [DATE] with diagnoses including [CONDITION(S)], respiratory failure, type two diabetes mellitus and chronic kidney disease. Review of the resident assessments revealed on 06/24/22 a fall assessment revealed Resident #14 was at high risk for falls. Review of care plan, dated 06/27/22 revealed the resident was at risk for falls. Interventions included two person assist for transfers, call light in reach, provide verbal reminders to call for assistance and personal alarm to wheelchair at all times and check for function. Review of the quarterly MDS 3.0 assessment, dated 07/04/22 revealed the resident had moderate cognitive impairment and required extensive two person assist for bed mobility, toilet use and transfers and extensive one person assist for dressing and personal hygiene. The assessment revealed Resident #14 was also always incontinent of bowel and bladder and received insulin injections and a diuretic medication. Review of a nursing progress notes revealed on 07/09/22 at 3:54 P.M. a nurse documented Resident #14 was observed lying on the floor on the left side of the bed, call light was in reach and the floor was clean and dry. The resident was wearing hard soled slippers and the wheelchair was in close proximity at the time of the incident. The resident's call light was on and he was last observed by staff 15 minutes prior to the fall sitting in his wheelchair and using the telephone. Resident stated he was trying to get into bed. Resident denied pain and had no visible signs of injuries On 07/09/22, 07/10/22, 07/12/22 and 07/13/22 neurological assessments were completed for the resident subsequent to a fall. On 08/25/22 at 8:02 P.M. a nurse documented Resident #14 was observed sitting on the floor in front of his wheelchair. The resident stated he was trying to scoot back in the chair and it was not locked and he slid to the floor. The resident stated he did not hit his head, nor have any pain. Vital signs for the resident were within normal limits for the resident and range of motion was within normal limits. On 08/25/22, 08/26/22, 08/27/22 and 08/28/22 neurological assessments were completed for the resident subsequent to a fall. Review of the resident's physician's orders revealed an order for personal alarm to wheelchair at all times, two person assist with wheeled walker for transfer, up in wheelchair as tolerated. The resident had medication orders that included [MEDICATION(S)] insulin, [MEDICATION(S)] and [MEDICATION(S)]. On 09/07/22 at 3:45 P.M. interview with the DON revealed there were no fall assessments completed for Resident #14 following the falls on 07/09/22 or 08/25/22 and there should have been. The DON verified there should have been a fall assessment documented after the falls. Review of the facility undated Fall Management policy revealed when a fall occurs with no injuries, the attending physician and family would be notified in an appropriate time frame, recommendations would be made and a safety nurse would follow through with an investigation. Review of the facility undated Fall Prevention Policy revealed upon admission and quarterly in correlation with the Minimum Data Set (MDS) assessment, a falls assessment would be completed on the resident with a fall risk score.

Based on record review and interview the facility failed to provide single rooms with at least 100 square feet of living space in each room. This affected six residents (#11, #14, #22, #29, and #30) of 44 residents residing in the facility. Findings include: On 09/06/22 at 9:42 A.M. interview with the Administrator revealed the facility had six single rooms with less than the required 100 square footage of living space. Five of the six rooms were occupied by residents at the time of the survey. Review of the space/occupancy certification waiver applications revealed Resident #11, #14, #22, #29, and #30 were in single rooms that measured less than the required 100 square feet of living space. The room measurements and residents affected were as follows: Room 128 (Resident #30) 96.47 square feet. Room 129 (Resident #14) 93.15 square feet. Room 130 (Resident #11) 96.46 square feet. Room 131 (Resident #22) 93.55 square feet. Room 132 (vacant) 97.75 square feet. Room 133 (Resident #29) 91.50 square feet.

Based on observation, interview and record review, the facility failed to ensure clean linens were kept separate from contaminated linens, also failed to ensure fans used in the laundry area were clean to prevent cross contamination of clean linen, and failed to ensure washing machines were kept in a clean sanitary condition to prevent cross contamination. This had the potential to affect all residents. The facility census was 40. Findings include: Observation on 11/02/20 between 11:15 A.M. and 11:30 A.M. with Laundry Supervisor #307 and Laundry Assistant #310 revealed the clean and soiled laundry area were located in the same room. The room had been rectangular shaped There were two washing machines in the room as you entered that were used to launder residents personal clothing including linen. The bottom section of both washing machines were rusted completely off up to the bottom of the door. Both doors had a thick layer of dried crusty material on the glass of the doors. Both washers had a thick film of sticky dust covering the outside of the machines. There were multiple spills of dried liquid on top of each machine running down the sides and front of both machines. This was verified by the Laundry Supervisor #307 and Laundry Assistant #310. Interview on 11/02/20 at 11:17 A.M. with Laundry Assistant # 310 revealed he could not recall when the washers had been cleaned inside our out last. Laundry Assistant # 310 stated, maybe a week or two ago. Observation on 11/02/20 of the drain behind the washers revealed the drain covers were completely rusted through with only the edges of the covers remaining. Approximately three inches high of rusted particles from the covers were laying on the floor of the drain system. This was verified by the Laundry Supervisor #307 and Laundry Assistant #310. Observation on 11/02/20 between 11:15 A.M. and 11:30 A.M. with Laundry Supervisor #307 and Laundry Assistant #310 revealed a shelving rack located directly across from the two washers (approximately three feet) with multiple open containers which held resident clean underclothes including socks, bras and underwear that had already been washed and dried which were ready to be delivered to resident rooms. Located approximately seven to eight feet from the washers were two dryers. Directly across from the dryers was the folding table which had clean linen and resident clothing laying on top of the table . A fan had been placed on top of the folding table next to the clean clothing and linen which had a thick build up of dust covering the entire fan with strands of build up of dust adhering to the covering of the fan. This was verified by the Laundry Supervisor #307 and Laundry Assistant #310. Observation on 11/02/20 at 11:24 A.M. with Laundry Supervisor #307 revealed Laundry Assistant #310 removed laundry from the washing machine and placed the laundry in the dryer without an apron or gloves on. This was verified by the Laundry Supervisor #307 and Laundry Assistant #310. Interview on 11/02/20 at 11:27 A.M. with Laundry Assistant # 310 revealed he frequently used the fan. Laundry Supervisor #307 and Laundry Assistant #310 confirmed the soiled laundry had to be brought into the same area as the clean laundry to wash the soiled laundry; then once washed, the clean laundry had been folded in the same area as the soiled laundry then returned to residents. Interview on 11/02/20 at 12:30 P.M. with Administrator confirmed he would expect the washers to be cleaned daily. Administrator confirmed there is a separate room to hold soiled laundry but the soiled laundry had to be brought into the same area as the clean laundry to be washed. Record review of laundry duties, undated, revealed duties end of shift clean up which stated all washers and dryers are to be wiped down.

Based on record review and interview the facility failed to administer pneumococcal vaccines upon informed consent or obtain a signed informed consent. This affected five residents (#10, #14, #20, #42, and #46) of five residents reviewed for pneumococcal vaccines. Findings include: 1. Record review for Resident #20 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Resident #20's record did not show any documentation she received the pneumococcal vaccine or any documentation as to the vaccine being medically contraindicated. Review of form titled, Informed Consent for Pneumococcal Vaccine for Resident #20 revealed she signed and dated the informed consent on 08/24/18 stating she gave the facility permission to administer a pneumococcal vaccination unless medically contraindicated. 2. Record review for Resident #42 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Resident #42's record did not show any documentation he received the pneumococcal vaccine or any documentation as to the vaccine being medically contraindicated. Review of form titled, Informed Consent for Pneumococcal Vaccine for Resident #42 revealed the facility received a telephone consent on 10/19/18 from Resident #42's wife stating she gave the facility permission to administer a pneumococcal vaccination unless medically contraindicated. 3. Record review for Resident #10 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Resident #10's record did not show any documentation she received the pneumococcal vaccine or any documentation as to the vaccine being medically contraindicated. Review of form titled, Informed consent for Pneumococcal Vaccine for Resident #10 revealed she signed stating she gave the facility permission to administer a pneumococcal vaccination unless medically contraindicated. 4. Record review for Resident #14 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of Resident #14's record did not show any documentation she received the pneumococcal vaccine or any documentation as to the vaccine being medically contraindicated. Review of form titled, Informed consent for Pneumococcal Vaccine for Resident #14 revealed she signed stating she gave the facility permission to administer a pneumococcal vaccine unless medically contraindicated. The informed consent was not dated. 5. Record review for Resident #46 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Resident #46's record did not show any documentation she received the pneumococcal vaccine or any documentation as to the vaccine being medically contraindicated. Review of form titled, Informed consent for Pneumococcal Vaccine for Resident #46 revealed the box was marked with a X giving the facility permission to administer a pneumococcal vaccination unless medically contraindicated. The informed consent was not signed or dated. Interview on 08/29/19 at 1:23 P.M. with the Director of Nursing and Assistant Director of Nursing (ADON) #328 verified they received signed consents from Resident #10, #14, #20, and #42 but had no documentation the pneumococcal vaccine was administered or any documentation the vaccine was medically contraindicated from being administered. They verified Resident #46's consent was marked with an X to receive the vaccine but was not signed or dated. They had no other documentation regarding Resident #46 consenting or refusing the pneumococcal vaccine or any documentation she received the vaccine or that the vaccine was medically contraindicated. Interview on 08/29/19 at 2:34 P.M. with the Director of Nursing revealed the facility did not have a policy regarding Pneumococcal vaccines.

Based on observation, record review and interview the facility failed to ensure water temperatures were maintained at a comfortable level for resident use between 105 - 120 degrees Fahrenheit in resident rooms and shower rooms. This had the potential to affect all 50 residents residing in the facility. Findings include: 1. On 08/26/19 at 10:30 [NAME]M. interview with Resident #6 revealed he wished the water in his room was hotter. Resident #6 explained he often took sponge baths and the water was not as hot as he would like it. On 08/26/19 at 10:36 [NAME]M. interview with Resident #38 revealed she had to let the hot water in her room run a long time before it would get warm. Review of the facility document titled Water Temperatures, dated 06/10/19 to 08/26/19 revealed all water temperatures below 106 or above 119 F would be immediately regulated to be in mid range by the Maintenance Supervisor. The documented water temperatures varied in a range of 112-118 in resident rooms and the shower rooms during this time period. An interview was conducted on 08/27/19 at 2:58 P.M. with Maintenance Supervisor (MS) #800 who stated he checked water temperatures in residents rooms and shower rooms once a week and the temperatures had been right around 116 to 117 degrees Fahrenheit (F). 2. On 08/27/19 from 2:59 P.M. to 3:09 P.M. water temperatures were obtained with MS #800 in resident rooms and shower rooms using a calibrated, digital thermometer. The results were as follows: room [ROOM NUMBER] - 95.5 degrees Fahrenheit (F). room [ROOM NUMBER] - 90.0 degrees F. room [ROOM NUMBER] - 92.0 degrees F. room [ROOM NUMBER] - 114.2 F room [ROOM NUMBER] - 89.2 degrees F. The B shower room B - 114 degrees F. During the above observations MS #800 let each water faucet run for two to four minutes before reading a final temperature. MS #800 revealed he did not know why there was such a difference in the room water temperatures. On 08/29/19 from 8:37 [NAME]M. to 8:55 [NAME]M. additional observations of the water temperatures during a tour with MS #800 of resident rooms and the shower room water temperatures revealed the following: room [ROOM NUMBER] - 95 degrees F. room [ROOM NUMBER] - 95.4 degrees F. Shower room B on 100 hall - 113 F. room [ROOM NUMBER] - 107 degrees F. room [ROOM NUMBER] - 109 degrees F. Shower room C1- 108 degrees F. Shower room C2 - 91.0 degrees F after running the water from 8:53 [NAME]M. to 8:55 [NAME]M. On 08/29/19 at 9:11 [NAME]M. interview with the Administrator revealed the facility was purchasing a circulation pump that would detect water temperatures in the pipes and work to circulate the water supply to keep water temperatures within an acceptable range for the residents. On 08/29/19 at 11:07 [NAME]M. interview with State tested Nursing Assistant (STNA) #329 revealed she had noticed the hot water temperatures were not consistent and not every resident room had a problem with hot water not being hot enough just some of the rooms. STNA #329 added she did not use shower room C2 because the water does not get hot enough to comfortably shower residents so she used only shower room C1. On 08/29/19 at 2:48 P.M. interview with MS #800 revealed the facility did not have a policy on how to regulate and monitor water temperatures. He added he had the guideline he followed at the bottom of the water temperature logs.

Based on record review and interview the facility failed to provide single rooms with at least 100 square feet of living space in each room. This affected six residents (#49, #48, #5, #7, #39, and #41) of 50 residents residing in the facility. Findings include: Interview on 08/28/19 at 9:42 [NAME]M. with the Administrator revealed the facility had six single rooms with less than the required 100 square footage of living space. Six of the six rooms were occupied by residents at the time of the survey. Review of the space/occupancy certification waiver applications revealed Resident #49, #48, #5, #7, #39, and #41 were in single rooms that measured less than the required 100 square feet of living space. The room measurements and residents affected were as follows: room [ROOM NUMBER] (Resident #49) 96.47 square feet. room [ROOM NUMBER] (Resident #48) 93.15 square feet. room [ROOM NUMBER] (Resident #5) 96.46 square feet. room [ROOM NUMBER] (Resident #7) 93.55 square feet. room [ROOM NUMBER] (Resident #39) 97.75 square feet. room [ROOM NUMBER] (Resident #41) 91.50 square feet.

Based on record review and interview, the facility failed to provide single rooms with at least 100 square feet of living space in each room. This affected five (Residents #14, #27, #30, #37 and #46) of fifty-one residents residing in the facility. Findings include: On 06/18/18, during the entrance conference at 7:45 P.M., interview with the Administrator verified the facility had six single rooms with less than the required 100 square footage of living space. Five of the six rooms were occupied by residents at the time of the survey. The room measurements and residents affected were as follows: 1. room [ROOM NUMBER] (Resident #37) 96.47 square feet. 2. room [ROOM NUMBER] (Resident #27) 93.15 square feet. 3. room [ROOM NUMBER] (Resident #46) 96.46 square feet. 4. room [ROOM NUMBER] (Resident #14) 93.55 square feet. 5. room [ROOM NUMBER] (unoccupied) 97.75 square feet. 6. room [ROOM NUMBER] (Resident #30) 91.50 square feet.

Based on record review, and interview, the facility failed to ensure staff completed a two-person transfer, as required according to the assessment and physician's orders [REDACTED]. Harm ocurred when STNA #102 assisted Resident #26 alone during a transfer, and the resident had to be lowered to the floor and sustained a fractured left ankle. This affected one (Resident #26) of three residents reviewed for accidents. The facility census was 49 residents. Findings include: Review of the medical record for Resident #26 revealed she was admitted to the facility 01/18/16 with [DIAGNOSES REDACTED]. Review of the Medicare 14-Day Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident was cognitively intact with no behaviors. She was dependent on two staff for transfers and required extensive assistance of two staff for toileting. She was occasionally incontinent of bowel and bladder. She had no recent falls. Review of a physician's orders [REDACTED].M. revealed Resident #26 was to have two-person assist for all transfers. Review of the fall investigation worksheet dated 12/28/17 revealed Resident #26 fell at 3:00 P.M. during a transfer to the toilet. Staff was transferring the resident off the commode when she stated she felt like her knees were giving out. She was lowered to the floor for safety. During the head-to-toe assessment, she stated she was having pain in her left ankle. Passive and active range of motion were within normal limits. She complained of pain in her left ankle when positioned outward. An x-ray was ordered for the left ankle and left knee. The x-ray results were positive for an acute occult fracture. Incident/accident direct care witness statement dated 12/29/17, signed by State tested Nurse Aide (STNA) #102, stated STNA #102 went into Resident #26's room. She was in the bathroom, already in her wheelchair. She stated she was not aware that she was still a two-person assist. She stated she assumed because she no longer required a Hoyer (mechanical lift) she was a one-person assist. She stated she went to help her grab the bar to stand. The resident's ankle went out, and she allowed the resident to slide down her knee onto the floor. She stated, had I known she was still a two assist I would have called for help. Interview on 01/18/18 at 9:30 A.M. with the Administrator revealed Resident #26 was transferred by one STNA, resulting in a fractured left ankle. She stated the resident had just had her orders changed from a Hoyer transfer to a two-person transfer. He stated STNA #102 attempted to transfer Resident #26 without assistance from a second STNA. He stated STNA #102 admitted she did not have another STNA assisting her, stating she was not aware that Resident #26 required two assists for transfers. He stated that STNA #102 was no longer employed by the facility. This deficiency substantiates Complaint Number OH 549.

Based on observation, record review and interview the facility failed to ensure one resident's (Resident #6) fractured right lower leg was immobilized as ordered during a transfer. This resulted in actual harm when the aligned fracture became displaced causing pain and requiring surgical intervention. In addition the facility failed to ensure fall prevention interventions were in place for one resident (Resident #44), who was assessed as a fall risk. This affected two residents (Resident #6 and #44) of four residents reviewed for accidents. Findings include: 1. Record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An x-ray, dated 12/14/15 (prior to admission) of the right lower extremity revealed Resident #6 had a comminuted (fragmented) fracture of the medial aspect of the right tibial plateau. The fracture lines ran vertically down the shaft of the proximal tibia for about 10 centimeters. In addition, there was a nondisplaced (in alignment) fracture of the right proximal metaphysis of the fibula. (These were both of the resident's lower right leg bones.) The history and physical, dated 12/15/15 included x-ray results that indicated a slightly comminuted right tibial plateau fracture. The computerized axial tomography (CAT) scan further showed that this was a bicondylar plateau fracture and that the fracture extended up the shaft of the bone of the right tibia. Resident #6 was not a surgical candidate for multiple reasons per the history and physical. Review of the physician order, dated 12/30/15 indicated (the right leg) was to be elevated on two pillows when in the bed or chair. The order dated 12/30/15 revealed a brace was to be on the right leg at all times except with daily skin checks and hygiene. The order dated 12/30/15 revealed Resident #6 was to be up in the wheelchair daily with the right leg on the wheelchair leg rest at all times. The care plan dated 01/07/16 revealed Resident #6 had an increased risk for falls. The interventions included to provide the appropriate level of assistance to promote the resident's safety. The resident was to be up in the wheelchair as tolerated with the right leg rest. The care plan dated 01/07/16 included to maintain the brace to the right lower extremity. Review of a nursing progress note, dated 01/12/16 at 11:00 A.M. revealed Resident #6 complained of right leg pain upon transfer into the bed from the shower and the family was notified. Record review revealed the facility completed an investigation related to the above transfer on 01/12/16. The following information was reviewed related to the incident on 01/12/16: A note written by the social service designee/Licensed Practical Nurse (LPN) #41, dated 01/12/16 at 11:00 A.M. revealed Resident #6 called LPN #41 to her room and informed her that she was in a lot of pain in her right leg/knee area where she had been following up with the orthopedic doctor for a fracture and she wanted to go to the hospital to be evaluated. The physician and daughter were notified. The ambulance was notified to transfer Resident #6 to the hospital. The note at 11:15 A.M. revealed Resident #6 had increased crying related to the pain. The resident told LPN #41 that while State tested Nursing Assistants (STNA) #30 and #40 were transferring her back to bed her fractured leg got bent. She stated her leg brace was not on per her request since the STNAs were still continuing her personal hygiene care. Record review revealed Resident #6 was admitted to the hospital and had surgery to repair the fracture sustained during the transfer on 01/12/16. X-ray results dated 01/12/16 at 2:15 P.M. of the right lower leg revealed a comminuted fracture of the proximal tibia that extended into the articular surface of the medical tibial plateau and a fracture of the proximal fibula. The surgical report dated 01/15/16 revealed Resident #6 had surgery on the fractured right lower leg that included the placement of a plate, screws and an incision. Record review revealed Resident #6 was re-admitted to the facility on [DATE] at 6:17 P.M. The physician progress notes [REDACTED].#6 had returned from the hospital after sustaining a fracture to her leg. The resident had subsequent surgery done and had a brace at this point. Resident #6 was observed on 02/17/16 at 11:20 A.M. in the wheelchair in her room with the right leg immobilizer on and the leg up on the leg rest of the wheelchair. Resident #6 was interviewed at that time. During the interview, the resident stated an incident had occurred on 01/12/16 which resulted in another fracture of the right leg. Resident #6 stated STNA #30 was transferring her from the shower room back to her room via the shower chair. She stated STNA #30 was very frustrated and talking about how she was not going to get a lunch on this date. Resident #6 stated STNA #30 asked STNA #40 to help her transfer her from the shower chair to the bed. The resident stated she did not have her leg immobilizer on at the time of the transfer. Resident #6 stated the staff were to support the right leg when they transferred her. Resident #6 reiterated STNA #30 was very frustrated and did not support the right leg when transferring her into bed via the Hoyer lift (mechanical lift). The resident stated she heard her right leg crack. Resident #6 stated she cried out in pain. The two STNAs then went to get the nurse. LPN #19 went into the resident's room and told the resident everything was fine. Resident #6 stated the pain was immense and she told the nurse that her right leg was broken. Resident #6 stated LPN #19 didn't do anything to help at all so she called LPN #41 to her room. After arriving to her room and being told what had happened, LPN #41 called for an ambulance. Resident #6 stated the director of nursing (DON) came to her room before she left to go to the hospital and asked what had happened. The resident stated she told the DON what had occurred and then left to go to the hospital. Resident #6 stated the initial fracture that had occurred prior to admission was well aligned and the physician was just going to use the immobilizer. Resident #6 stated when she went to the hospital with the new injury/fracture that occurred at the facility; the physician informed her that he would have to operate. Resident #6 stated she had to have surgery which involved placing a plate, screws and 28 stitches. An interview with the director of nursing (DON) on 02/17/16 at 6:00 P.M. verified Resident #6 did not have the immobilizer on at the time she was being transferred via the Hoyer lift on 01/12/16. An interview on 02/18/16 at 6:05 P.M. with LPN #19 revealed STNA #30 and #40 informed her Resident #6 was complaining of pain when they transferred her from the shower chair to the bed via the Hoyer lift. They stated the resident was taken from the shower room via the shower chair to complete personal hygiene. The STNAs informed the nurse the immobilizer was not in place because the resident did not want it on until they completed her bath. LPN #19 stated she went into the resident's room to find her crying and complaining of pain to her right hip and right leg. LPN #19 stated there were no visible injuries. LPN #19 stated she medicated Resident #6 with Norco, a narcotic pain medication. LPN #19 stated she returned to the resident's room and found the Norco was not effective and the resident was still crying in pain. LPN #19 stated she notified the physician of the increased pain. LPN #19 stated she saw LPN #41 in the resident's room at some point. LPN #19 stated she called for the ambulance and indicated she saw the DON going down the hall toward the resident's room. LPN #19 stated the STNA #30 and #40 were visibly upset when they informed her about the resident's pain upon transfer. LPN #19 stated the STNAs did not seem to know what happened. An interview with LPN #41, who functioned as the facility social service designee on 02/18/16 at 6:20 P.M. revealed the activity person asked her to go to Resident #6's room on 01/12/16. Upon entering the room she found Resident #6 crying in pain. LPN #41 stated she told LPN #19 to call the doctor. LPN #41 stated Resident #6 told her STNA #30 was in a hurry, did not support her right leg during the transfer and her knee bent. An interview with the DON on 02/18/16 at 6:40 P.M. verified Resident #6 sustained a fracture at the facility due to an unsafe transfer into the bed. The DON verified STNA #30 did not support Resident #6's right leg during a transfer into the bed via the Hoyer lift. The DON verified Resident #6's right leg was to be supported at all times due to the previous fractures. The DON stated the orthopedic surgeon informed her surgery was now necessary due the fracture was no longer aligned. 2. Record review revealed Resident #44 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) quarterly assessment, dated 12/26/15 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 which reflected the resident had good cognition/memory. The MDS revealed the resident had not sustained any falls since admission or prior assessment. The resident was assessed to have trouble with sleep and concentration. Review of the plan of care dated 10/12/15 revealed Resident #44 was at risk for falls. The goal was to reduce his risk for falls and fall related injuries. Interventions included assistance of one staff member for all activities of daily living and staff were to provide the appropriate amount of assistance to promote the resident's safety. Review of the fall risk assessment dated [DATE] revealed Resident #44 had a history of [REDACTED]. The fall risk score was 15 and a score of nine or greater indicated the resident was at risk for falls. Review of the February 2016 physician's orders [REDACTED].#44 to have the assistance of one staff member for transfers. On 11/25/15 there was a physician's orders [REDACTED]. Review of a fall investigation dated 01/19/16 revealed Resident #44 sustained a fall on 01/18/16 while ambulating to the bath room. His roommate turned on the call light. When the nurse responded the resident was sitting on the floor in front of his closet. Resident #44 stated he was going to the bathroom. He was using his walker and tripped trying to go around his wheel chair. He was assessed to have a red area on his left upper back. The new intervention listed on the falls investigation worksheet was to apply a bed alarm to his bed. On the bottom of the falls investigation worksheet it was documented that the bed alarm was discontinued on 01/22/16 because it caused increased anxiety and agitation for the resident. There were no other interventions listed to prevent further falls from occurring following this incident. Record review revealed Resident #44 sustained another fall on 02/01/16. Review of the fall investigation dated 02/01/16 revealed Resident #44 was found by a housekeeper to have fallen in his room. The nurse entered the room to find the resident on the floor near his bed between the bed and the wheelchair. No injuries were noted. The new intervention listed on the fall investigation worksheet was to apply a bed alarm again. The investigation report revealed the nurse explained to the resident the alarm was for his safety and the resident seemed to be in agreeance with the alarm at that time. There were no other recommendations. On 02/18/2016 at 4:40 P.M. an interview with LPN #5, the facility safety nurse was conducted. She verified she did not implement any new interventions to prevent further falls after the bed alarm was discontinued on 01/22/16. She stated she should have in-serviced staff on not leaving the resident's walker at his bedside or put another intervention into place. Review of the Investigation of Incident Management policy and procedure dated April 2013 revealed after a fall, staff would explore the environment for any causative factors. Recommendations would be made and the safety nurse would follow through with an investigation.

Based on observation, record review and interview, the facility failed to address Resident #50's complaints of severe pain resulting in pain during treatment of [REDACTED]. This affected one of three residents reviewed for pain control. The facility census was 42. Findings include: Resident #50 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #50 was interviewed on 05/08/12 at 10:12 A.M., and he indicated he sometimes had pain in his legs due to blisters on his heels. Resident #50 was observed on 05/09/12 at 9:00 A.M., in his wheelchair in his room. Resident #50 stated he did not sleep the night before. He stated his legs hurt all night. He described his pain as "severe". Resident #50 stated that his legs don't hurt as much when he is up in his wheelchair but they do hurt once he is in bed. He stated it had been that way the past three nights. On 05/09/12 at 5:35 P.M., Licensed Practical Nurse (LPN) #12 was observed changing five pressure ulcer dressings on Resident #50's lower left leg and bilateral feet. Resident #50 indicated that both of his feet hurt. He stated after the dressing changes if he rested a while the pain would go away and then would come back two to three hours later. During the treatment, LPN #12 removed the outer dressing from the left calf pressure ulcer and the inside gauze was stuck to the wound bed. Resident #50 stated that was the part that hurt, indicating when the dressing was pulled off the wound bed. He stated the pain would go away a little while after the dressing was removed. Resident #50 was observed to grimace as LPN #12 removed the dressing. The left heel dressing elicited the same response from Resident #50. The gauze was dried in the wound bed and Resident #50 indicated it hurt when it was removed and again he grimaced. Resident #50 indicated the pain was a 9 on a scale of 0-10, with 0 being no pain and 10 being the worst pain he had ever had. Resident #50 stated the pain was "severe". Resident #50 asked LPN #12 if he could have a "present" after the treatment was over and he said by "present" he meant a pain pill. LPN #12 told him he got a pain pill at 4:00 P.M., and that they were given every four hours, indicating it would not be due to be given until 8:00 P.M. LPN #12 continued with the treatment to his left great and second toe pressure ulcers. Resident #50 was observed to grimace when the left second toe was cleaned with normal saline and the new dressing was applied. LPN #12 then removed the dressing from Resident #50's right heel and the inner gauze was stuck in the wound bed. Again, Resident #50 was observed grimacing when it was removed and he verified it hurt as much as the other heel. After the treatment was completed, Resident #50 indicated he would take additional pain medications if they were available. The observation lasted until 6:35 P.M. Interview with LPN #12 immediately following the dressing changes observation verified the observations of pain and Resident #50's verbalizations of pain. She indicated she should have completed the dressing change closer to the time she administered his 4:00 P.M. pain medication. The director of nursing (DON) joined the conversation and was made aware that Resident #50 had voiced that he had not slept for the last three nights due to pain in his legs. The DON indicated she knew about this and had discussed this with Resident #50 during the morning on 05/07/12. The DON indicated she offered to get him a recliner or his bed from home since the pain occurred when he was primarily lying down. She stated Resident #50 refused both options. The physician was not notified on 05/07/12 of Resident #50's complaints of unrelieved pain, which interfered with his sleep. This concern was verified with the DON and LPN #12. Review of a social service note dated 03/14/12, indicated Resident #50 had an increase in mouth pain due to [MEDICAL CONDITION] and his pain medications were increased. The social service note on 03/29/12, indicated Resident #50 was doing good other than complaints of pain unresolved with medication. The next social service note on 04/12/12, indicated Resident #50 continued to complain of pain despite medication changes and continued with [MEDICAL CONDITION]/[MEDICAL CONDITION]. The concern was reviewed with the primary care physician and he requested the families phone number to speak with the niece (POA) for possible consideration of hospice care. Review of the social service note dated 04/16/12, revealed Resident #50 had one day with complaints of pain but his medications were adjusted and he had no further pain. There were no additional social service notes. A care plan dated 01/31/12, addressed Resident #50's pain related [MEDICAL CONDITION] of the head and neck, [MEDICAL CONDITION] and overall debility and weakness as evidenced by verbalizations of pain. It indicated Resident #50 complained of pain in his legs. Interventions to address pain included: administering pain medication per the orders of the attending physician, assess the characteristics of pain including location, severity on a scale of 0-10, type of pain, frequency of pain, precipitating factors and relief factors. Observe for nonverbal signs of pain such as grimacing or moaning, guarding and elevated vital signs. It included to offer comfort measures such as distraction, back rubs, and re-positioning and to notify the attending physician if pain medication became ineffective. Additions to the plan of care included: 03/12/12- [MEDICATION NAME] ES (a narcotic pain reliever) increased to two tablets every 6 hours as needed for pain, and the [MEDICATION NAME] (a narcotic pain reliever) was increased from 50 micrograms (mcg) to 75 mcg every three days due to increased pain. On 03/28/12, an entry indicated Resident #50 had complaints of pain and [MEDICATION NAME] (a narcotic pain reliever) 15 milligrams (mg) every four hours as needed was changed to every four hours around the clock. As a result of continued complaints of pain on 04/12/12, the [MEDICATION NAME] dose at bedtime was increased to 30 mg. On 04/21/12, [MEDICATION NAME] 100 mg was ordered to be given every evening at bedtime for pain in his legs; and, an intervention included schedule his dressing change within 30-45 minutes after routine pain medications were administered (no date for when this intervention was added to the plan of care was listed). An interview with the DON on 05/10/12 at 11:15 A.M., confirmed that a pain assessment tool should be completed daily and kept with the Medication Administration Record, [REDACTED]. The most recent pain interview form completed was at the time of the comprehensive assessment which was dated 04/17/12. That assessment indicated Resident #50 had occasional pain in the last five days and the pain had made it hard for him to sleep at night. The assessment indicated Resident #50 reported his pain as a 9 (on a scale of 0-10) and described it as "severe". The narrative note indicated that medications were adjusted on 04/12/12. The DON verified that the nurses were not assessing him on a routine daily basis to ensure he was achieving adequate pain control.

Based on interview and record review, the facility failed to consistently monitor blood parameters related to anti-coagulant ([MEDICATION NAME]) therapy for Resident #29 resulting in active bleeding, decreased level of consciousness and hospitalization . This affected one (Resident #29) of two sampled residents on [MEDICATION NAME] therapy. The facility identified five residents on [MEDICATION NAME] therapy and 42 residents received medications in the facility. The facility census was 42. Findings include: Resident #29 was admitted to the facility on [DATE], with diagnoses, including [MEDICAL CONDITION], hypertension and a pacemaker. According to a telephone order dated 03/13/12, the physician started the resident on a blood thinner ([MEDICATION NAME]) 2.5 milligrams (mg) daily. The physician also ordered on [DATE], PT/INR blood levels to be drawn weekly. PT/INR is used to determine the time it takes for the resident's blood to clot. A telephone order, dated 03/28/12, revealed the physician increased the dose of [MEDICATION NAME] to 5 mg daily on 03/28/12. There was no change to the frequency of the PT/INR levels. The facility developed a care plan on 03/27/12, addressing the use of [MEDICATION NAME]. The care plan directed the nurses to monitor lab reports. The facility had an undated policy, titled Anticoagulant PT/INR Monitoring. The policy indicated resident's receiving anticoagulation therapy ([MEDICATION NAME] therapy), require regular monitoring for safe laboratory parameters and preventing adverse reactions. Adverse reactions of anticoagulant therapy include bleeding and changes in mental status. The policy also stated, in bold print, "Do not administer the medication if laboratory results are not clearly identified". According to a nurse's note dated 04/08/12 at 9:00 P.M., a nursing assistant reported that the resident had blood on his chin and hands. The resident indicated it was from his nephew shaving him with a regular razor. The next nurse's note, dated 04/09/12 at 1:00 P.M., indicated the bleeding had continued on the resident's lower neck and chin. The next nurse's note written, 04/10/12 at 8:30 A.M., indicated the resident was "very lethargic", awakens then falls right back to sleep. The nurse noted the pressure dressing was "saturated" with blood. Further nurses notes, dated 04/10/12 at 1:00 P.M., revealed the resident was becoming more lethargic" with "increased confusion". The nurse noted the resident was "pale" and bleeding continued to the resident's face and neck. The nurse noted the pressure dressing was 50% saturated with bright red blood. The facility received an order on 04/10/12 at 2:00 P.M. to send the resident to the hospital. The facility had obtained Resident #29's PT/INR level on 03/16/12. The lab results from that date showed both the PT and INR values to be high. Elevated PT/INR means it takes longer for the blood to clot. The facility obtained a PT/INR on 03/28/12, which also revealed an elevated PT and INR. There were no further PT/INR levels completed, until the resident was admitted to the hospital on [DATE]. A copy of PT/INR levels drawn in the emergency roiagnom on [DATE] indicated the resident's PT level was high at 30.6 and INR was critically high at 6.2. The normal range for PT level is 9.5 to 11.8 seconds and the normal range for INR is 0.9 to 1.1. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #29 subsequently developed active bleeding and a decreased level of consciousness, resulting in a hospitalization . The director of nursing (DON), resident assessment coordinator (RAC #40), and Licensed Practical Nurse (LPN) #57, were interviewed on 05/09/12 at 4:10 P.M. They confirmed that PT/INR levels were ordered to be drawn weekly for Resident #29. They verified that a PT/INR should have been drawn for Resident #29 on or around 04/04/12. They verified there was no evidence that the PT/INR was monitored as ordered, and that the nurses continued to administer [MEDICATION NAME], even without regular monitoring of PT/INR.