Every finding on record at Northcrest Rehab and Nursing Center

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, staff interview, review of the fall investigation, review of staff statements, and review of the facility policy, the facility failed to follow the care plan and the information on the Kardex (mechanism that provides Certified Nursing Assistants the care needs of the residents) when providing care to a dependent resident. This resulted in Actual Harm on 02/10/26 when Resident #11 fell out of bed and sustained a laceration to the back of her head. This affected one (Resident #11) of three residents reviewed for falls. The facility census was 59.Findings include:Review of the medical record for Resident #11 revealed an admission date of 08/12/24. Diagnoses included traumatic subdural hemorrhage (bleeding in the brain) with loss of consciousness, chronic respiratory failure, paraplegia, contractures, heart failure, tracheostomy dependence for breathing, gastrostomy tube (for nutrition), and aphasia.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #11 revealed she was severely cognitively impaired. Resident #11 was dependent for all care, incontinent of both bowel and bladder, and had special needs for tracheostomy care, suctioning, oxygen, and dependent on gastrostomy tube to meet all the required daily nutritional needs.Review of the care plan revised March 2026 for Resident #11 revealed she was care planned for activity of daily living (ADL) self-care deficit related to traumatic subdural hemorrhage form motor vehicle accident (MVA), paraplegia, cervical fracture, and contractures with intervention in place for two assists with bed mobility due to dependence. Resident #11 also had a care plan for increased risk for pressure ulcer development due to disease process and had an intervention in place for low air loss pressure reducing mattress with bolsters that required two staff assistance due to Resident #11's dependent care needs. Review of the Kardex for Resident #11 revealed the resident required two the assistance of two people for bed mobility due to her dependent status for care and the resident required the use of a low air loss mattress with bolsters and the assistance of two people for care. Review of the nursing progress note dated 02/10/26 at 12:40 A.M. authored by Licensed Practical Nurse (LPN) #500 for Resident #11 revealed the resident was found lying on the floor on her back between the side of the bed and the nightstand. Blood was on the floor near the head of the resident. Resident #11 was alert, eyes open, grinding teeth, and tracking (following) the writer with her eyes. Resident #11 was assessed; the physician was notified of the incident and was then sent to the local emergency room for evaluation and treatment.Review of the nursing progress notes dated 02/10/26 at 6:15 A.M. for Resident #11 revealed she returned from the local emergency room.Review of the local emergency room records dated 02/10/26 for Resident #11 revealed a computed tomography (CT) scan of the head, neck, brain, spine, and pelvis were completed and no acute findings were noted. All results were normal, no broken bones or bleeding on the brain were identified. Resident #11 revealed she had a fall from her bed. She sustained a laceration to the back of her head, that did not require staples or sutures and was sent back to the facility.Review of the nursing schedule for 02/09/26 revealed Certified Nursing Assistant (CNA) #400 and CNA #430 were both working the night shift from 6:00 P.M. to 6:00 A.M. on the 100 and 200 halls.Review of the facility's fall investigation dated 02/10/26 revealed Resident #11 was dependent for all care. She sustained a fall from bed as the result of a staff member performing ADL care independently when the needs of Resident #11 were two staff assistance for resident safety for all bed mobility due to her vegetative state and use of the low air loss mattress.Review of the written statement dated 02/10/26 authored by CNA #400 revealed she was in Resident #11's room providing evening care and performing incontinence care. She propped Resident #11 on her side and walked away from the bedside to get washcloths from the bathroom. CNA #400 heard a crash and saw Resident #11 lying on the floor with blood coming from the back of her head. CNA #400 stated she was the only CNA in the room and the other CNA, CNA #430, was assisting another resident when the incident occurred. Review of the written statement dated 02/10/26 authored by CNA #430 revealed she was in Resident #11's room along with CNA #400 and Resident #11 was in her bed. CNA #430 then left the room to check on other residents on the 100 hall and when she returned to Resident #11's room, the resident was lying on the floor, and the bed was in a high position at approximately waist high. CNA #400 asked CNA #430 to lower the bed and assist with getting Resident #11 back into bed. CNA #430 refused and immediately went to get the nurse. Review of the incident and accident report dated 02/10/26 at 12:40 A.M. for Resident #11 revealed predisposing environmental factors, predisposing physiological factors, and predisposing situation factors were all marked as other. The explanation of other was documented as the resident had an air mattress and CNA #400 was assisting the resident by herself. The Interdisciplinary Team (IDT) met on 02/10/26, reviewed the incident and a Self-Imposed Plan of Correction (SIPOC) (the facility's internal root cause analysis with plan of correction) was initiated along with education. During an interview on 03/31/26 at 12:00 P.M., the Director of Nursing (DON) stated that for night shift there are two aides per unit and the expectation of the aides is to work together on the unit to help each other with the residents that are two assists with care. Each CNA is assigned a specific hallway for documentation purposes. During an interview on 03/31/26 at 12:20 P.M., the Administrator stated the facility's interdisciplinary team (IDT) meets twice daily on weekdays at 9:00 A.M. and 3:00 P.M. to review any clinical concerns, this includes fall that have occurred. The Administrator stated the meetings are documented on the Clinical Checklist form that collects the weeks minutes from the meetings.Review of the Clinical Checklist for the week of 02/09/26 through 02/15/26 revealed Resident #11's incident of fall was reviewed per protocol.Attempted phone interviews on 03/31/26 with CNA #430 and LPN #500 were unsuccessful. CNA #400 was not interviewed as she was no longer employed at the facility.Review of the facility policy titled Falls and Fall Risk, Managing, revised December 2007, revealed based on previous and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.The deficient practice was corrected on 02/11/26 when the facility implemented the following corrective actions: On 02/10/26 a head to toe assessment was completed by LPN #500 and Resident #11 was assisted off the floor and returned to bed by LPN #500 and CNAs #400 and #430. Another head to toe assessment was completed by the DON/designee on 02/10/26 and included thorough skin, wound, pain, and neurological assessments along with a check of Resident #11's range of motion (ROM). On 02/10/26 physician was notified by the DON/designee, and an order was obtained to send Resident #11 to the local emergency room for evaluation and treatment. On 02/10/26 the DON/designee notified the family of the incident and the plan to transfer Resident #11 to the emergency room for evaluation. On 02/10/26 fall risk assessment was completed for Resident #11 by the DON/designee. On 02/10/26 all residents with an order for a low air loss mattress was checked to ensure appropriate for use and replace with a regular pressure reduction mattress as appropriate by DON/designee.On 02/10/26 all residents with a low air loss mattress were audited to ensure the care plan and Kardex adequately reflected two person assistance being required for bed mobility by DON/designee.On 02/10/26 the facility identified that all residents that utilize a low air loss mattress are at risk.On 02/10/26 all nurses were educated on ensuring residents are appropriate to use LAL mattress by DON/designee.On 02/10/26 all nursing staff were educated on the use of two assistance for bed mobility for anyone who utilizes a LAL mattress by DON/designee.On 02/10/26 CNA #400 was administered a Teachable Moment related to the care provided to Resident #11 by utilizing only one staff member for bed mobility for the resident when two staff assistance was required by the nurse on duty. On 02/10/26 CNA #400 was administered progressive discipline following the fall investigation by way of phone by the Administrator and DON, however, CNA #400 refused to sign the discipline form.Ongoing audits began on 02/11/26 to audit two residents with low air loss mattresses three times per week for four weeks and then randomly thereafter by DON/designee.Ongoing audits began on 02/11/26 to audit two residents with low air loss mattresses and all newly ordered air mattresses to ensure the care plan and Kardex accurately reflect two person assistance for bed mobility three times a week for four weeks and randomly thereafter by DON/designee. Ongoing audits began on 02/11/26 to audit two residents with low air loss mattresses three times per week for four weeks to ensure bed mobility is completed with the assistance of two staff members.Results of the audits were presented to the Quality Assurance Performance Indicators (QAPI) on 03/31/26 to review the plan of correction; no changes or issues were noted.This deficiency represents non-compliance investigated under Master Complaint Number 2748389 and Complaint Number 2746217.

Based on observation, staff interview, record review, and review of the facility policies, the facility failed to ensure proper infection control practices were implemented related to COVID-19 droplet isolation and contact isolation. This affected four (#37, #28, #56 and #12) residents and had the potential to affect all 29 residents on the 300 and 400 halls (#1, #2, #3, #4, #7, #9, #10, #13, #16, #18, #20, #22, #26, #27, #30, #34, #36, #40, #41, #42, #44, #45, #46, #47, #48, #49, #51, #58, and #163). The facility census was 62. Findings include: 1. Review of the medical record for Resident #37 revealed an admitted [DATE] with diagnoses of vascular dementia and COVID-19 (initiated 01/13/25). Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had intact cognition. Review of a current physician order dated 01/13/25 revealed Resident #37 was in droplet isolation for COVID-19 with all services to be provided in the room. Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses of spinal cord cancer and chronic respiratory failure. Review of the quarterly MDS assessment dated [DATE] revealed Resident #28 had impaired cognition. Observation on 01/21/25 at 11:28 A.M. revealed signage posted outside Resident #37's room indicating he was in droplet precautions and staff should wear an N95 mask, a gown, and disposable gloves prior to entering the room. Additional signage revealed staff should remove all PPE before exiting the room, perform hand hygiene, and use a new N95 upon exiting the room. Observation on 01/21/25 at 11:30 A.M. revealed CNA #771 wearing an N95 mask and carrying a meal tray toward Resident #37's room. CNA #771 stopped outside the room and put on a disposable gown, did not put on gloves, and entered Resident #37's room. Continued observation from the open doorway revealed CNA #771 set the meal tray on Resident #37's overbed table, uncovered the plate, spoke with Resident #37, covered the plate and began to exit the room. CNA #771 removed the gown and disposed of it in a trash bag that was resting on the floor by holding the bag open with one ungloved hand and putting the soiled gown into the bag. CNA #771 exited Resident #37's room without removing or changing his N95 mask. CNA #771 did not perform hand hygiene before he observed Resident #28's call light was on and proceeded across the hall to provide care to Resident #28. Observation from the hall revealed CNA #771 rubbing Resident #28's legs and providing reassurance. CNA #771 then covered Resident #28 with a blanket and left the room. Interview on 01/21/25 at 11:34 A.M. with CNA #771 confirmed he did not wear gloves upon entering Resident #37's room with the meal tray and did not perform hand hygiene upon exiting the room before entering Resident #28's room. CNA #771 stated he was not aware he needed to wear gloves when providing meal trays. CNA #771 further confirmed he did not change his N95 mask upon exiting Resident #37's room and before entering Resident #28's room and providing care. CNA #771 was unaware Resident #37 was in droplet precautions for COVID-19. 2. Review of the medical record for Resident #56 revealed an admitted [DATE] with diagnoses of COVID-19 (01/20/25), and Alzheimer's dementia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #56 had severely impaired cognition and required supervision or touching assistance with eating. Review of the current physician order dated 01/20/25 revealed Resident #56 was in droplet isolation for COVID-19. Observation on 01/21/25 at 11:40 A.M. revealed a sign posted outside Resident #56's room indicating he was in droplet precautions and staff should wear an N95 mask, a gown, and disposable gloves prior to entering the room. Additional signage revealed staff should remove all PPE before exiting the room, perform hand hygiene, and use a new N95 upon exiting the room. Observation on 01/21/25 at 11:44 A.M. revealed CNA #771 entering Resident #56's room without donning PPE and pulling the curtain closed around Resident #56's bed. Observation and interview on 01/21/25 at approximately 11:45 A.M. with Licensed Practical Nurse (LPN) #664, who donned a disposable glove and pulled back the curtain around Resident #56's bed, revealed CNA #771 sitting next to Resident #56's bed wearing an N95 but no gloves or gown. CNA #771 was preparing to assist Resident #56 with eating his meal. LPN #664 directed CNA #771 to don a gown and gloves before continuing to assist Resident #56. 3. Review of the medical record for Resident #12 revealed an admitted [DATE] with diagnoses of type 2 diabetes mellitus, local infection of the skin and subcutaneous tissue, and morbid obesity. Review of the quarterly MDS assessment dated [DATE] revealed Resident #12 had intact cognition. Review of a the current physician order dated 11/27/24 revealed Resident #12 was on contact isolation for MRSA (methicillin-resistant Staphylococcus aureus). Review of nursing progress notes dated 11/19/24 through 01/22/25 revealed Resident #12 had a MRSA infection to his right lower extremity. Observation on 01/21/25 at 9:05 A.M. revealed a sign posted outside Resident #12's room stating he was in contact precautions. Further review of the sign revealed providers and staff must don gloves and gown before entry. Observation on 01/21/25 at 9:15 A.M. revealed Certified Nursing Assistant (CNA) #604 entering Resident #12's room without donning PPE. Observation on 01/21/25 at 9:16 A.M. from the open doorway of Resident #12's room, revealed CNA #604 standing next to Resident #12 wearing disposable gloves. CNA #604 was not wearing a disposable gown. Concurrent interview with CNA #604 confirmed she was not wearing a disposable gown and planned to assist Resident #12 to the toilet. CNA #604 stated she only was required to wear a disposable gown if she planned to come into contact with his legs. Interview on 01/21/25 at 9:24 A.M. with Unit Manager (UM) #700 revealed she planned to assist CNA #604 with Resident #12's care and confirmed CNA #604 should be wearing a disposable gown and gloves while providing any care to Resident #12 because he was in contact isolation. Interview on 01/21/25 at 5:40 P.M. with the Infection Preventionist, Registered Nurse (RN) #718, confirmed staff entering a resident's room with droplet precautions should wear a gown, gloves, and an N95. Further interview confirmed staff should remove all PPE prior to exiting the room, perform hand hygiene, and don a new N95 mask upon exit from the room. Continued interview with RN #718 confirmed staff should wear a gown and gloves prior to entering a resident's room in contact precautions, regardless of the type of care to be provided. Additionally, RN #718 confirmed Resident #12 was in contact precautions. Review of the staff schedule dated 01/21/25 revealed CNA #604 and CNA #771 were assigned to the 300 and 400 halls. Review of the undated policy, Infection Control Guidelines for All Nursing Procedures, revealed staff should use alcohol-based hand rub before and after direct contact with residents. Review of the policy, COVID-19 - Identification and Management of Ill Residents, revised May 2023, revealed staff entering the room of a resident diagnosed with COVID-19 shall wear an N95 mask, a gown, and gloves. Review of the policy, PPE - Using N95 Face Masks, dated 11/29/21, revealed staff should use a mask only once and discard it.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure fingernails were kept cleaned and trimmed on a dependent resident. This affected one resident (#2) of one resident reviewed for clean and trimmed nails. The facility census was 62. Findings include: Review of the medical record for Resident #2 revealed he was admitted on [DATE] with diagnoses of cerebral vascular accident (CVA - stroke) with left sided hemiplegia and hemiparesis (weakness and paralysis). Review of the annual Minimum Data Set (MDS) dated [DATE] for Resident #2 revealed he had moderate cognitive impairment and was dependent on staff for personal hygiene. Review of the care plan revised 01/25 for Resident #2 revealed the resident is care planned for self-care deficit due to CVA with left sided hemiplegia and was dependent on staff for personal hygiene. Review of the shower sheets dated 01/02/25 for Resident #2 revealed he had a bed bath per his preference and his fingernails were cleaned and trimmed. Further review of the shower sheets dated 01/09/25 and 01/16/25 for Resident #2 revealed he had his bed bath and his fingernails were cleaned but not trimmed. Review of the Certified Nursing Assistant (CNA) documentation for the past 30 days for Resident #2 revealed he did not have any rejection of care. Observation on 01/21/25 at 11:03 A.M. of Resident #2 revealed his fingernails were long and approximately one quarter to one half inch in length beyond the tip of his finger and under the nail was dirty with black and yellow caked under the nails especially under the right thumb nail. Observation on 01/22/25 at 9:05 A.M. of Resident #2 revealed his fingernails remained long and dirty. Interview on 01/22/25 at 11:07 A.M. with Certified Nurse Aide (CNA) #634 verified the long and dirty fingernails on Resident #2. Review of the facility policy titled, Care of Fingernails/Toenails, dated 10/10, revealed the purpose of the procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care includes daily cleaning and regular trimming.

Based on record review, observation, interview, and policy review, the facility failed to apply brace/splint per physician order. This affected one (#55) of one resident reviewed for position and mobility. The facility census was 62. Findings include: Review of the medical record for Resident #55 revealed an admitted [DATE] with diagnoses including but not limited to traumatic subdural hemorrhage with loss of consciousness, gastrostomy status, displaced fracture of second cervical vertebra, tracheostomy status, presence of other vascular implants and grafts, and anemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 had severe cognitive impairment and was dependent on staff for activities of daily living. Review of current physician orders revealed left lower extremity PRAFO brace on in the morning and off at bedtime, passive range of motion to upper and lower extremities, rolled up wash cloth in right and left hand, remove every six hours and check skin integrity. Review of care plan dated 01/09/25 revealed Resident #55 had an activities of daily living self-care performance deficit related to disease process. Interventions included left lower extremity brace, ensure resident has sock on prior to placing brace, put on in the morning and remove at bedtime and check skin integrity with application and removal. Review of the Treatment Administration Record (TAR) for January 2025 revealed wash cloth to right hand, wash cloth to left hand, and PRAFO boot were signed off as completed on 01/21/25 and 01/22/25. Observation on 01/21/25 at 1:52 P.M. of Resident #55 in bed revealed no splints or braces on at this time. Bilateral soft heel boots observed on resident. No wash cloths or splints observed in bilateral hands. Observation on 01/22/25 at 9:00 A.M. of Resident #55 in bed revealed bilateral soft heel protector boots in place. No splint or wash clothes in bilateral hands. No PRAFO boot on left lower extremity. Interview on 01/22/25 at 9:26 A.M. with Certified Nursing Assistant (CNA) #642 verified Resident #55 did not have on a splint or any wash clothes in either hand. CNA #642 stated the resident did not have any splints. CNA #642 stated the resident only had a boot that she wears at night and a belly band that she is aware of. CNA #642 pulled the boot from the chair under a pillow to show the surveyor and placed the boot back on the chair. Follow-up observation on 01/22/25 at 10:04 A.M. of Resident #55 revealed PRAFO boot now on left foot and wash rag observed in left hand. No wash cloth observed in the right hand. Further observation on 01/23/25 at 9:13 A.M. of Resident #55 revealed PRAFO boot on left foot, towel in left hand and nothing in right hand at this time. Review of policy titled, Rehabilitative/Functional Maintenance Nursing Care, not dated, revealed rehabilitative nursing care is performed daily for those residents who require such service. Such program includes, but is not limited to assisting residents to adjust to their disabilities, to use their prosthetic devices, and to redirect their interests and others as prescribed by the resident's attending physician.

Based on observation, record review, staff interview, and review of facility policy, the facility failed to ensure fall interventions were implemented. This affected two residents (#15 and #48) of two residents reviewed for falls. The facility census was 62. Findings include: 1. Review of Resident #15's medical record revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis, osteoarthritis, cerebral infarction, and convulsions. Review of Resident #15's Minimum Data Set (MDS) 12/27/24 revealed a Brief Interview for Mental Status (BIMS) score of 10 indicting Resident #15 was moderately cognitively impaired. Resident #15 was dependent on staff for toilet use, parts of dressing, bed mobility, and transfer. Resident #15 required maximal assistance with bathing. Resident #15 displayed verbal behavioral symptoms directed towards others one to three days during the review period. Review of Resident #15's care plan revised 12/27/24 revealed supports and interventions in place for risk for falls. Fall interventions included providing safe environment including personal items in reach, two assist with transfer, nonskid strips applied by bed, in-front of the recliner, and next to the recliner, call light in reach, Dycem on wheelchair, encourage hipsters and nonskid socks. Additionally, on 03/03/16 an intervention was noted for Resident #15's bed to be in the lowest position and the wheels locked. Observation on 01/21/25 at 9:41 A.M. found Resident #15 lying in bed with her head and her right arm partially hanging over the side of the bed. Resident #15's bed was not in a low position and skid strips were not observed to be in front or on the floor to the right side of the recliner. Observation on 01/22/25 at 9:03 A.M. of Resident #15 found her lying in bed with her head and right arm hanging over the right side of the bed. Resident #15's bed was not in a low position and skid strips were not observed to be in front or on the floor to the right side of the recliner. Interview on 01/22/25 at 9:15 A.M. with Certified Nursing Assistant (CNA) #668 reported Resident #15 was at risk for falls and one of her interventions was to be in a low bed. An observation of Resident #15 was made with CNA #668 and CNA #668 verified Resident #15's bed was not in the lowest position. CNA #668 was observed asking Resident #15 if she would allow her to adjust her in the bed and Resident #15 declined. CNA #668 then proceeded to lower Resident #15's bed to the lowest position. Interview on 01/22/25 at 11:53 A.M. with CNA #772 verified there were no skid strips next to or in front of the recliner. Follow up observation and interview on 01/22/25 at 1:35 P.M. with Assistant Director of Nursing (ADON) #718 found clear nonskid strips had been applied to the floor next to Resident #15's bed and verified there were none in front of or next to the recliner. ADON #718 reported Resident #15's room had been rearranged when a bed was added. 47057 2. Review of the medical record for Resident #48 revealed she was admitted on [DATE] with diagnoses of history of falling and dementia. Review of the annual MDS dated [DATE] for Resident #48 revealed she was cognitively impaired and has had falls since her admission. Review of the care plan revised 10/24 for Resident #48 revealed she was at risk for falls and had the following interventions: touch pad call light, non-skid strips applied to the end of the roommate's bed and non-skid strips applied to the left side of the bed. Observation on 01/22/25 at 11:15 A.M. of Resident #48's room revealed the call light was a regular push button type call light and not a touch pad style call light, there were no non-skid strips at the foot of the roommate's bed or to the left side of Resident #48's bed. Interview on 01/22/25 at 11:19 A.M. with Licensed Practical Nurse (LPN) #770 verified the call light for Resident #48 was a regular push button type of call light and not a touch pad type of call light, and there were not any non-skid strips to either the foot of the roommate's bed or to the left side of the bed for Resident #48. LPN #770 further stated Resident #48 had recently changed rooms. Observation of the previously occupied room for Resident #48 revealed there were no non-skid strips to the floor in the old room. Review of the facility policy titled, Managing Falls and Fall Risk, revised December 2007, revealed based on evaluations and current data the staff would identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling.

Based on observation, medical record review, staff interview, resident interview, and review of facility policy, the facility failed to ensure medications were stored in a proper manner. This affected two (Residents #22 and #16) of two residents observed for medication storage. The facility census was 62. 1. Review of the medical record for Resident #22 revealed an admitted [DATE] and a readmitted [DATE] with diagnoses of chronic obstructive pulmonary disease and dementia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #22 had impaired cognition. Review of the Self-Medication Assessment, completed 12/04/24, revealed Resident #22 was unable to self-administer medications. Observation on 01/21/25 at 9:20 A.M. revealed a bottle of aspirin, dose 325 milligrams (mg), lying on top of Resident #22's bedside cabinet. Resident #22 was not in the room during the observation. Interview and observation on 01/21/25 at 9:24 A.M. with Unit Manager (UM) #700 confirmed bottle of 325 mg aspirin was on Resident #22's bedside cabinet. UM #700 stated Resident #22 was not able to self-administer medications and removed the bottle of aspirin from Resident #22's room. Interview on 01/23/25 at 7:36 A.M. with Resident #22 revealed she purchased the aspirin at a local store. Resident #22 stated she was aware she was not allowed to have medication in her room. Resident #22 stated she planned to crush up the aspirin and apply it to her face to help with acne. Interview on 01/23/25 at 11:14 A.M. with UM #700 revealed Resident #22's bottle of aspirin was unopened, and was labeled and stored in the medication room. UM #700 stated she spoke with Resident #22 who wished to use the aspirin as a skin treatment for acne. UM #700 stated she had not yet spoken with the physician regarding Resident #22's request to use aspirin for a skin treatment. Review of the policy titled Administering Medications, revised 04/19, revealed medications are administered in a safe manner. Review of the policy titled Storage of Medications, revised 04/19, revealed the facility stores all drugs and biological's in a safe, secure, and orderly manner. 47057 2. Review of the medical record Resident #16 revealed she was admitted on [DATE] with diagnoses of ovarian and breast cancer. Review of the quarterly MDS dated [DATE] for Resident #16 revealed she had mild cognitive impairment. Review of the Self-Medication assessment dated [DATE] for Resident #16 revealed she is not able to self-administer medication. Observation on 01/21/25 at 9:37 A.M. of Resident #16 revealed she was sitting on her bed and her overbed table was in front of her, on the overbed table was a medication cup containing four unidentified medications, one round red pill, one white oblong pill, and two small round white pills. Interview on 01/21/25 at 9:43 A.M. with Registered Nurse (RN) #648 verified the medication cup was left unattended at the bedside with four unidentified pills in the medication cup. RN #648 further stated Resident #16 stated she didn't want to take them all and so she left them for her to take and she would check back to make sure she took the medication.

Based on observation, medical record review, and staff interview, the facility failed to obtain blood glucose levels as ordered. This affected one (#11) of three residents observed during medication administration. The facility census was 59. Findings include: Observation on 10/01/24 at 10:51 A.M. noted Licensed Practical Nurse (LPN) #300 obtained Resident #11's medications from the medication cart. Medications included the administration of Novolog insulin determined by sliding scale blood glucose levels. At the time of the observation, LPN #300 stated she was unable to locate Resident #11 when the resident's insulin coverage was due at 7:00 A.M. and confirmed the 7:00 A.M. blood glucose lever was not obtained at that time. LPN #300 proceeded to Resident #11's room and obtained a blood sugar reading of 204 milligrams per deciliter (mg/dL). LPN #300 returned to the medication cart and obtained four (4) units of insulin via syringe, returned to the resident's room, and injected the dose of insulin into the resident. Review of Resident #11's medical record noted a physician order dated 09/24/24 for the administration of Novolog insulin via sliding scale as follows: for blood glucose levels between 150 mg/dL and 199 mg/dL, give two units; between 200 mg/dL and 249 mg/dL, give 4 units; between 250 mg/dL and 299 mg/dL, give six units; between 300 mg/dL and 349 mg/dL, give eight units; and between 350 mg/dL and 399 mg/dL, give 10 units subcutaneously (SQ) before meals and at bedtime related to type II diabetes mellitus with hyperglycemia. The physician prescribed administration times were set for 7:00 A.M., 11:00 A.M., 4:30 P.M., and 8:00 P.M. Review of Resident #11's October 2024 medication administration record revealed no documented blood glucose level was obtained on 10/01/24 at 7:00 A.M. On 10/01/24 at 11:00 A.M. interview with LPN #300 verified Resident #11's blood glucose level was not obtained as ordered at 7:00 A.M. and was not obtained until the next scheduled time. This deficiency represents an incidental finding discovered during the complaint investigation.

Based on observation, medical record review, and staff interview, the facility failed to maintain resident indwelling urinary catheters in an effective and sanitary manner. This affected one (#3) of one residents reviewed for urinary catheter care and function. The facility census was 59. Findings include: Review of the medical record for Resident #3 revealed the resident was admitted to the facility on [DATE] with the diagnoses including type II diabetes mellitus, neuropathy, xerosis cutis, neurofunction dysfunction of bladder, urinary retention, morbid obesity, acquired buried penis, chronic respiratory failure, chronic obstructive pulmonary disease, erythema intertrigo, congestive heart failure, hypertension, lymphedema, adult failure to thrive, and major depression. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #3 with intact cognition, was dependent on staff for the provision of activities of daily living, utilized a indwelling urinary catheter, was incontinent of bowel, experienced hallucinations and delusions, had no behaviors regarding refusal of care, and was at risk for pressure ulcer development with no skin breakdown. Review of Resident #3's medical record revealed on 11/06/23 the physician ordered the placement of an indwelling (Foley) urinary catheter 16 French (Fr) with a 10 cubic centimeter (cc) balloon. In addition, and order was given for catheter care to be completed every shift on day and night shift. On 11/10/23 the facility physician ordered the resident to have the Foley catheter changed monthly as indicated by the resident's urologist. On 02/25/24 a physician order was acquired for the Foley catheter change every month to be completed by the Director of Nursing (DON) on day shift every month starting on the 25th. There was no documentation contained in the medical record indicating the urologist was informed of the resident's Foley catheter function. Review of a nursing plan of care dated 11/06/23 revealed the care plan was initiated to address Resident #3's risk for bladder incontinence related to urinary retention, neuromuscular dysfunction of bladder, acute renal failure, acquired buried penis, and admitted with urinary tract infection (UTI) from a catheter. On 08/06/24 the plan of care was revised with interventions to provide catheter care as ordered; clean the peri-area with each incontinence episode; monitor/document for signs and symptoms of UTI including pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns; monitor, document, and report as needed any possible causes of incontinence including bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, medication side effects; and urology/DON to change the catheter monthly. Review of the treatment administration record (TAR) noted Resident #3's Foley catheter was changed on 08/25/24. On 09/25/24 an entry on the TAR indicated a progress note was placed into the medical record regarding the changing of the Foley catheter. Review of the medical record was silent to an entry or evidence the Foley catheter was changed in September 2024. Review of the nurses notes on 08/08/24 at 11:00 P.M. revealed Resident #3 was started on the antibiotic Bactrim double strength (DS) for UTI. On 09/18/24 at 6:07 P.M. Resident #3's bedding visibly soiled and there was concern that the catheter may not be draining as it should after seeing soiling to bed. Resident #3 refused to allow the bedding to be changed, and refused to allow an assessment of catheter. The physician was provided with an update and no new orders were obtained. On 10/01/24 at 4:03 P.M. Resident #3 was seen by the physician and received new orders for treatment of cellulitis due to redness, warmth, and drainage noted to the left side of the abdomen. No interventions to address the leaking catheter were initiated. On 10/02/24 at 8:00 P.M. Resident #3's linens were soiled with drainage and the resident refused to allow staff to change linens which was attempted several times. No documentation indicating the physician was notified of the leaking Foley catheter. On 10/03/24 at 6:25 A.M. interview with State tested Nurse Aide (STNA) #400 revealed she assumed Resident #3's care at 6:00 P.M. the previous night with the shift ending at 6:00 A.M. on 10/03/24. STNA #400 stated Resident #3 required catheter care during the shift and refused. The resident had soiled the bed with a leaking indwelling urinary catheter and would not allow the bed linen or catheter care to be provided the entire shift. STNA #400 stated the urinary catheter had been leaking for an undetermined amount of time and the resident refused care. STNA #400 reported the resident condition and refusal to Licensed Practical Nurse (LPN) #301. Observation on 10/03/24 at 6:35 A.M. discovered Resident #3 in bed soiled with a yellowish-brown stain under the right leg leading to the foot of the bed. Interview with Resident #3 at that time stated refusal of staff to change the linens due to leaking of catheter occurring frequently for an undetermined time and did not want to be bothered during the night. Resident #3 stated the DON changed the catheter yesterday and was still having drainage. On 10/03/24 at 6:42 A.M. interview with LPN #301 confirmed assuming Resident #3's care on 10/02/24 at 7:00 P.M. until 10/03/24 at 7:00 A.M. LPN #301 stated staff made attempts during the night to change the resident's bed linen and he refused to be disturbed. LPN #301 confirmed the indwelling urinary catheter has been leaking for an undetermined amount of time. Interview with LPN Unit Manager #302 on 10/03/24 at 7:40 A.M. confirmed ongoing concerns with Resident #3's indwelling urinary catheter and verified Resident #3 was heavily soiled in bed with urine draining under him. On 10/03/24 at 7:50 A.M. interview with the DON revealed Resident #3's indwelling catheter was changed on 10/01/24 and confirmed the catheter was still leaking. Due to the resident's anatomical condition the placement of the catheter was difficult. Further interview with the DON during review of the medical record confirmed no current documentation related to Resident #3's catheter being changed on 10/01/24. Additional interview verified no additional interventions had been implemented to address the leaking catheter other than attempting to change the catheter. The DON also verified no documentation indicated the catheter was changed as ordered during the month of September 2024 and the TAR on 09/25/24 indicated a progress note was placed into the record and the medical record was silent to an entry on 09/25/24. The DON confirmed no attempts to contact the urologist have occurred since the resident was admitted to the facility. This deficiency represents non-compliance investigated under Complaint Number OH00157794.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure medications were administered as ordered by the physician, and within prescribed time frames, resulting in a medication error rate above five (5) percent (%). This affected two (#9 and #10) of three residents observed during medication administration. A total of two medications errors were observed out of 29 opportunities for a medication administration error rate of 6.9%. The facility census was 59. Findings include: 1. Observation on 10/01/24 at 10:13 A.M. noted Licensed Practical Nurse (LPN) #300 preparing Resident #9's medications for administration. At 10:22 A.M., LPN #300 proceeded into Resident #9's room and provided the resident's medications contained inside a medication cup. One medication included the antidepressant Cymbalta 30 milligram tablet. Resident #9 consumed the medications and LPN #300 exited the room. Review of Resident #9's medical record revealed a physician order dated 07/17/24 for the administration of Cymbalta oral capsule delayed release particles 30 mg by mouth every morning and at bedtime for depression related to major depressive disorder. The physician prescribed administration times were designated for 7:00 A.M. and 8:00 P.M. and listed on the 10/01/24 medication administration record (MAR). 2. On 10/01/24 at 10:24 P.M. LPN #300 obtained Resident #10's medications from the medication cart. The medications included budesonide-formoterol fumarate inhalation aerosol 160-4.5 micrograms per actuation (mcg/act). At 10:36 A.M., LPN #300 proceeded into Resident #10's room and the resident took two inhalations (puffs) from the inhaler. LPN #300 then exited the resident room. Review of the medical record discovered a physician order for the administration of budesonide-formoterol fumarate inhalation aerosol 160-4.5 mcg/act two puffs inhaled orally two times a day related to pulmonary fibrosis and chronic obstructive pulmonary disease (COPD). The physician prescribed administration times were documented as 8:00 A.M. and 8:00 P.M. and indicated on the 10/01/24 MAR. On 10/01/24 at 11:00 A.M. interview with LPN #300 verified Resident #9's Cymbalta and Resident #10's budesonide-formoterol fumarate inhaled medication were not administered within prescribed times. Review of facility administering medications policy, revised April 2019, revealed medications including insulin and any oral or subcutaneous hypoglycemic, are administered in accordance with prescriber orders, including any required time frame and medications are administered within one hour of their prescribed time, unless otherwise specified. This deficiency represents an incidental finding discovered during the complaint investigation.

Based on observation and staff interview the facility failed to maintain resident common showers in a sanitary manner. This affected all 27 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #24, #24, #25, #26, #27) residing on the 100 and 200 halls. The facility census was 61. Findings include: Observation 09/10/24 at 9:48 A.M. with Environmental Services Director (ESD) #1 revealed the front 200-A common shower room had a black substance clinging to the ceiling and the corner of the wall above the shower stall. A black and orange colored substance and residue was observed on the shower stall baseboard. Continued observation on 09/10/24 at 9:50 A.M. of the 200-B common shower with ESD #1 revealed an orange and black substance clinging to the baseboard of the common shower stall. Interview on 09/10/24 at 9:51 A.M. with ESD #1 verified the above findings. ESD #1 stated he was unaware of the black and orange substances located in the 200-A and 200-B common shower rooms. Interview on 09/10/24 at 10:03 A.M. with State tested Nurse Aide (STNA) #300 and STNA #301 verified residents residing on the 100 and 200 halls used the front common showers known as 200-A and 200-B. A follow-up interview on 09/10/24 at 2:52 P.M. with ESD #1 revealed during evaluation of the two shower rooms, it was discovered the exhaust fans were not operable and may have contributed to the increased moisture in the shower rooms. This deficiency represents non-compliance investigated under Complaint Number OH00156623.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure pressure ulcer treatments were completed in accordance with physician orders. This affected one (#1) of three residents reviewed for wound care. The facility census was 61. Findings include: Review of Resident #1's medical record revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, intellectual disabilities, stage III pressure ulcer to the upper right back, localized swelling mass and lump to trunk, cerebral infarction affecting right side with hemiplegia and hemiparesis, hypertension, scoliosis, chronic pain syndrome, neuromuscular dysfunction of the bladder, severe protein calorie malnutrition and muscle wasting and atrophy. Review of the Minimum Data Set (MDS) assessment, dated 08/04/24, revealed Resident #1 was moderately cognitively impaired, had bilateral range of motion impairment to the upper and lower extremities, was dependent on staff for the completion of activities of daily living (ADLs), required substantial to maximal assistance with bed mobility, utilized an indwelling urinary catheter, was incontinent of bowel, was at risk for pressure ulcer development and admitted with a stage IV pressure ulcer. Review of the plan of care, revised on 07/15/24, revealed Resident #1 had a pressure ulcer to the right flank area. Interventions included to administer treatments as ordered and monitor for effectiveness and to follow facility policies/protocols for the prevention/treatment of skin breakdown. Review of wound specialist certified nurse practitioner (WSCNP) wound assessment report, dated 08/26/24, revealed a right flank stage IV pressure ulcer wound was present upon admission on 04/30/24. Wound descriptions included measurements with length 10.50 centimeters (cm) by (x) width 6.20 cm x depth 0.60 cm with a moderate amount of serosanguineous, tan/green drainage. Review of a physician order, dated 08/30/24, revealed an order to cleanse the right posterior chest wall and back pressure ulcer with normal saline (NS), pat dry, apply adaptic (non-adhering dressing) over the bone, pack wound with Calcium Alginate and cover with foam dressing every three days and as needed (PRN) if soiled or saturated. Review of a WSCNP wound assessment, dated 09/09/24, revealed Resident #1's right flank stage IV pressure ulcer wound as stable, measuring 10.50 cm long x 4.00 cm wide x 0.40 cm deep with a moderate amount of serosanguineous, tan/ green drainage. Observation on 09/10/24 at 12:35 P.M. revealed State tested Nurse Aide (STNA) #600 in Resident #1's room, attempting to reposition the resident. Continued observation revealed Resident #1 had an undated abdominal (ABD)gauze dressing applied to the right back. The dressing was saturated with drainage, which was draining onto the bed linen. A large area of green and tan drainage was noted on the linen. Concurrent interview with STNA #600 verified the findings. Observation on 09/10/24 at 12:48 P.M. with Registered Nurse (RN) #400 and RN #401 revealed Resident #1 was positioned in bed to the left side. The resident's right back dressing was exposed and noted to be draining a copious amount of drainage through the ABD dressing. RN #400 proceeded to remove the dressing, cleanse the wound with NS and pat dry. RN #400 then applied adaptic over the bone, packed wound with Calcium Alginate and covered with a foam dressing with initials and date applied on the dressing surface. Concurrent interview with RN #400 and RN #401 confirmed the dressing was saturated with a tan and green drainage, which drained onto the resident's bed linen. Further interview with RN #401 revealed Resident #1's wound was evaluated by the WSCNP on 09/09/24 and the dressing was applied at that time. RN #401 confirmed the dressing order was to change every three days and PRN and the resident's bed was heavily soiled with a tan/green drainage from the wound. RN #401 further verified the dressing removed from Resident #1's wound did not include a foam border dressing as indicated in physician orders and no attempts were made to change the saturated ABD dressing before the drainage penetrated the ABD and caused drainage to saturate the residents bed linen. Review of the facility policy titled Wound Care, revised October 2010, revealed to verify there is a physician order for the procedure, wound procedure/treatments shall be completed per physician order and, when applying dressing, place tape with initials, time and date onto the dressing. This deficiency represents non-compliance investigated under Master Complaint Number OH00157138.

Based on observation, medical record review and staff interview, the facility failed to ensure resident nutritional supplements were administered and monitored in accordance with physician orders. This affected one (#1) of three residents reviewed for nutritional support interventions. The facility census was 61. Findings include: Review of Resident #1's medical record revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, intellectual disabilities, stage III pressure ulcer to the upper right back, localized swelling mass and lump to trunk, cerebral infarction affecting right side with hemiplegia and hemiparesis, hypertension, scoliosis, chronic pain syndrome, neuromuscular dysfunction of bladder, severe protein calorie malnutrition and muscle wasting and atrophy. Review of the Minimum Data Set (MDS) assessment, dated 08/04/24, revealed Resident #1 was moderately cognitively impaired, had bilateral range of motion impairment to upper and lower extremities, was dependent on staff for the completion of activities of daily living (ADLs), required substantial to maximal assistance with bed mobility, utilized an indwelling urinary catheter, was incontinent of bowel, had no identified weight loss, received a mechanically altered diet, was at risk for pressure ulcer development and admitted with a stage 4 pressure ulcer. Review of the dietitian nutrition/hydration status documentation, dated 08/01/24, revealed Resident #1 weighed 111.4 pounds (lbs), with no planned weight loss. Further review revealed current supplement orders included fortified pudding once daily, Thrive (nutritional supplement) with meals and Proheal (protein supplement) three times daily. Resident #1's supplement intake was between 75-100% and increased nutritional demands was evidenced by wounds and protein-calorie malnutrition. Additional comments included to honor resident food and beverage preferences. Review of current physician orders revealed on 08/05/24, a physician order was implemented for the nutritional supplement Boost Breeze to be given three times a day for oral intake/nutritional status. Instructions included to record the amount consumed. Review of the medication administration records (MAR) from August 2024 and September 2024 revealed the physician order dated 08/05/24 to administer Boost Breeze three times a day for oral intake/nutritional status and in all capital letters to RECORD AMOUNT CONSUMED. Further review of the MAR revealed staff initials for the administration of Boost Breeze; however, the MAR did not include documentation of the amount consumed. Observation on 09/10/24 at 12:01 P.M. of the lunch meal revealed Resident #1 was provided with his lunch meal and received assistance with eating from State tested Nurse Aide (STNA) #600. No Boost Breeze supplement was observed with the resident's meal. A vanilla flavored Thrive was on the meal tray. Continued observation revealed Resident #1 finished the lunch meal. The Thrive container remained unopened and no Boost Breeze supplement was provided. Further observation on 09/11/24 at 8:20 A.M. of the breakfast meal revealed Resident #1 was served hot cereal (oatmeal) and a container of vanilla Thrive, which was opened but none consumed. No Boost Breeze was provided. Concurrent interview with Registered Nurse (RN) #400 verified Resident #1 did not receive the fortified beverage (Boost Breeze) during breakfast and she had not observed Boost Breeze provided to Resident #1 during the lunch meal on 09/10/24. RN #400 stated dietary provided supplements and Resident #1 preferred to consume the chocolate Boost Breeze. Interview on 09/11/24 at 8:24 A.M. with Dietary Manager (DM) #2 and [NAME] #500, during a review of Resident #1's diet/tray card, revealed Boost Breeze was not listed on the card. DM #2 verified Resident #1 was not being provided with a Boost supplement during meals. Interview on 09/11/24 at 8:30 A.M. with RN #401 verified Resident #1 had a physician order for Boost Breeze to be provided three times daily and to document the amount consumed. RN #401 confirmed there was no documentation of how much Resident #1 consumed of the the supplement. Interview on 09/11/24 at 8:45 A.M. with STNA #600 verified Resident #1 was not provided with the Boost Breeze supplement during the breakfast and lunch meal on 09/10/24 or during the breakfast meal on 09/11/24. STNA #600 stated Resident #1 preferred chocolate beverages and reported to the nurse the resident was not consuming the vanilla Thrive; however, no action was taken and no additional supplement was provided by the nurse. Interview on 09/11/24 at 10:35 A.M. with the Director of Nursing (DON) and Diet Technician (DT) #4 revealed Resident #1 was last evaluated by the dietitian on 08/01/24 due to weight loss. DT #4 confirmed staff were not documenting the percent of supplements taken as ordered for further monitoring and assessment of Resident #1's weights. This deficiency represents non-compliance investigated under Master Complaint Number OH00157138.

Based on observation, medical record review, and staff interview, the facility failed to ensure clean bed linens were provided to the residents. This affected one (#4) of three residents reviewed for clean and sanitary bed linens. The facility census was 61. Findings include: Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), peripheral vascular disease, contracture left and right knee, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had moderate cognitive impairment, dependent on staff with activities of daily living, continent of bladder, and incontinent of bowel. Review of the nursing plan of care dated 09/07/23 revealed Resident #4 had an activity of daily living self care performance deficit related to impaired cognition, weakness, and pain. Interventions included toileting assistance with perineal hygiene, required substantial/maximal assistance with hygiene, and bathing/showering. Observation and interview on 12/27/23 at 8:37 A.M. revealed Resident #4 was in bed. Interview with State tested Nurse Aide (STNA) #200 at the time revealed Resident #4 was last checked and repositioned at the beginning of the shift at approximately 6:00 A.M. During the observation, STNA #200 provided Resident #4 with a bed bath and discovered the resident's bed linen to be soiled with dried urine. The stain soaked through a folded bath blanket onto the fitted sheet under the resident. The top sheet was also discovered with dried urine stains. STNA #200 indicated she was unaware of the stains until the 8:37 A.M. bed check. This deficiency represents non-compliance investigated under Complaint Number OH00149103.

Based on observation, medical record review, staff interview, and review of the facility protocol, the facility failed to ensure wound treatments were administered in accordance with physician orders. This affected one (#4) of four residents reviewed for skin integrity. The facility census was 61. Findings include: Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, peripheral vascular disease, contracture left and right knee, malnutrition, and chronic pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had moderate cognitive impairment, dependent on staff with activities of daily living, and had a skin tear. Review of the nursing plan of care dated 09/11/23 revealed Resident #4 was at risk of developing complications to skin integrity related to right knee inflammation and skin tear. Intervention included to follow facility protocols for treatment of injury. Review of the physician orders dated 12/19/23 revealed an order for a dressing application to Resident #4's right anterior knee. The treatment included cleansing with normal saline and pat dry. Apply adapt then silver alginate. Cover with ABD (abdominal dressing) and rolled gauze to be completed every day shift. Observation on 12/27/23 at 8:37 A.M. with State tested Nurse Aide (STNA) #200 noted Resident #4 was in bed with a roll gauze dressing dislodged and around Resident #4's right ankle. The dressing was dated 12/24/23. Covering the resident's right anterior knee was an ABD. STNA #200 confirmed the dressing was dated 12/24/23. STNA #200 proceeded to cut the roll gauze dressing off, leaving the ABD in place. On 12/27/23 at 9:55 A.M., Registered Nurse (RN) #300 was observed to obtain dressing supplies and proceed to Resident #4's room. RN #300 attempted to remove the ABD from Resident #4's wound and the dressing was observed to cling to the wound. RN #300 proceeded to place normal saline to the soiled wound and the dressing became dislodged. RN #300 proceeded to cleanse the wound and obtained a measurement of 3.0 centimeters (cm) long by 3.5 cm wide. RN #300 then applied the dressing as ordered and placed the date on the dressing (12/27/23). Interview with RN #300 confirmed the dressing was dated 12/24/23 and confirmed the physician orders were for the dressing to be to be changed daily. No documentation contained in the medical record indicated Resident #4 refused the dressing change the previous days. Review of the facility's pressure ulcer and skin breakdown clinical protocol revealed the physician will authorize pertinent orders related to wound treatments, including wound cleansing, debridement approaches, dressings, and application of topical agents if indicated for type of skin alteration. This deficiency represents non-compliance investigated under Complaint Number OH00149103.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure provide an assessment, including measurements and staging, of a pressure ulcer identified upon admission, and failed to initiate treatments timely when pressure ulcers were identified. This affected one (#63) of three residents reviewed for pressure ulcers. The facility census was 61. Findings include: Review of the medical record revealed Resident #63 had an admitted [DATE] and a discharge date of [DATE]. Diagnoses included cellulitis of right and left upper limbs, depressive disorder, lymphedema, chronic obstructive pulmonary disease, chronic pain, morbid obesity, generalized anxiety disorder, hypertension, and stage three chronic kidney disease. Diagnoses added on 09/08/23 included an unstageable pressure ulcer to the right buttock, an unstageable pressure ulcer to the left buttock, a stage three pressure ulcer of other site, and a pressure-induced deep tissue damage of other site. Review of hospital documentation dated 08/28/23 and 08/29/23 revealed the resident's skin was red and excoriated with sloughing of skin noted to the right buttocks area. The resident was treated with triad paste (skin protectant) twice a day and as needed. The resident was also noted with lymphedema to the bilateral lower extremities with chronic recurrent venous leg ulcers. The resident was also noted with cellulitis of the lower back and buttocks region as well as the middle thigh region. There was no documentation of pressure ulcers to the bilateral buttocks or posterior thighs. Review of the admission physician orders, dated 09/01/23, revealed the resident had orders to apply triad paste to the bilateral posterior thighs with each incontinence episode every day and night shift and an order to apply triad paste to the bilateral buttocks with each incontinent episode every night shift for wound care. Review of the admission skin assessment, dated 09/01/23, revealed the resident's skin was normal, warm, and dry. The resident had a pressure ulcer to the coccyx and a skin tear to the right buttock. There was no documentation the pressure ulcer had been assessed, measured or staged at the time of the assessment. No other wounds were documented. Review of the physician orders revealed no new orders for treatment of the pressure ulcer on the coccyx. Review of the plan of care, initiated on 09/01/23, revealed the resident was at increased risk for pressure ulcer development related to the disease process, decreased mobility, and moisture exposure due to lymphedema. Interventions included to administer treatments as ordered and monitor for effectiveness, encourage small frequent position changes, float heels while in bed, follow facility policies/protocols for prevention/treatment of skin breakdown, monitor nutritional status and obtain/monitor/report laboratory/diagnostic work as ordered, a pressure reduction cushion to wheelchair at all times, and a pressure reducing mattress to bed. Review of the treatment administration record (TAR) from 09/01/23 through 09/08/23 revealed the triad paste treatments were completed as ordered to the bilateral posterior thighs and the bilateral buttocks until discontinued on 09/08/23. There was no documentation of treatment or assessment for the coccyx pressure ulcer. Review of Nurse Practitioner's (NP) #300's wound assessment dated [DATE] revealed the resident had a stage three pressure ulcer to the posterior distal right thigh. The wound measured 2.7 centimeters (cm) in length, 1.2 cm in width, with a depth of 0.20 cm with exposed subcutaneous tissue. The wound had 100% granulation tissue, with intact surrounding skin, moderate serosanguineous exudate and no odor. A treatment was ordered to cleanse wound with wound cleanser, calcium alginate and hydrocolloid, change three times per week. The resident also had a deep tissue injury to the right proximal posterior thigh measuring 4.5 cm length by 4.5 cm in width and zero depth with 100% epithelial tissue, attached wound edges, no exudate and no odor. A treatment was ordered to cleanse with wound cleanser, zinc oxide paste twice a day and leave open to air. The resident had an unstageable pressure ulcer to the right buttock measuring 1 cm in length by 2 cm in width by 0.20 cm depth with 1-24% granulation tissue and 75% to 99% slough, no eschar, exposed subcutaneous tissue, unattached wound edges, intact surrounding skin and moderate serosanguineous drainage with no odor. A treatment was ordered to cleanse with wound cleanser, calcium alginate and hydrocolloid three times per week. The resident also had an unstageable pressure ulcer to the left buttock measuring 0.7 cm in length by 1 cm in width by 0.10 cm in depth. The wound had exposed subcutaneous tissue, unattached wound edges, moderate serosanguineous drainage with no odor and the surrounding skin was intact. A treatment was ordered to cleanse with wound cleanser, treat with calcium alginate and hydrocolloid three times per week. There was no evidence these orders were written on the date of the assessment. Review of a physician order dated 09/08/23 at 7:00 P.M. revealed to cleanse the right posterior thigh-proximal with normal saline, pat dry, apply zinc oxide paste twice a day and as needed every day and night shift. An order to cleanse with normal saline, pat dry, apply zinc oxide paste twice daily and as needed was also initiated and completed but there was no documentation where the treatment was to be applied. Review of the TAR revealed the treatment was completed once on 09/08/23 and twice daily from 09/09/23 through 09/15/23. Review of physician order dated 09/09/23 revealed to cleanse the right and left buttock with normal saline, pat dry, apply calcium alginate and cover with hydrocolloid, change three times per week and as needed on Tuesdays, Thursdays and Saturdays. Also orders to cleanse the right posterior distal thigh with normal saline, pat dry, apply calcium alginate and cover with hydrocolloid change three times per week and as needed on Tuesdays, Thursdays and Saturdays. Review of the TAR revealed the treatments were completed on 09/09/23, 09/12/23 and 09/14/23. Interview on 10/12/23 at 11:35 A.M. the Director of Nursing (DON) verified upon admission a complete wound assessment including wound measurements and wound staging was not completed for the resident. The DON verified there were no physician orders for wound treatments for the pressure ulcer to the coccyx other than triad paste cream to the bilateral buttocks and thighs initiated upon admission. Further interview with the DON revealed WNP #300 saw the resident on 09/07/23, however no orders for wound treatments were received until 09/08/23. The DON verified the wound to right posterior thigh pressure ulcer was not treated until after 7:00 P.M. on 09/08/23. The DON revealed the treatments for the pressures ulcers on the left and right buttocks and right distal thigh were not initiated until first shift on 09/09/23. Review of the facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised 03/2014, revealed the nurse would describe, document and report a full assessment of pressure sore including location, stage, length, width, depth and presence of exudate or necrotic tissue, pain assessment, resident's mobility status, current treatments, including support surfaces; and all active diagnoses. This deficiency represents non-compliance investigated under Complaint Number OH00146689.

Based on staff interview, record review, review of the fall investigations, review of the neurological assessments, and review of the facility policy, the facility failed to ensure neurological checks were completed for residents after a fall. This affected two (#12 and #61) of three residents reviewed for falls. The facility census was 57. Findings include: 1. Review of the medical record for Resident #12 revealed an admitted [DATE] with a diagnosis of repeated falls. Review of the fall investigations with the Director of Nursing (DON) and MDS Coordinator #503 on 06/07/23 at 3:43 P.M. and on 06/08/23 at 9:35 A.M. revealed Resident #12 had an unwitnessed falls on 03/27/23 and neurological checks were not completed. Interview at the time of the review on 06/07/23 at 3:43 P.M. and on 06/08/23 at 9:35 A.M. verified the findings. 2. Review of the medical record for Resident #61 revealed a readmitted [DATE] with diagnoses of Parkinson's disease, urgency of urination, repeated falls, and dementia. Review of the fall investigations during an interview on 06/08/23 at 9:35 A.M. with the DON and MDS Coordinator #503 revealed Resident #61 had falls on 03/04/23, 03/05/23, 03/07/23, 03/25/23, 04/05/23, 04/25/23, and 05/22/23. Review of the neurological checks for Resident #61 revealed the forms were not completed for the falls on 03/04/23, 03/05/23, 03/07/23, 03/25/23, 04/05/23, 04/25/23, and 05/22/23. interview on 06/08/23 at 9:35 A.M. with the DON confirmed neurological checks were indicated for the falls on 03/04/23, 03/05/23, 03/07/23, 03/25/23, 04/05/23, 04/25/23, and 05/22/23 and were not completed. Review of the facility policy titled Neurological Assessment, revised October 2010, revealed neurological assessments should be completed following an unwitnessed fall or following a fall involving head trauma. Further review revealed neurological checks would be performed with the frequency as ordered or per falls protocol. Review of the facility policy Falls - Clinical Protocol, revised September 2012 revealed no guidance regarding the frequency or duration of neurological assessments after a fall. This deficiency represents non-compliance investigated under Complaint Number OH00143359.

Based on observation, staff interview, review of the medical record, review of the fall investigations, and review of the facility policy, the facility failed to ensure fall prevention interventions were in place for two (#12 and #61) of three residents reviewed for fall risk. Further, the facility failed to document and monitor residents' response to interventions intended to reduce falling and failed to identify and address trends in falls. This affected two (#12 and #61) of three residents reviewed for falls. Findings include: 1. Review of the medical record for Resident #12 revealed an admitted [DATE] with a diagnosis of repeated falls. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 03/20/23, revealed Resident #12 had impaired cognition and required extensive assistance of two people for bed mobility, transfers, and toileting. Further review revealed Resident #12 had one fall in the month prior to admission. Review of the progress notes for Resident #12 revealed she fell 13 times between 03/17/23 and 05/24/23. Review of the current care plan for Resident #12 revealed she was at risk for falls due to deconditioning. Interventions included non-skid strips in front of the toilet, low bed, fall mat, call light within reach, a defined perimeter mattress, and non-skid socks at all times. Observation on 06/07/23 at 9:03 A.M. of Resident #12's room revealed no non-skid strips in the bathroom. Concurrent interview with the Administrator confirmed there were no non-skid strips in Resident #12's bathroom. Review of the fall investigations with the Director of Nursing (DON) and MDS Coordinator #503 on 06/07/23 at 3:43 P.M. and on 06/08/23 at 9:35 A.M. with the staff reading the facility investigation to the surveyor, revealed the investigations into eight falls occurring on 03/23/23, 03/27/23, 04/01/23, 04/13/23, 04/19/23, 05/02/23, 05/06/23, and 05/08/23 did not identify if previously implemented fall interventions were in place at the time of the fall, including non-skid socks and a floor mat beside the bed. Further review revealed the root cause identified for nine falls occurring on 03/22/23, 03/23/23, 03/25/23, 03/27/23, 04/01/23, 04/19/23, 05/02/23, 05/06/23, and 05/08/23 were identified as either ambulating without assistance or self-transferring without assistance with no attempt to identify the reason the resident attempted self mobility. The interdisciplinary team (IDT) developed interventions in response to the nine falls included a low bed, a floor mat, non-skid socks, non-skid strips, resident education on call light use, and medication reviews. The investigations for the falls on 03/22/23 at 6:30 P.M., 03/23/23 at 7:00 A.M., 03/25/23 at 7:00 P.M., 03/27/23 at 7:30 A.M., 05/06/23 at 10:30 P.M., 05/08/23 at 8:20 P.M., and 05/24/23 at 5:10 A.M. identify the use of the bathroom, or desire to use the bathroom as a contributing factor to the fall. An intervention was developed after the fall on 03/23/23 to offer toileting prior to meals. An intervention was developed after the fifth bathroom related fall on 05/06/23 to assist Resident #12 to the bathroom upon rising, before bed, and after meals. Interviews with the DON and MDS Coordinator #503 at the time of the fall reviews confirmed the findings. Continued interview on 06/07/23 at 3:43 P.M. and on 06/08/23 at 9:35 A.M., the DON confirmed non-skid strips in the bathroom were developed as an intervention after Resident #12's third fall in the bathroom on 03/25/23. 2. Review of the medical record for Resident #61 revealed a readmitted [DATE]. Diagnoses included Parkinson's disease, urgency of urination, repeated falls, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #61 had impaired cognition and required extensive assistance of two people for bed mobility, transfers, and toileting. Further review revealed Resident #61 had two or more falls without injury and one fall without major injury since the previous assessment completed 01/03/23. Review of a physician order dated 08/31/22 revealed Resident #61 should have a pressure reducing perimeter mattress. Review of the current care plan revealed Resident #61 was at risk for falls related to impaired safety awareness and a desire to reach to the floor to look for something. Interventions included a call light within reach, a perimeter mattress, keeping Resident #61 in the lobby area during waking hours, encouraging Resident #61 to stay in the common area for supervision, encouraging Resident #61 to stay in the common area in line of sight of staff when awake, and encouraging Resident #61 to toilet every two hours as accepted/tolerated. Review of the Fall Risk Assessments completed on 03/06/23, 03/07/23, 04/05/23, 04/26/23, 04/29/23, 05/08/23, 05/24/23, 05/25/23, and 05/27/23 revealed Resident #61 was at high risk for falls. Observation on 06/07/23 at 8:52 A.M. revealed Resident #61 lying in bed in his room asleep. The call light was not within reach and his bed was a standard mattress. Interview and observation on 06/07/23 at 8:54 A.M. with Administrator in Training (AIT) #505 confirmed Resident #61's call light was on the floor beyond the foot of the bed and not within reach of Resident #61. Interview and observation on 06/07/23 at 8:59 A.M. with the Director of Nursing (DON) confirmed Resident #61 did not have a perimeter mattress as ordered and care planned. Observation on 06/07/23 at 9:30 A.M. revealed Maintenance Director (MD) #501 carrying a perimeter mattress through the facility toward Resident #61's room. Interview at the time with MD #501 confirmed the mattress was for Resident #61. Review of the fall investigations with the DON and MDS Coordinator #503 on 06/07/23 at 3:43 P.M. and on 06/08/23 at 9:35 A.M. with the staff reading the facility investigation to the surveyor, revealed Resident #61 had 14 falls between 03/04/23 and 05/26/23. Of the 14 falls, 13 occurred between 4:52 P.M. and 10:16 P.M. Five falls occurred in the lounge and six falls occurred in or near the bathroom. Further interview revealed the root cause for 11 of the falls occurring on 03/05/23, 03/07/23, 03/25/23, 04/25/23, 05/07/23, 05/08/23, 05/22/23, 05/24/23, twice on 05/25/23, and 05/26/23 was Resident #61's attempts to self-transfer. Interventions developed by the interdisciplinary team included keeping resident in common areas when he was awake, reminders to call for assistance, evaluation by therapy, medication reviews, non-skid strips in bathroom, keeping the television on the sports channel, offering to sit in recliner, and increased staffing assistance in the bathroom. The fall investigations did not always include an assessment of the effectiveness of prior interventions, did not include the presence or absence of staff with Resident #61 for falls occurring in the bathroom, and did not always address the actions of staff during witnessed falls. Resident #61 did not remain in the common area or within the line of sight of staff while he was awake as evidenced by six falls in or near the bathroom and three unwitnessed falls in the common area. The facility did not identify or develop interventions to address the repeated falls from approximately 5:00 P.M. until approximately 10:00 P.M. Interviews with the DON and MDS Coordinator #503 at the time of the fall reviews confirmed the findings. Review of the facility policy titled Falls - Clinical Protocol, revised September 2012, revealed the staff and physician would monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. If an individual continues to fall, the staff and physician would re-evaluate the situation and consider other possible reasons for the resident's falling and would re-evaluate the continued relevance of current interventions. This deficiency represents non-compliance investigated under Complaint Number OH00143359.

Based on observation, staff interview, review of the medical record, and review of the facility policy, the facility failed to ensure residents received thickened water as ordered by the physician. This affected one (Resident #30) of three residents reviewed for thickened beverages. The facility census was 57. Findings include: Review of the medical record for Resident #30 revealed an admitted [DATE] with a readmitted [DATE] and a medical diagnosis of dysphagia. Review of the physician order dated 06/02/23 revealed Resident #30 was on a regular diet with regular textured foods and nectar thickened liquids. Observation on 06/06/23 at 7:17 A.M. revealed Resident #30 lying in bed with her call light on waiting for assistance. Resident #30 had a thermos mug on her overbed table. Interview with Resident #30 at that time revealed she was able to reach the water in the thermos mug. Observation on 06/06/23 at 7:23 A.M. with Registered Nurse (RN) #206 revealed the thermos mug within reach of Resident #30 was filled almost full with un-thickened water. Interview at that time with RN #206 confirmed Resident #30 had thin liquids in the thermos mug at bedside. Interview on 06/06/23 at 8:06 A.M. in the dining room with Speech Language Pathologist (SLP) #500, who was providing therapy treatment to Resident #30 during the meal, confirmed she recommended Resident #30 receive thickened liquids and consume liquids while sitting up. SLP #500 further stated she determined Resident #30's likelihood for aspiration with fluids was positional (such as reclining or slouching), rather than a mechanical (muscle-based) swallowing difficulty. Interview on 06/06/23 at approximately 9:41 A.M. with SLP #500 revealed the facility did not use the Frazier Water Protocol (a protocol that allows residents on thickened beverages to consume un-thickened water). Review of the facility policy titled Therapeutic Diets, revised November 2015, revealed a therapeutic diet must be prescribed by the resident's Attending Physician and staff will ensure each resident receives his or her diet as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00143359.

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to provide indwelling urinary catheter care to prevent cross contamination. This affected one (#1) of three residents identified with indwelling urinary catheters in a facility census of 74. Findings include: Review of the medical record revealed Resident #1 admitted to the facility on [DATE]. Diagnoses included extrarenal uremia, chronic pain syndrome, urogenital implants, urinary incontinence, diverticulum of bladder, metabolic encephalopathy, morbid obesity, bacteremia, neuromuscular dysfunction of bladder, hydronephrosis, right sided nephrostomy, ureteral stent, sepsis, extended spectrum beta lactamase resistance at nephrostomy tube site, methicillin resistant staph aureus, and urinary tract infection. Review of the Minimum Data Set assessment, dated 12/30/22, revealed the resident had moderately impaired cognition, was dependent on staff for activities of daily living, and had an indwelling urinary catheter. Review of hospital community referral form (CRF), dated 12/20/22, noted physician orders for a urinary indwelling catheter. Review of the care plan, revised on 02/23/23, revealed a nursing plan of care was implemented to address Resident #1's risk for bladder incontinence related to the diagnosis of uremia, bladder diverticulum, urinary-stents, urinary incontinence, surgical aftercare for right ureteral stone cystoscopy with ureteroscopy laser lithotripsy with infection, erectile dysfunction, and indwelling urinary (Foley) catheter. Interventions included catheter care as ordered, clean perineal area with each incontinence episode, follow up appointments as ordered, and medications as ordered. Monitor/document for signs and symptoms of urinary tract infection (UTI): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Physician consult as needed (prn) and treatments as ordered. Observation on 03/02/23 at 10:40 A.M. revealed Registered Nurse (RN) #200 and State tested Nurse Aide (STNA) #300 to position Resident #1 to his back in bed. RN #200 removed the front of the resident's adult brief exposing his genitalia and indwelling urinary catheter tubing. Observation of the residents perineal area, penis and urinary indwelling catheter insertion site noted a moderate amount of dried and moist tan drainage. STNA #300 obtained a washcloth with soap, washcloth with clean water, and a clean towel. STNA #300 proceeded to use the washcloth containing soap to cleanse the dried drainage from the resident's penis glans and without changing the area of the washcloth. STNA #300 then cleansed the insertion site of the indwelling urinary catheter. STNA #300 went on to use the washcloth to remove the dried and moist drainage from the residents perineal area coming in contact with the catheter tubing and the soiled portion of the wash cloth. STNA #300 rinsed and dried the resident's perineal area and indwelling catheter site with the same technique. Interview on 03/02/23 at 10:50 A.M., STNA #300 and RN#200 verified while STNA #300 conducted indwelling catheter care cross-contamination occurred by touching soiled areas of the washcloth to areas being cleansed. Review of the facility policy titled Urinary Catheter Care Policy, revised September 2014, revealed steps for catheter care included filling a basin half full of water. Wash residents genitalia and perineum thoroughly with soap and water. Rinse area well and towel dry. Discard water and place soiled linen into designated container. Put on clean gloves, with non-dominant hand retract the foreskin and maintain the position throughout the procedure. Use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return foreskin to normal position. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. This deficiency represents non-compliance investigated under Complaint Number OH00140374.

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to follow the policy to provide nephrostomy care and failed to obtain a physician order for the care of a nephrostomy. This affected one (#1) of one resident identified by the facility with a nephrostomy in a facility census of 74. Findings include: Review of the medical record revealed Resident #1 admitted to the facility on [DATE]. Diagnoses included extrarenal uremia, chronic pain syndrome, urogenital implants, urinary incontinence, diverticulum of bladder, metabolic encephalopathy, morbid obesity, bacteremia, neuromuscular dysfunction of bladder, hydronephrosis, right sided nephrostomy, ureteral stent, sepsis, extended spectrum beta lactamase resistance at nephrostomy tube site, methicillin resistant staph aureus, and urinary tract infection. Review of the Minimum Data Set assessment, dated 12/30/22, revealed the resident had moderately impaired cognition, was dependent on staff for activities of daily living, and had an indwelling urinary catheter. The medical record revealed on 01/12/23 the resident was sent out to the hospital for evaluation and returned on 01/18/23. Hospital discharge orders included leave urinary catheter in place, flush nephrostomy tube every twelve hours with ten milliliters (ml) of normal saline, and change dressing daily and as needed. Review of the medical record revealed on 02/17/23 the resident was admitted to the hospital and returned on 02/23/23. Hospital documentation revealed the resident underwent a procedure to exchange nephrostomy catheter. There were no admission orders for nephrostomy care. There were no orders for the placement of an indwelling urinary catheter and associated care. On 02/28/23 the resident was evaluated in the hospital emergency room and returned the same day with no new physician orders. Review of the nursing care plan, dated 12/20/22 and revised on 02/23/23, revealed Resident #1 was at risk for bladder incontinence related to the diagnoses of uremia, bladder diverticulum, urinary-stents, urinary incontinence, surgical aftercare for right ureteral stone cystoscopy with ureteroscopy laser lithotripsy with infection, erectile dysfunction. and indwelling urinary (Foley) catheter. The care plan stated the resident readmitted [DATE] with diagnoses of hydronephrosis of right kidney, neuromuscular dysfunction of bladder, and right nephrostomy tube replaced on 02/17/23. On 01/30/23 nephrostomy care as ordered was added. Interventions included catheter care as ordered. On 01/30/23 additional interventions included nephrostomy care as ordered and monitor/document/report as needed (PRN) any possible causes of incontinence, bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, and medication side effects. Monitor/document for signs and symptoms of UTI such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. Physician consult as needed (prn) and treatments as ordered. There was no documentation in the medical record identifying the nephrostomy tube was flushed, a dressing change was implemented daily or related assessments with nephrostomy tube care since return from the hospital on 02/28/23. Interview on 03/02/23 at 9:05 A.M. with the Director of Nursing (DON) verified there were no current orders regarding nephrostomy care or treatment, no consistent documentation indicated the nephrostomy was assessed, and no evidence nephrostomy care was completed. Observation on 03/02/23 at 10:30 A.M. noted Resident #1 in bed with a nephrostomy collection bag draining amber clear urine, urinary indwelling catheter draining yellow urine with sediment. Registered Nurse (RN) #200 and State tested Nurse Aide (STNA) #300 positioned the resident to the left side exposing the right nephrostomy site. A dressing was in place with a small amount of serosanguinous (red tinge) drainage. No date was on the dressing to determine when the dressing was placed. Interview at this time with RN #200 revealed the dressing appeared to be a hospital type dressing. RN #200 removed and disposed of the dressing. Observation of the nephrostomy site noted intact tissue to the stoma. RN #200 washed hands, obtained an indwelling urinary catheter kit, opened the kit and applied sterile gloves. RN#200 placed a sterile drape to the nephrostomy site, opened a package of iodine swabs and proceeded to swipe around the site, discarding the swab after each swipe. RN #200 placed normal saline to a clean 4 x 4 (non-sterile) gauze and wiped the site. RN #200 then placed a gauze drainage sponge around the nephrostomy tube, securing it in place with paper tape and dating the tape. Review of the facility policy titled Nephrostomy Tube Care, revised October 2010, revealed in preparation of the procedure verify there is a physicians order for the procedure. Use sterile technique during dressing changes. Dressing change instructions included carefully remove the wet or soiled dressing and discard and observe the dressing site for signs of skin breakdown, infection, or drainage. Remove gloves, wash hands and put on sterile gloves. With iodine swab cleanse the nephrostomy tube site in outward circles from the insertion site. Use a new swab with each circle. Cleanse outward to approximately three (3) inches in diameter from the insertion site. Allow iodine to dry. Place one to two (1-2) sterile drain dressings on the nephrostomy tube site and secure with adhesive tape. Document the following information in the residents medical record: the date and time the procedure was performed, name and title of person who performed procedure, assessment including drainage characteristics, signs and symptoms of infections, signs of tube obstruction, signs of skin breakdown, and any problems or resident complaints during the procedure. Interview on 03/02/23 at 11:25 A.M., RN #200 confirmed he/she did not follow the policy and allow the iodine to dry and wiped the iodine from the nephrostomy insertion site with the non-sterile 4 x 4 gauze. RN #200 verified there were no orders from the physician for the frequency of nephrostomy care or the type of dressing change to be completed. RN #200 confirmed there was no evidence of nephrostomy care was being completed since Resident #1 returned from the hospital on 02/28/23. This deficiency represents non-compliance investigated under Complaint Number OH00140374.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to monitor Resident #19's skin underneath a heel protector boot. This resulted in actual harm when Resident #19 developed two Deep Tissue Injuries (DTI) on the right foot, consistent with the strap of the heel protector boot being too tight. Additionally, the facility failed to complete accurate skin assessments and failed to ensure recommended interventions were in place for Resident #60. This resulted in actual harm when Resident #60 was discovered with an in-house acquired DTI to the foot. This affected two (Residents #19 and #60) of three residents reviewed for skin breakdown. The facility's census was 64. Findings include: 1. Medical record review for Resident #19 revealed the resident admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was severely cognitively impaired and was dependent upon staff for Activities of Daily Living (ADLs) including bed mobility and transfers. Resident #19 was incontinent of urine and admitted to the facility with a DTI. Review of the Pressure Sore Development Risk assessment dated [DATE] revealed the resident was at high risk for developing pressure ulcers. Review of Resident #19's care plan developed on 06/20/22 and revised on 07/13/22 revealed the resident was at risk for skin breakdown related to decreased mobility, occasional bowel incontinence, admitted with pressure ulcers, and often refuses to turn/reposition. Interventions included alternating air mattress to bed initiated on 06/20/22, assist/encourage resident to turn/reposition every two hours and as needed initiated on 06/20/22, bilateral heel boots as ordered initiated 07/22/22, monitor skin with daily care, report any new or worsening abnormalities added on 06/20/22, and monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to physician initiated on 06/20/22. Review of Resident #19's physician orders dated 07/11/22 revealed an order was obtained for heel boots to be worn at all times. There was no documentation indicating the resident's skin integrity was assessed under the heel boots each shift. Continued review of Resident #19's physician orders revealed an order dated 07/21/22 for heel boots to be worn at all times. MAKE SURE STRAP IS EXTREMELY LOOSE TO R (right) FOOT!!! every shift for protection. Review of Resident #19's Treatment Administration Records from 07/11/22 to 08/04/22 revealed the heel boots were documented as applied on each shift. Further review of the medical record revealed no documentation the skin integrity to Resident #19's right foot was assessed each shift. Review of the change in condition progress note dated 07/23/22 at 7:16 A.M. revealed Resident #19 was noted to have a purple area to the top and side of the right foot. The area to the top of the foot measured 10 centimeters (cm) long by (x) 3 cm wide x 0 cm deep and the area to the side of the foot measured 1 cm long x 1 cm wide x 0 cm deep. The resident had heel boots on, but the strap laid across the top of his foot. Recommendations included wrap foot with kerlix gauze wrap instead of ace bandage and keep the strap loose to the heel boot. No further wound assessment was documented until 07/27/22 when the wound nurse, Registered Nurse (RN) #262, evaluated the wounds to the right foot. The wound located on the top of the right food was documented as in-house acquired and described as a suspected DTI measuring 8 cm long x 3 cm wide x 0 cm deep and purple in color. The right outer (lateral) foot wound was documented as in-house acquired and described as a suspected DTI measuring 2 cm long x 2 cm wide x 0 cm deep and purple in color. On 08/04/22 a physician order was initiated, DO NOT UTILIZE HEEL BOOTS! Float bilateral heels with pillows, AT ALL TIMES! Interview on 08/11/22 at 9:00 A.M., RN #262 verified Resident #19 developed two unstageable areas to the right food, resulting from the application of a heel protector. RN #262 confirmed there was no documentation contained in the resident's medical record indicating the skin under the heel protector was assessed or monitored daily as described in the plan of care. Observation on 08/11/22 at 10:55 A.M. of RN #262 providing wound care to Resident #19 revealed the wound to the right top foot was noted to be described as unstageable, measuring 8.0 cm long x 3.0 cm wide x 0.0 cm deep and lateral right foot was noted to be described as unstageable, measuring 2.0 cm long x 2.0 cm wide x 0.0 cm deep. 2. Medical record review for Resident #60 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #60's MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired. Resident #60 was at risk for pressure ulcers with a pressure reducing device for the bed. According to the assessment, Resident #60 had no pressure ulcers. Review of the Pressure Sore Development Risk Assessments dated 05/12/22 and 06/29/22 revealed Resident #60 was at moderate risk for developing pressure ulcers. Review of the Pressure Sore Development Risk Assessments dated 06/01/22, 07/30/22, and 08/06/22 revealed Resident #60 was at high risk for developing pressure ulcers. Review of the Skin Assessments dated 07/17/22 and 07/24/22 revealed Resident #60 had no new skin abnormalities noted. Review of the physician order dated 07/17/22 and updated 07/21/22 revealed an order to cleanse the left heel (originally ordered for right heel) with normal saline, pat dry, apply skin prep every day and night shift. Review of the physician order dated 07/26/22 revealed an order to elevate heels on a pillow when in bed every shift. Review of Resident #60's Treatment Administration Record (TAR) for July 2022 revealed wound treatments were completed as ordered. Review of the Interdisciplinary Team (IDT) progress note revealed a late entry from 07/18/22 at 10:00 A.M. documented on 07/24/22 at 2:48 P.M. indicating Resident #60 was found with an area to the left heel. Interventions included heel boot protector and treatment to cleanse with normal saline, pat dry, and apply skin prep to area twice a day. Review of the Wound Evaluation Flowsheets dated 07/20/22, 07/27/22, and 08/03/22 revealed an in-house acquired suspected DTI was acquired on 07/17/22 measuring 1 cm x 1 cm. Treatment included skin prep twice a day with current treatment initiated 07/20/22. Prevention interventions included wearing a heel boot while in bed. The physician was notified on 07/18/22 at 12:00 A.M. Review of the change in condition progress note dated 07/21/22 revealed RN #262 and an unidentified nurse were providing care for Resident #60 and found a DTI on the left foot. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order dated 07/26/22 revealed an order to elevate the resident's heels with a pillow when in bed, every shift. Review of the care plan initiated on 05/29/22 revealed Resident #60 was at increased risk for pressure ulcer development due to decreased bed mobility, bladder incontinence, diabetes mellitus, and pain. The care plan was updated on 07/27/22 to include off-loading of heels while in bed. Observation on 08/09/22 at 12:40 P.M. revealed Resident #60 was lying in bed and moved the blankets slightly to show heel boots were applied. No pillow was observed to be in place to off load the heels as ordered. Interview on 08/09/22 at 12:45 P.M. with Licensed Practical Nurse (LPN) #276 verified there was no pillow under Resident #60's heels as ordered. Observation and interview on 08/10/22 at 1:15 P.M. revealed Resident #60 was in bed and reported the heel was causing less pain than the previous day. Resident #60 was observed to be wearing heel boots with a pillow under the knees rather than under the heels as ordered. RN #262 verified the pillow was not placed correctly and was not offloading the heels. RN #262 evaluated Resident #60's left heel wound and reported the wound appeared to be a DTI and measured approximately 1 cm by 0.9 cm. Interview on 08/11/22 at 8:57 A.M. with the Director of Nursing (DON) verified Resident #60's DTI was discovered on 07/17/22 and verified the skin assessment dated [DATE] at 11:45 P.M. and 07/24/22 documented no new skin abnormalities. The DON reported the interdisciplinary team progress note dated 07/18/22 was a late entry documented on 07/24/22. The DON further verified Resident #60's wound was not evaluated until 07/20/22. Review of the facility policy titled, Pressure Ulcers/Skin Breakdown, revised March 2014, revealed the physician will help identify medical interventions related to wound management and will assist with staff review and modify the care plan as appropriate.

Based on medical record review, resident and staff interviews, surveyor observations, and review of the facility's fall investigation, policy on falls, and "Recreation Services Guide", it was determined the facility failed to provide adequate supervision for one resident (#2) who was left in a wheelchair on a sloped sidewalk. This resulted in actual harm when Resident #2's wheelchair began to roll down the sloped sidewalk and ultimately off of a cement curb where he fell head first on the cement parking lot. The fall resulted in a laceration above the right eye requiring eight stitches, a laceration below his right lower lid requiring four stitches, a laceration on his nose, multiple bruises on his face and neck and abrasions on both of his hands. This affected one (#2) of three sampled residents reviewed for falls of 17 the facility identified as confused, mobile, and at risk for falls. Findings include: Review of Resident #2's medical record revealed he was admitted to the facility on [DATE]. The resident had current [DIAGNOSES REDACTED]. Review of the most recent minimum data set (MDS) assessment dated [DATE] identified the resident with severe cognitive impairment and short-term memory problems. He required extensive assistance with two person physical assistance for transfers and extensive assistance with one person physical assistance for ambulation off the unit. His primary mode of locomotion was a wheelchair. The plan of care initiated 12/14/10 for at risk for falls related to a history of falls, unsteadiness at times and anti-depressant and anti-anxiety medication use was reviewed. Interventions included to provide one assist with transfers and ambulation with walker and gait belt; a non-skid pad to the seat of the wheelchair at all times; a personal alarm to be on at all times; and restorative nursing for active range of motion to both upper extremities. Review of the nurses progress notes dated 05/09/11 at 2:31 P.M. revealed the MDS nurse coordinator received a telephone call from the activities department at 11:20 A.M. stating that the resident had fallen while on an outing at the bowling alley for an activity. The nurse and the Director of Nursing (DON) went to the bowling alley to assess the resident. The emergency squad was already on the scene when they arrived at the bowling alley. The Activities Director stated the resident was sitting in a wheelchair with the brakes locked on a sidewalk waiting to be loaded on the bus to return to the facility. While activities staff were assisting other residents onto the bus, staff looked up and saw the resident's wheelchair move off the sidewalk curb and he fell forward hitting his head. Staff immediately called 911. Resident #2 reported to activities staff that his nose hurt but he denied any pain when the MDS nurse coordinator and DON arrived on the scene. When the activities staff assessed the wheelchair the brakes were not unlocked. The resident had lacerations on his right forehead and right upper cheek. He was transferred to the local hospital's emergency department for an evaluation. Review of the hospital's emergency department note dated 05/09/11 revealed the resident fell out of his wheelchair and landed on a cement surface. He hit his head first. The resident complained of pain in his head and face. Swelling was noted around his right eye and multiple lacerations on his face. The physician documented there were no exact details of the accident due to Resident #2's dementia. A physical examination revealed a laceration above the right eye, facial lacerations just below the right lower eye lid, a small laceration on his nose, left forearm tenderness and multiple abrasions on both hands. A cervical spine computed axial tomography (CAT) scan was negative for fractures, a facial bone CAT scan was negative for skull fracture and showed no intracranial abnormality. A left forearm, elbow, and humerus x-rays were negative for a fracture. The upper right eye laceration required eight stitches to close, the laceration below the right eye required four stitches to close and the nasal laceration was closed using Dermabond, a tissue adhesive that forms a strong bond across apposed wound edges. The physician's assessment concluded Resident #2 suffered from a fall which resulted in lacerations, facial contusions, and a head injury. On 05/24/11 at 9:50 A.M., interview with the Activity Assistant (AA) revealed she was on the outing at the bowling alley with Resident #2. The Activities Director (AD) went out to get the bus and put the lift down. Resident #2 was on the sidewalk when she (AA) assisted Resident #25 onto the bus. She stated the AD took Resident #2 out to the sidewalk and locked his wheelchair brakes. Residents #2 and #34 were in their wheelchairs on the sidewalk and Resident #9 was standing next to Resident #2 with her walker. She was assisting Resident #25 to his seat on the bus when Resident #2 fell out of his wheelchair. The AD was on the sidewalk assisting Resident #34 because the resident had unlocked her wheelchair brakes. She heard the AD yell Resident #2's name. She looked up from putting Resident #25 in his seat and saw Resident #2 rolling down the slanted sidewalk and go over the curb. He fell head first out of his wheelchair. She's not sure how the wheelchair brakes became unlocked. During an interview on 05/24/11 between 10:20 A.M. and 10:30 A.M., the AD stated per a telephone call that they had taken the residents on the bus to an outing at the bowling alley. The AA took Resident #2 out to the sidewalk and locked his wheelchair brakes. The AA was on the bus with Resident #25. The sidewalk had an incline. She looked up from locking Resident #34's wheelchair brakes and saw Resident #2 rolling down the sidewalk. She yelled at him to put his feet down to stop himself but apparently he did not hear or understand what to do because he has dementia. The AA told her she set Resident #2's wheelchair brakes and set him sideways on the sidewalk (so he was perpendicular to the slope in the sidewalk). She thought Resident #2's wheelchair started to turn due to the slope of the sidewalk. The other two residents in their wheelchairs were taken back into the bowling alley right after the incident. On 05/24/11 at 10:50 A.M., the AA further stated she was in the bowling alley with other residents. Resident #2 was already on the sidewalk in his wheelchair when she went out to the bus. On 05/24/11 at 10:55 A.M., Resident #2 was observed up in his wheelchair with a personal alarm clipped to his clothing on his back. He was noted with yellowish/green bruising on his right cheek and neck area, and dark purple bruising was noted on both cheek bones (where the bottom of his glasses touch his face) and under his chin. Two steri-strips were in place on a healing laceration under his right eye, a scabbed over area with the surrounding skin reddened on the distal end and one steri-strip over a healing laceration at the proximal end of the laceration above the right eye. On 05/24/11 at 1:23 P.M., stated tested nurse aides (STNA's) #3 and #4 both stated they have observed Resident #2 unlock his wheelchair brakes. On 05/24/11 at 1:28 P.M., Resident #2 was observed in his wheelchair in his room. The resident was asked to show the surveyor how he unlocks his wheelchair brakes. After some misunderstanding on the resident's part due to dementia and several requests, he demonstrated that he was able to unlock the wheelchair brakes. On 05/24/11 at 1:40 P.M., Resident #9 stated the AD took Resident #2 in his wheelchair outside on the sidewalk by the bus when they were at the bowling alley. In a further interview with the AA on 05/24/11 between 1:47 P.M. and 2:00 P.M., she stated she thought the wheelchair brakes were locked because the resident was not moving. She did not remember if the resident's feet were on the ground. On 05/24/11 between 2:07 P.M. and 2:17 P.M., the AD stated in person that she did not remember which resident she took out to the bus first. As she was locking Resident #34's wheelchair brakes, she turned and saw Resident #2 rolling down the sidewalk slope with his feet up and his hands near his torso. At 2:36 P.M., she was not aware of a policy regarding resident supervision while outside the facility on an activity outing. On 05/24/11 at 2:40 P.M., the AA stated she was not aware of a policy regarding resident supervision while on an outside facility activity. But, now confused and mobile residents are loaded on the bus first. She was aware Resident #2 was able to unlock his wheelchair brakes. Review of the facility's "Recreation Services Guide" with no effective date revealed it was the responsibility of the facility to provide the necessary staff and volunteers to ensure the comfort and safety of the residents. Review of the facility's Fall Assessment Protocol dated March 2002 revealed the purpose of the protocol was to identify residents at risk for falls, assessment of the individual resident condition for complications after a fall has occurred and identify the potential causative and contributing factors involved in a resident fall in order to revise the plan of care to reduce the potential for falls to reoccur. Review of the Post Fall Investigation Summary dated 05/09/11 revealed Resident #2 was waiting to be loaded on the bus. The wheelchair was sitting parallel to the curb with the brakes locked. Resident #2 or another resident unlocked the wheelchair brakes and the resident rolled off the curb. The two activity staff statements were obtained and reflect the above interviews. Resident #2 was unable to participate in an interview due to his confusion. This deficiency substantiates Complaint Number OH 830.