Every finding on record at Norwich Springs Health Campus

Based on closed medical record review and staff interview, the facility failed to ensure timely coordination of outside medial appointments. This affected one (#77) of three residents reviewed for medical appointment follow-up. The facility census was 50. Findings include:Review of the closed medical record revealed Resident #77 was admitted to the facility on [DATE]. Diagnoses included Type II diabetes mellitus, chronic kidney disease, morbid obesity, and spinal stenosis. The resident discharged to the hospital on [DATE].Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #77 had mild cognitive impairment. Review of the hospital After Visit Summary (AVS), dated 05/01/26, revealed Resident #77 had spinal surgery and needed an orthopedic follow-up appointment within two weeks. Review of a nursing progress note dated 05/25/26 revealed Resident #77 should have a follow-up appointment with the (orthopedic) surgeon, please call to make appointment and arrange transportation. Review of a physician order dated 05/27/26 revealed Resident #77 had an orthopedic appointment scheduled for 05/28/26 at 1:20 P.M. Further review of Resident #77's medical record revealed no evidence an orthopedic follow-up appointment was scheduled, or was attempted to be scheduled, within two weeks as indicated on the hospital AVS. Interview on 06/10/26 at 10:03 A.M. with Resident #77 revealed that during the initial care conference at the facility, Social Services Director (SSD) #189 stated she would schedule the orthopedic appointment and arrange transportation. Interview on 06/10/26 at 11:15 A.M. with SSD #189 revealed she did not arrange outside physician appointments, but rather relayed the appointment request to the medical records nurse. A telephone interview on 06/10/26 at 2:17 P.M. with Patient Care Coordinator (PCC) #202 with the orthopedic physician's office revealed the facility's first contact with them regarding an appointment for Resident #77 was not until 5/26/26, when they received a voicemail from the facility. PCC #202 stated they returned the call on 05/27/26 at 9:26 A.M. and scheduled an appointment for 06/01/26. PCC #202 stated the facility called back on 05/27/26 at 3:04 P.M. and requested a sooner appointment, which was arranged for 05/28/26.This deficiency represents non-compliance investigated under Complaint Number 3026049.

Based on observation, resident interview, staff interview, and policy review the facility failed to ensure infection control procedures were followed for laundry which had the potential to affect all 52 residents residing in the facility. Additionally, the facility failed to ensure infection control was followed for wound care for one (Resident #12) out of three residents reviewed for pressure ulcers. Lastly, the facility failed to follow infection control procedure for indwelling urinary catheter care for one (Resident #02) out of one resident reviewed for catheter care. The facility census was 52.1.Interview on 03/25/26 from 8:10 A.M. to 8:20 A.M. with Director of Housekeeping #655, revealed the facility's normal laundry process included aides placing laundry in dirty linen rooms and housekeeping staff collecting the items using personal protective equipment (PPE), then separating, washing, drying, and delivering the clean laundry items. Director of Housekeeping #655 stated PPE was worn during collection and separation. When asked about isolation procedures, Director of Housekeeping #655 stated housekeeping staff only retrieved laundry from dirty linen rooms and aides were responsible for separating laundry from contact isolation rooms. During the same interview Housekeeping Staff #33 revealed aides did not separate clothing from contact isolation rooms or from incontinence episodes prior to placing items in the dirty linen rooms and laundry staff could not determine which items needed to be washed separately. Interview on 03/25/26 at 8:23 A.M. with Certified Nursing Assistant (CNA) #364 revealed aides placed laundry from isolation rooms into standard trash bags rather than yellow isolation bags. She stated items with blood were placed in red biohazard bags and taken directly to laundry. Interview on 03/25/26 at 8:25 A.M. with CNA #176 revealed dirty linen, including linen from contact isolation rooms, was placed in standard trash bags with no identifying differences and taken to the dirty linen room. She stated only items with blood were placed in red bags. Interview on 03/25/26 at 8:29 A.M. with CNA #569 revealed staff were expected to place isolation laundry in yellow bags and transport soiled items separately. Interview on 03/25/26 at 8:43 A.M. with CNA #569 revealed she was unable to locate any yellow isolation bags in the facility. CNA #569 attempted to locate yellow bags in the soiled linen room, outside of two active contact isolation rooms, in the laundry room, and in two additional soiled linen rooms. Yellow isolation bags were not available in any of these locations and CNA #569 stated there would be no additional locations to find the yellow isolation bags. 2. Review of the medical record for Resident #12 revealed an admission date of 12/22/23. Diagnoses included malignant neoplasm of part of the right bronchus or lung, severe protein calorie malnutrition, chronic respiratory failure with hypoxia, and sepsis. Review of the annual Minimum Data Set (MDS) 3.0 assessment for Resident #12, dated 01/11/26, revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident was moderately cognitively impaired. The assessment indicated the resident was dependent on staff for most activities of daily living and had a pressure ulcer requiring treatment. Review of physician orders for Resident #12 revealed a wound care order dated 03/06/26 to cleanse the right pinky plantar wound with wound cleanser or normal saline, pat dry, apply hydrogel, cover with an abdominal dressing, and wrap with kerlix from toes to knee, to be completed every other day through 03/19/26. Review of physician orders further revealed a wound care order dated 03/19/26 to cleanse the right pinky plantar wound with wound cleanser or normal saline, pat dry, wrap with an unna boot and kerlix from toes to knee, to be completed every three days and as needed if dislodged or soiled, ongoing. Review of the plan of care for Resident #12, initiated 07/29/25, revealed the resident required enhanced barrier precautions during high contact care related to the presence of a wound with dressing changes. Interventions included performing hand hygiene before and after care, utilizing personal protective equipment including gown and gloves, and following infection control practices per policy. Observation on 03/25/26 at 2:03 P.M. of a wound dressing change performed by Wound Nurse (WN) #570, with Registered Nurse (RN) #284, and Certified Nursing Assistant (CNA) #364 revealed multiple and repeated breaches in infection control practices. WN #570 donned gloves without performing hand hygiene and immediately touched multiple surfaces including the door, personal protective equipment storage on the door, and the bedside tray before initiating care, WN # 570 did not remove the gloves that had touched all the environmental surfaces or perform hand hygiene prior to starting the wound care procedure. WN #570 removed the resident's boot and used scissors that were placed on a chair. The scissors were repeatedly placed on and retrieved from the chair and later from the windowsill without being cleaned. WN #570 then touched the open wound on the right foot with contaminated gloves after contacting environmental surfaces. During the procedure, both WN #570 and RN #284 were observed touching the open wound multiple times with the same pair of gloves after touching soiled surfaces. RN #284 held and repositioned the resident's foot while her gloved hands made direct contact with the wound area and surrounding skin. She then used the same gloves to adjust room equipment, including turning off heat in the room, and resumed contact with the resident's wound without changing gloves. WN #570 placed a washcloth into water and cleansed the wound using the same gloves that had contacted multiple surfaces. The same washcloth and gloves were then used to clean other areas of the resident's legs that had skin areas from previous impetigo. WN #570 then returned to the wound on the right foot and continued cleansing with the same contaminated gloves and washcloth. Moisture and drainage from the leg wounds were observed transferring onto linens beneath the resident. After removing gloves and performing hand hygiene once, WN #570 donned a new pair of gloves and immediately touched the outside of a medication container and supply packaging. Without changing gloves, she applied medication directly to the resident's skin and wound areas with soiled gloves. RN #284 used scissors that had been sitting on the windowsill to open clean dressing supplies, and the same scissors were used to cut clean dressing materials. At approximately 2:10 P.M., CNA #364 entered the room, donned personal protective equipment without performing hand hygiene, applied gloves, and then handled the resident's foot during the wound care process. During the dressing application, WN #570 handled both clean and previously used materials with the same gloves, including reusing an ace wrap, and continued wrapping the resident's leg after contacting soiled surfaces. WN #570 donned new gloves at one point without performing hand hygiene prior to application and continued the procedure. Interview on 03/25/26 at 2:30 P.M. with WN #570 confirmed the observed wound care process as described with the breaks in infection control. Review of a policy titled, Guideline for handwashing/hand hygiene, dated 11/18/25, revealed staff were required to perform hand hygiene before and after patient contact, change gloves between tasks, maintain clean and sterile technique when performing wound care, and prevent cross contamination by avoiding contact between contaminated and clean surfaces or supplies. 3.Resident #02 was admitted on [DATE] with diagnoses of mechanical complication of indwelling urethral catheter, neuromuscular dysfunction of bladder, and calculus (stone) of kidney. Review of the Resident #02 's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident used indwelling urinary catheters and had moderate cognitive impairment. Review of the medical record for Resident #02 revealed an order written 02/25/26 for Foley catheter care every shift (twice a day) with special instructions to monitor proper placement of leg securement device. Observation of Resident #02 in his room on 03/25/26 at approximately 11:39 A.M. on 03/25/26 revealed the resident was lying in bed. The Foley catheter drainage bag was resting on the floor on the right side of the Resident inside an outer blue urinary drainage bag holder. Certified Nurse Aide (CNA) #176 came in the residence room about 11:53 A.M. on 03/25/26 to perform Foley catheter care. The Resident was moved to the bathroom for Foley catheter care. After Foley catheter care the Resident was placed back in bed. The Foley catheter bag was placed resting on the floor on the right side of the Resident inside a blue urinary drainage bag holder. Interview with CNA #176 on 03/25/26 at approximately 12:10 P.M. confirmed the Foley catheter bag was resting on the ground inside the blue urinary drainage bag holder. At 12:19 P.M. on 03/25/26 the Director of Health Services (DHS) #377 was interviewed in the Resident's room. DHS #377 confirmed the Foley catheter bag was resting on the floor, but not directly, as it was inside the blue urinary drainage bag holder. DHS #377 provided product information on the urinary drainage bag holder at 8:19 A.M. on 3/26/26. Review of the provided product information of the urinary drainage bag holder documented the holder is designed to hang from wheelchairs, geriatric chairs, or bed rails. The urinary drainage bag holder is of heavy vinyl material with welded seam construction, and its purpose is to protect urinary drainage bags from accidental leakage and damage. Review of the Facility Clinical Standard Operating Procedure (SOP) titled Urinary Catheter Care (reviewed 12/16/24) revealed the guidance for staff in the SOP stated to be sure the catheter tubing and drainage bag are kept off the floor. The United States Center for Disease Control (CDC) Guideline for Prevention of Catheter Associated Urinary Tract Infection 2009 was reviewed. In the section titled Proper Technique for Urinary Catheter Maintenance, a recommendation was to not rest the (urinary drainage) bag on the floor.

Based on review of medical records, staff interview, and facility policy review, the facility failed to follow care instructions for nephrostomy care for Resident #02. This affected one resident (Resident #02) of three residents investigated for urinary catheters. The facility census was 52.Findings include:Resident #02 was admitted on [DATE] diagnoses include mechanical complication of indwelling urethral catheter, neuromuscular dysfunction of bladder, and calculus (stone) of kidney.Review of the Resident #02's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident used indwelling urinary catheters and had moderate cognitive impairment. Resident #02 was discharged from hospital on [DATE] after insertion of a right nephrostomy tube. Review of Resident #02's care instructions included nephrostomy tube care at the time of the hospital discharge. The care instructions stated to clean around the (nephrostomy) tube and change the dressing daily or as instructed by your care team and also to change the dressing if it becomes wet or dirty.Review of the Resident #02's medical record revealed the resident re-admitted to the facility on [DATE]. Review of the medical record between 12/16/25 and 01/21/26 revealed no orders to change the dressing around the nephrostomy site. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) between 12/16/25 and 01/21/26 found no documentation of dressing changes being completed for Resident #02 around the nephrostomy site. Interview on 03/26/26 at approximately 11:32 A.M. with the Director of Health Services #377 confirmed there were no documented occurrences of dressing changes around the nephrostomy site for Resident #02 between 12/16/25 and 01/21/26.Review of facility clinical standard operating procedure (SOP) titled Urinary Catheter Care (reviewed 12/16/24) does not define a minimum frequency of dressing changes for catheter sites. The SOP advises staff to determine if changes in daily urinary catheter care procedures have been made.

Based on record review, resident interview, and staff interview the facility failed to ensure a specialist appointment was scheduled for one (Resident #12) out two residents reviewed for activities of daily living. The facility census was 52.Review of the medical record for Resident #12 revealed an admission date of 12/22/2023. Diagnoses included but not limited to polyneuropathy, contracture of right knee, contracture of left knee, and contracture of muscle of left upper arm.Review of the annual Minimum Data Set (MDS) 3.0 assessment for Resident #12, dated 01/11/2026, revealed a Brief Interview for Mental Status score of 12, indicating the resident was cognitively intact. The assessment indicated the resident required extensive to total assistance with activities of daily living including dressing, hygiene, and mobility, placing the resident at risk for complications related to immobility and contractures.Review of physician orders for Resident #12 revealed orders dated 02/01/2025, 10/10/2025, and 12/19/2025 for a consult with a community provider for Physical Medicine and Rehabilitation for evaluation and treatment related to weakness and contractures.Review of the plan of care for Resident #12 revealed problems related to pain and decreased participation in activities due to physical limitations including contractures. The plan of care did not include interventions related to splint use, management of contractures, or follow up for specialty consultation related to contractures.Review of therapy documentation and interviews revealed on 03/24/2026 at 10:30 A.M., Rehabilitation (Rehab) Director (RD) #650 stated the resident had confirmed wrist contractures. The Rehab Director stated that during evaluation the resident was unable to tolerate splinting or stretching to the wrists. The Rehab Director further stated a splint representative was brought in and determined due to the severity of range of motion impairment, no splint could be applied. The Rehab Director stated there were no further recommendations for the resident's wrist contracture and confirmed the Nurse Practitioner was aware of these findings.Review of therapy interview on 03/24/2026 at 2:52 P.M. revealed RD #650 stated the initial measurement of the resident's left wrist flexion contracture was -70 degrees and remained unchanged throughout subsequent sessions.Review of nursing progress notes for Resident #12 revealed on 11/20/2025 at 4:31 P.M., staff attempted to schedule an appointment for weakness and contractures as ordered and were informed the provider had retired and rescheduling at a different office may be required. The Nurse Practitioner and responsible party were notified. Review of documentation dated 12/31/2025 revealed staff spoke with the community provider for Physical Medicine and Rehabilitation regarding scheduling, and the facility was informed an appointment would not be scheduled due to prior attempts and reported refusals. No documentation was identified to support resident refusals.Observation on 03/23/2026 at 12:58 P.M. revealed Resident #12 had contractures of the bilateral wrists with multiple fingers locked in place. Resident #12 stated he believed he had splints but did not know where they were and reported the facility was not addressing his contractures. Resident #12 further stated he had not been sent to a specialist and was told the only option was in another city.Interview on 03/24/2026 at 1:51 P.M. with Resident #12 revealed he had been provided a phone number on that date to schedule the appointment. Resident #12 stated he had not previously been provided a contact number and reported receiving one automated call from the specialist but did not understand how to schedule the appointment. Resident #12 stated he required assistance from the facility to schedule the appointment and reported no follow up assistance was provided.Interview on 03/24/2026 at 1:36 P.M. with Registered Nurse (RN) #366 revealed the facility attempted to schedule a specialist appointment, however, the community provider of Physical Medicine and Rehabilitation declined to schedule due to reported prior refusals. The staff member stated there was no documentation available to support the alleged refusals.Interview on 03/24/2026 at 2:33 P.M. with Director of Nursing (DON) revealed there was no evidence of additional attempts to schedule the specialist appointment for Resident #12's contractures. The Director of Nursing was unable to identify the initial date of referral or explain the gap between attempts to schedule the appointment. The Director of Nursing stated the facility would assist with transportation but acknowledged uncertainty regarding whether Resident #12 understood the need to arrange transportation. The Director of Nursing confirmed the facility did not follow up to assist Resident #12 in scheduling the appointment.

Based on observation, record review, and staff interview, the facility failed to provide oxygen therapy services per physician's order for Resident #52 and Resident #33, the facility also failed to ensure the nasal cannula was kept in sanitary condition for Resident #33. This affected two Residents (#52 and #33) of four reviewed for respiratory services. It had the potential to affect 10 residents the facility identified as using oxygen therapy in their plan of care. The facility census was 52.Findings include: 1.Resident #52 was admitted on [DATE] with diagnoses that included sepsis due to Methicillin resistant Staphylococcus aureus (MRSA) and pulmonary hypertension. Review of the Resident #52's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident used continuous oxygen therapy and was cognitively intact. Review of Resident #52's physician orders revealed an order written on 3/11/26 for oxygen to be administered at three liters (L)(per minute) per nasal cannula continuous. Observation on 03/25/26 at 8:53 A.M. revealed Resident #52 resting in bed and the gauge on the oxygen concentrator indicated the oxygen was being delivered at two L per minute. Concurrent interview with Registered Nurse (RN) #378 who was present for the observation confirmed the oxygen was being delivered at two L per minute. Further interview with RN #378 at 8:56 A.M. on 3/25/26 confirmed that the physician's order for delivery of oxygen was three L per minute. Review of the Clinical Standard Operating Procedure (SOP) titled Administration of Oxygen (reviewed 12/13/24) revealed staff are to verify the physician's order for administering oxygen. The SOP further directs staff to start the flow of oxygen at a rate of two to three Liters per minute, unless otherwise ordered. 2. Review of the medical record for Resident #33 revealed an admission date of 03/04/26. Diagnoses included paroxysmal atrial fibrillation, gastrointestinal hemorrhage, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease. Review of the admission Minimum Data Set (MDS) 3.0 assessment for Resident #33, dated 03/10/26, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The assessment indicated the resident was receiving oxygen therapy. Review of physician orders for Resident #33 revealed an order dated 02/23/26 for oxygen at two liters per minute via nasal cannula continuously and an order dated 02/23/26 to change oxygen tubing monthly. Observation on 03/25/26 at 9:14 A.M. revealed the nasal cannula was hanging on the side of the bed and was not stored in a sanitary bag. The nasal prongs were observed pressed against the side of the hospital bed. During this observation, Certified Nursing Assistant (CNA) #364 was present and observed to placed the nasal cannula on the resident without replacing it. Concurrent interview with CNA #364 confirmed the nasal cannula should be stored in a sanitary bag when not in use. Observation on 03/25/26 at 9:28 A.M. with Registered Nurse (RN) #284 revealed the oxygen concentrator was set at two and a half liters per minute. Interview at that time with RN #284 confirmed the oxygen flow rate was set above the ordered two liters per minute and no adjustment was made at that time. Review of a policy titled, Administration of Oxygen, dated 12/13/24 revealed oxygen was to be administered as ordered by the physician and equipment was to be maintained in a clean and sanitary manner when not in use. This deficiency represents non-compliance investigated under Complaint Number 1404883.

Based on record review and staff interview, the facility failed to ensure antibiotic stewardship was followed for two (Residents #11 and #12) out of four residents reviewed for antibiotic stewardship. The facility census was 52. 1.Review of the medical record for Resident #11 revealed an admission date of 02/04/26. Diagnoses included dementia, pulmonary fibrosis, anxiety, and pleural effusion.Review of the five-day Minimum Data Set (MDS) 3.0 assessment for Resident #11, dated 02/10/26, revealed a Brief Interview for Mental Status score of 10, indicating the resident had moderate cognitive impairment.Review of physician orders for Resident #11 revealed an order dated 03/09/26 for Levofloxacin (antibiotic) 500 milligrams by mouth once daily for a urinary tract infection through 03/11/26. Review of physician orders further revealed an order dated 02/04/26 indicating urine may be dipped for signs and symptoms of urinary tract infection and sent for culture and sensitivity if leukocytes were present.Review of clinical documentation revealed a late entry progress note dated 03/06/26 at 2:30 P.M. indicating the resident reported urinary frequency and cloudy urine. The Nurse Practitioner (NP) was notified and a urine analysis with culture and sensitivity was ordered.Review of laboratory results dated [DATE] revealed a urine culture positive for 50,000 to 100,000 Klebsiella aerogenes.Review of the NP progress note dated 03/09/26 revealed the resident reported urinary frequency and urgency described as needing to urinate again approximately 15 minutes after voiding with only small amounts of urine output. The resident denied fever, chills, flank pain, suprapubic pain, dysuria, hematuria, or other systemic signs of infection. Physical assessment revealed no suprapubic tenderness or costovertebral angle tenderness. The NP documented urinary tract infection and initiated Levofloxacin 500 mg daily for three days. The note referenced McGeer criteria as being met based on urinary frequency, urgency, and urine culture results.Interview on 03/24/26 at 11:15 A.M. with Assistant Director of Nursing (ADON) #570 confirmed the urinary tract infection did not meet McGeer criteria. ADON #570 stated the NP documentation was referenced as justification for antibiotic initiation; however, staff were aware the clinical criteria for McGeer were not actually met based on the resident's symptoms.Interview on 03/24/26 at 11:15 A.M. with Director of Nursing revealed awareness that antibiotics were being prescribed in situations where McGeer criteria were not met, even when provider documentation indicated criteria were met.2. Review of the medical record for Resident #12 revealed an admission date of 12/22/23. Diagnoses included malignant neoplasm of part of right bronchus or lung, severe protein-calorie malnutrition, aneurysm of other specified arteries, and enterocolitis due to Clostridium difficile not specified as recurrent.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had moderate cognitive impairment. The MDS further revealed the resident was frequently incontinent of bladder and always incontinent of bowel.Review of infection surveillance documentation revealed an infection tracker entry indicating a urinary tract infection was present and McGeer criteria were documented as being met based on urine culture colony count thresholds of 100,000 CFU/mL.Review of laboratory results dated [DATE] revealed urine culture results of 10,000-50,000 CFU/mL growth of Proteus mirabilis, Pseudomonas aeruginosa, and Enterococcus faecalis. The culture results were below the 100,000 CFU/mL threshold referenced in the infection tracker documentation and did not meet the documented criteria used to justify infection classification.Review of a provider progress note dated 11/24/2025 revealed the Nurse Practitioner (NP) documented urinary tract infectious disease after the resident reported urinary frequency and intermittent dysuria. The NP noted the resident was high risk for progression to severe infection due to a history of septic UTI and initiated Levofloxacin for three days. The note referenced McGeer criteria as being met, however, supporting laboratory results did not align with the stated threshold, and clinical symptoms documented were non-specific and insufficient alone to meet McGeer surveillance criteria.Interview on 03/26/26 at 11:04 A.M. with Assistant Director of Nursing (ADON) #570 revealed the November UTI did not meet McGeer criteria. ADON #570 stated the infection tracker incorrectly reflected 100,000 CFU/mL and confirmed the actual culture results were significantly lower. ADON #570 further stated concerns had been previously discussed with the Nurse Practitioner regarding antibiotic initiation without meeting McGeer criteria.Interview on 03/26/26 at 11:04 A.M. with DON confirmed the November UTI episode did not meet McGeer criteria based on culture results and resident presentation. DON confirmed staff awareness of ongoing concerns regarding antibiotic initiation when criteria were not met.

Based on review of resident record, observations and staff interviews, the facility failed to ensure dignity for a resident. This affected one resident (Resident #58) of three residents reviewed for dignity. The facility census was 52 residents. Findings include: Resident #58 was admitted to the facility on [DATE] and had diagnoses that included cirrhosis and ascites, mood disorder, and alcohol induced major neurocognitive disorder. Review of Resident #58's Brief Interview for Mental Status (BIMS) score on 03/23/26 revealed that he had a score of eight indicative of moderately impaired cognitive status.An observation on 03/23/26 at 2:46 P.M. revealed that Resident #58 was able to be viewed from his open room door from the hallway. Resident #58 was dressed in a gown, sitting on a shower chair, with his buttocks exposed. An interview with Certified Resident Care Associate #413 and Registered Nurse #38 on 03/23/26 at 2:46 P.M. confirmed Resident #58's exposed buttocks were visible from the hallway. Certified Resident Care Associate #413 revealed she had heard a resident in an adjacent room yell, so she left Resident #58's room quickly to check on the resident in the room next door. Certified Resident Care Associate #413 revealed in her haste, she had forgotten to shut the door or pull the privacy curtain for Resident #58. This deficiency represents non-compliance investigated under Complaint Number 1404883.

Based on observation, record review, staff interview, review of protective cream labels, and review of facility policy, the facility failed to ensure a Stage 3 pressure ulcer present upon admission received treatment and failed to ensure proper linens were used with a pressure reducing mattress to promote healing of the pressure ulcer for one (Resident #3) of three residents reviewed for pressure ulcers. The facility census was 52. Findings include:Review of the medical record revealed Resident #3 was admitted on [DATE]. Diagnosis included hypertensive chronic kidney disease and peripheral vascular disease. Review of the Wound Management note dated 09/23/25 revealed Resident #3 had a Stage 3 pressure ulcer to the coccyx measuring 3 centimeters (cm) by 2 cm by 0.2 cm deep. The wound had serosanguineous drainage and the surrounding skin was a dark purple or rusty discoloration.Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition and was assessed to have a stage 3 pressure ulcer. Review of the care plan dated 09/30/25 revealed Resident #3 had a pressure ulcer. Interventions included pressure reducing mattress, treatment per physician order, and notify physician if treatment not effective. Review of the Physicians Orders revealed an order dated for 09/23/25 to cleanse skin with personal cleanser and apply protective ointment/cream as needed after each incontinence episode twice a day. On 10/01/25 an order was provided for treatment to coccyx wound cleanse with wound cleanser or normal saline, pat dry, apply skin prep to periwound, apply hydrogel, and cover with foam, change dressing as needed. Observation on 10/14/25 at 3:00 P.M. of Resident #3's wound care with Assistant Director of Nursing (ADON) #10 revealed the resident was observed on a low air loss mattress covered with a fitted sheet, a cloth bed pad for repositioning and wearing an incontinence brief. Observation of the wound revealed no drainage, surrounding tissue appeared red and the center of the wound had a yellow discoloration. The ADON's wound measurements revealed 1.0 cm long by 0.7cm wide. The surrounding redness measured 2.5 cm. Review of the Thera Calazinc Body Shield (protective cream) revealed a warning label which read Do not use on deep or puncture wounds. Review of the low air loss mattress user manual titled Med Aire Plus 10 Alternating Pressure and Low Air Loss Bariatric Mattress Replacement System by Drive Medical, revealed under the heading Recommended Linen: Drive DeVilbiss Healthcare bed support surfaces are designed to be used with appropriate linens. Deep pocketed fitted or flat sheets are recommended. Multiple layering of linens or under pads beneath the patient should be avoided, when possible, for the prevention and treatment of pressure injuries. Interview on 10/14/25 at 3:30 P.M. with ADON #10 revealed on 09/23/25 Resident #3 was admitted with a Stage 3 pressure ulcer. The treatment ordered was a barrier cream. ADON #10 verified the order to treat the pressure ulcer on 09/23/25 was for a protective cream that was still in place to use with incontinent care. ADON #10 verified the wound on admission was a stage 3 pressure ulcer with depth and that would be a deep wound. ADON #10 stated the protective cream is a routine order and ordered at admission and no dressing was used to cover the pressure ulcer until 10/01/25. ADON #10 confirmed the SR#3 had multiple layers between wound and low air loss mattress and the user manual recommends avoiding multiple layers.This deficiency represents non-compliance investigated under Complaint Number 2637068.

Based on record review, interview and policy review, the facility failed to maintain a water management plan that included monitoring measures and acceptable ranges and failed to identify the presence of abnormal test results and take appropriate action. This had potential to affect all facility residents. The facility census was 39. Findings include: Review of microbiological analyses dated 01/25/24 of the water system revealed lab results should be maintained between 0.1 and 0.9. Of 14 areas tested in the nursing facility, two had abnormal reading and should have had site flushing and consider disinfection and five areas had abnormal readings and should have had site flushing and immediate site disinfection. Several areas of the connected assisted living were also tested with five of six testing in the abnormal range requiring flushing and disinfection. Review of the Legionella Water Management Plan dated 03/05/24 revealed monthly testing would be completed of the cold and hot water for hardness, total alkalinity and ph testing, water temperatures shall be done weekly and visual inspections should be done of the sinks showers and toilets daily. The plan did not include information on the acceptable ranges for each measure. Review of facility documentation revealed some weekly temperatures were logged but no range of acceptable limits and no evidence of monthly testing of water hardness, alkalinity and PH testing were found or provided. During an interview on 05/29/24 at 12:35 P.M., Corporate Maintenance (CM) #146 stated the facility completed testing and confirmed if over 9.9 should complete flush and retest if over 10 should complete flushing and disinfectant. CM revealed facility did not complete any flushing or disinfectant and confirmed abnormal test results up to 248. CM confirmed they needed to get lab results from GFS (contracted water testing company), but stated he was unsure what information the lab company would be able to provide. He also revealed facility should have acceptable ranges for all the testing measures, but was unable to provide upon request. CM confirmed the facility water management plan did not include specific measures or ranges staff look for or interventions if outside the acceptable ranges. Review of the facility policy titled Guidelines for Water Management, dated 12/31/23, revealed facility shall establish procedures to reduce the risk of Legionella in the facilities water system. The policy stated based on the risk assessment, control measures would be established to address potential hazards. Testing protocols and acceptable ranges would be established for each measure. The individual responsible would document findings. If control limits (ranges) were not maintained, corrective actions would be taken and documented.

Based on record review, interview, and policy review, the facility failed to implement care plans regarding care needs for seven (Residents #27, #34, #36, #190, #194, #3, #13 and #28) residents. The facility census was 39. Findings include: 1. Review of medical record for Resident #27 revealed admitted [DATE] with diagnoses including syringomyelia and syringobulbia, ventricular tachycardia, Charocot's joint right elbow, spinal stenosis, anxiety, depression, chronic pain, hypertension, and localized swelling, mass and lump, unspecified upper limb. Review of care plan revealed no interventions regarding the use of mobility bars or interventions that can be reviewed and what the facility was monitoring. 2. Review of medical record for Resident #34 revealed admitted [DATE] with diagnoses including fracture of superior rim of right pubis, fracture of sacrum, atrial fibrillation, mantle cell lymphoma, malignant neoplasm of breast, anemia, hypertension, and pain. Review of MDS assessment dated [DATE] revealed the resident was cognitively intact. The resident required extensive assistance for ADL. Review of care plan revealed no interventions regarding the use of psychotropic medications or the use of mobility bars or what the facility was monitoring. 3. Review of medical record for Resident #36 revealed admitted [DATE] with diagnoses including but not limited to nondisplaced trimalleolar fracture of right lower leg, atrial fibrillation, cardiomegaly, intervertebral disc degeneration lumbar region, and hypertension. Review of MDS dated [DATE] revealed the resident was cognitively intact. Resident #36 required extensive assistance for ADL. Review of care plan revealed no interventions regarding the use of mobility bars and what the facility is monitoring. The care plan profile guide contained intervention walking/mobility devices: wheelchair, may use mobility bars as enabler for safe transfers or increased mobility. 4. Review of medical record for Resident #190 revealed admitted [DATE] with diagnoses including but not limited to fracture of neck of left femur, urinary tract infection, congestive heart failure, anemia, anxiety, irritable bowel syndrome without diarrhea, hemorrhoids, and personal history of malignant neoplasm of kidney. Review of MDS dated [DATE] the resident had severe cognitive impairment. The resident required extensive assistance for ADL. Review of care plan revealed on interventions regarding psychotropic drug use or the use of mobility bars or what the facility was monitoring. 5. Review of medical record for Resident #194 revealed admitted [DATE] with diagnoses including but not limited to sepsis, endocarditis, hypotension, dementia, anemia, mild cognitive impairment, suicidal ideation, and poisoning by 4-aminophenol derivatives accidental. Review of MDS dated [DATE] revealed Resident #194 was cognitively intact. Resident #194 required extensive assistance for ADL. Review of care plan revealed no interventions for mobility bars or psychotropic drug use or what the facility was monitoring. During an interview on 05/29/24 at 2:57 P.M., MDS Nurse #137 verified that the care plan and interventions for the psychotropic drugs for Resident #34, Resident #190 and Resident #194 were not in place. During an interview on 05/30/24 at 12:34 P.M., Director of Nursing (DON) and Corporate Registered Nurse (CRN #145) verified that there were no care plans for side rails to include what will be monitored. CRN #145 stated the care plans use the terminology of may use side rails in case the facility/resident decided they did not want side rails they would not have to change the care plan. Both verified the care plans did not include the actual use of the side rails for the residents. Review of the policy titled Guidelines for Restraint/Enabler Use, revised 12/31/23, revealed a comprehensive care plan shall be developed that addresses medical symptoms, safety issues because of restraint/enabler use, based on informed choice with the risks and benefits explained, an observation trilogy informed consent for restraint/enabler should be completed in the resident's electronic health record (EHR), identifies measures to minimize the risk of resident decline and maintain strength and mobility, is reviewed as necessary, at least quarterly. 44070 6. Record review for Resident #3 revealed an admitted [DATE]. Diagnoses included chronic respiratory failure, major depression, altered mental status, dysphagia, cognitive communication deficit. Review of the MDS assessment dated [DATE] revealed Resident #3 was cognitively impaired. Resident #3 had a physician order dated 03/19/24 to take out hearing aides every evening and an order dated 05/09/24 to place hearing aides in ear every morning. Resident had one for both ears and informed staff to listen for a whistle and if a whistle was not heard to change the battery. Review of the care plan revealed the resident had hearing loss. Hearing aides were not included on the care plan and no interventions on monitoring hearing loss and hearing aides was available. During an interview on 05/30/24 at 10:38 A.M., Resident #3's representative stated the resident wore hearing aides. She stated she had a care meeting with the facility and asked for them to ensure staff to put in hearing aides and ensure they have active battery life. During an interview on 05/30/24 at 1:33 P.M., the DON stated she thought a care plan was in place as the orders had been changed recently regarding the hearing aide placement. The facility was unable to provide evidence of a care plan for hearing loss or hearing aides. 49039 7. Review of the medical record for Resident #13 revealed an admitted [DATE] with diagnosis that included osteoporosis, muscle weakness, hemiplegia, and hemiparesis. Review of MDS quarterly assessment completed on 01/21/24 revealed Resident #13 was dependent with toileting, showering, dressing and ambulation. Resident #13 was severely cognitively impaired. Review of the occupational therapy plan dated 03/21/24 revealed Resident #13 was to tolerate wearing a splint on her left hand/wrist for four hours per day with a target date of 05/15/24. Review of skilled services note for 05/14/24 revealed orthotic management was in place at this time due to contracture management and to decrease risk of skin breakdown. Review of the physician order dated 05/14/24 revealed an order for a left hand/wrist splint for six hours per day. Review of the care plan for Resident #13 revealed this resident has impairment in functional status related to decreased mobility and dependence in mobility. Review of care plan revealed no information regarding a splint. During an interview on 05/30/24 12:56 P.M., the DON , Corporate Nurse #145 and Assistant Director of Health Services #62 verified Resident #13's care plan was not updated to reflect current splint use. 8. Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses that included encephalopathy, Parkinson disease, depression, insomnia, altered mental status and repeated falls. Review of Resident #28's elopement admission assessment completed on 07/24/23 revealed unknown elopement risk per family, states he lives alone and they are unaware of elopement risk. Review of care plan dated 01/10/24 for Resident #28 dated 07/31/24 revealed this resident was at risk for cognitive status decline. Nursing interventions included assess for change in level of consciousness. Review of the MDS quarterly assessment dated [DATE] revealed this resident was moderately cognitively impaired, did not wander, and wanderguard was not implemented. Review of physician order dated 04/15/24 revealed change wander device one month before expiration date. Review of physician order dated 05/20/24 check function and placement of wandering alter bracelet/device daily. Review of progress notes dated 05/13/25 revealed Resident #28 wheeled himself down the service hallway and out the service door. Resident #28 walked 15 feet into the parking lot, when found he was escorted back into building and put with staff with one to one care. Review of exit seeking event report dated 05/15/24 revealed Resident #28 was seen exiting the building, change in plan of care was initiated with wandering alert device applied and one to one observation implemented. During an observation on 05/29/24 at 11:01 A.M., Licensed Practical Nurse (LPN) #125 confirmed Resident #28 had a wander guard implemented due to elopement risk. During an interview on 05/30/24 12:56 P.M., the DON, Corporate Nurse #145 and Assistant Director of Health Services #62 verified Resident #28 was seen exiting the building and the care plan was not updated to reflect current wandering behaviors. Record review of elopement policy dated 12/31/23 revealed staff are required to implement elopement interventions and update the residents care plan.

Based on observation, interview, and policy review the facility failed to ensure medications were not left at the bedside. This affected one (Resident #30). The facility identified four mobile cognitively impaired residents (#3, #26, #28, and #248) in the facility. The facility census was 39. Findings included: Review of medical record for Resident #30 revealed admitted [DATE] with diagnoses including multiple sclerosis, anemia, shock, gastrointestinal hemorrhage, sepsis, hypertensive heart disease with heart failure, congestive heart failure, non-ST elevations (NSTEMI) myocardial infarction, pleural effusion, and cardiomyopathy. Review of minimum data set (MDS) dated [DATE] revealed a which indicated Resident #30 was cognitively intact. Review of current physician orders revealed that from 7:00 P.M.-11:00 P.M. the following medications were to be administered: Atorvastatin 80 milligrams (mg) (cholesterol), carvedilol 3.125 mg (heart), entresto 24-26 mg (heart), hydroxyzine 25 mg (itching), and melatonin 6 mg. Review of Medication Administration Record (MAR) for May 2024 revealed the above six medications were marked as given by the nurse on 05/28/24. During an observation on 05/29/24 at 7:52 A.M., there were medications in medication cup at bedside for Resident #30. Six medications were in the cup. Resident #30 was not in the room. During an interview on 05/29/24 at 7:53 A.M., Licensed Practical Nurse (LPN) #115 verified that six pills were left on the overbed table in Resident #30's room and the resident was not in the room. LPN #115 stated she did not pass his medications. During an interview on 05/29/24 at 8:24 A.M. the Director of Nursing (DON verified the medications were from the night shift medication pass. Review of policy titled Medication Administration General Guidelines revised January 2018 revealed the resident is always observed after the administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, and action is taken as appropriate.

Based on record review, interview and policy review the facility failed to ensure signed consents were completed and vaccinations were administered timely for pneumonia and flu vaccines. This affected three (Residents #14, #25, and #28) of five residents revealed for vaccinations. Facility census was 39. Findings include 1. Review of the medical record for Resident #28 revealed an admitted [DATE]. Review of the vaccination consents dated 07/25/23 revealed Resident #28 consented to have the flu vaccine administered. Review progress notes dated 08/14/24 revealed a phone call to the resident's responsible party who agreed to Resident #28 receiving the pneumonia vaccine. The vaccine was given Pneumonia was given on 08/19/23. Review of the vaccination consents dated 10/20/23 revealed Resident #28 consented to have the flu vaccine administered. The flu vaccine was administered on 10/30/23. 2. Review of the medical record for Resident #14 revealed an admitted [DATE]. Review progress notes dated 06/28/23 revealed the resident's responsible party was contacted regarding an order for a pneumonia vaccine. The vaccination was given on 06/28/23. The facility was unable to provide evidence of any consent being signed for the pneumonia vaccination. 3. Review of the medical record for Resident #25 revealed an admitted [DATE]. Review of the vaccination consents dated 11/01/23 revealed Resident #25 consented to have the pneumonia vaccine administered. Review of vaccination administration record revealed no evidence the pneumonia vaccine was administered. The administration record stated this vaccine was refused, but no notation or consent was refused. During an interview on 05/29/24 at 3:01 P.M., Assistant Director of Nursing (ADON) #62 stated the facility was unable to provide evidence Resident #25 received the pneumonia vaccine or that consents had been signed for Residents #28 and #14. Review of facility policy titled, Influenza, Pneumococcal and COVID-19 Immunizations, dated 12/31/23 revealed Resident or representative would complete a signed an informed consent indicating acceptance/refusal of immunization. A copy shall be retained in the medical record. The policy also stated each resident shall receive the immunization per resident/representative request.

Based on record review, interview, and policy review the facility failed to assess and/or obtain consents or orders for the use of bed rails. This affected six (Residents #27, #34, #36, #190, #194, and #196) of six reviewed for bed rails. The facility identified 29 residents who use side rails. The facility census was 39. Findings include: 1. Review of medical record for Resident #27 revealed admitted [DATE]. Review of the Minimum Data Set (MDS) assessment revealed the resident was cognitively intact. Resident #27 required extensive assistance to dependent on staff for activities of daily living (ADL) . Review of observations revealed bed rail assessment and bed rail informed consent were completed on 06/28/23. No further documentation or assessments completed after first assessment. Review of current physician orders revealed no order for bed rails. 2. Review of medical record for Resident #34 revealed admitted [DATE]. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. The resident required extensive assistance for ADL. Record review revealed no bed rail assessments or consent for enabler/mobility bars. Review of current physician orders revealed no order for bed rails. 3. Review of medical record for Resident #36 revealed admitted [DATE]. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. Resident #36 required extensive assistance for ADL. Record review revealed no bed rail assessments or consent for enabler/mobility bars. Review of current physician orders revealed no order for bed rails. 4. Review of medical record for Resident #190 revealed admitted [DATE]. Review of the MDS dated [DATE] revealed the resident had severe cognitive impairment. The resident required extensive assistance for ADL. Record review revealed no bed rail assessments or consent for enabler/mobility bars. Review of current physician orders revealed no order for bed rails. 5. Review of medical record for Resident #194 revealed admitted [DATE]. Review of the MDS assessment dated [DATE] revealed Resident #194 was cognitively intact. Resident #194 required extensive assistance for ADL. Record review revealed no bed rail assessments or consent for enabler/mobility bars. Review of current physician orders revealed no order for bed rails. 6. Review of medical record for Resident #196 revealed admitted [DATE]. Review of the MDS dated [DATE] revealed Resident #196 had severe cognitive impairment. Resident #196 required extensive assistance for ADL. Record review revealed no bed rail assessments or consent for enabler/mobility bars. Review of current physician orders revealed no order for bed rails. During an interview on 05/29/24 at 8:24 A.M., the Director of Nursing (DON) verified the bed rail assessments and consents are located under the observation tab in the electronic health record. During an interview on 05/29/24 at 1:50 P.M., the DON verified that no bed rail assessments were located in the electronic health record. Review of policy titled Guidelines for Restraint/Enabler Use, dated 12/31/23, revealed each resident will have an individualized nursing observation upon admission, quarterly, and as needed that shall address the need for a safety device, medical symptom for use of the device and identification of whether the device restricts movement or limits the resident from doing something they could previously do. An order shall be obtained that specifies the type of restraint/enabler and reason for use, a comprehensive care plan shall be developed that addresses medical symptoms, safety issues because of restraint/enabler use, based on informed choice with the risks and benefits explained, an observation trilogy informed consent for restraint/enabler should be completed in the resident's electronic health record (EHR), identifies measures to minimize the risk of resident decline and maintain strength and mobility, is reviewed as necessary, at least quarterly.

Based on record review, observations and interview the facility failed to ensure a the correct catheter bag was used to prevent urine reflux into Resident #28 bladder. This affected one (Resident #28) of three residents reviewed for urinary catheters. The facility census was 39. Findings include: Review of the medical record for Resident #28 revealed an admitted [DATE] with a primary diagnosis of urinary tract infection as secondary diagnoses of infection and inflammatory reaction due to indwelling urethral catheter, chronic kidney disease, benign prostatic hyperplasia with lower urinary tract symptoms and retention of urine. Review of admission assessment completed on 05/25/25 revealed Resident #28 has a urinary catheter. Direct care staff were required to monitor for signs of infection or worsening infection, and he required assistance or supervision for transfer and ambulation. Review of Resident #28's care plan with a start date of 05/28/24 revealed this resident uses a foley catheter for diagnosis of obstructive uropathy and direct care staff should maintain a closed system with urinary bag below the resident's bladder. Observation of Resident #28 on 05/29/24 at 10:10 A.M. and 2:01 P.M. revealed this resident was laying in bed with a leg bag at bladder level. Observation of the tubing revealed the urine was not flowing freely into the catheter bag. During an interview on 05/29/24 at 2:01 P.M., Registered Nurse (RN) #118 stated the facility does not provide leg bags and the bag was from his most recent hospital discharge on 05/25/24. The nurse confirmed the leg bag should have been switched over to a regular catheter bag. She confirmed that Resident #28 was still utilizing a urinary catheter leg bag and it was at bladder level. RN #118 confirmed the catheter should be below his bladder.

Based on observation, record review and interview, the facility failed to ensure a resident was assessed prior to removal of a Wanderguard bracelet. This affected one (Resident 321) of two residents reviewed for wandering and elopement. The facility census was 39. Findings include: Review of the medical record for Resident #21 revealed an admitted [DATE]. Diagnoses included dementia, heart disease, edema, cognitive communication deficit and muscle weakness. Review of care plan dated 06/30/22 revealed resident was at risk of elopement and wandering with intervention for a Wanderguard bracelet to the right wrist for exit seeking behaviors entered on 08/24/22. Review of Physician order dated 01/12/24 stated to check function of wander alert bracelet daily. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was severely cognitively impaired. Review of the assessment dated [DATE] documented Resident #21 remained at risk for elopement and the current intervention, a Wanderguard bracelet, was left in place. Review of a progress note dated 05/17/24 documented Resident #21's Wanderguard bracelet was removed. The note did not specify reasoning or what precipitated the removal. During an interview on 05/29/24 at 12:06 P.M., Registered Nurse (RN) #118 stated Resident #21 may have had the Wanderguard bracelet removed. She was unsure why it was removed and confirmed facility had no assessment prior to removal that showed Resident #21 was no longer an elopement risk. RN #118 went to Resident #21 and checked her arms and legs and confirmed no Wanderguard bracelet was in place. During an interview on 05/29/24 at 4:33 P.M., the Administrator, Director of Nursing (DON), Assistant DON #62, and Corporate Nurse #145 confirmed facility had no documentation of Resident #21 being reassessed for elopement risk prior to the Wanderguard bracelet being removed. Review of facility policy titled, Elopement Risk Assessment and Prevention dated 12/31/23 revealed facility would assess residents for elopement risk upon admission, quarterly and upon change in condition.

Based on record review, interview, and policy review the facility failed to address bed rails on the baseline care plan. This affected one (Resident #196) of three residents reviewed for baseline care plans. The facility census was 39. Findings include: Review of medical record for Resident #196 revealed admitted [DATE] with diagnoses including wedge compression fracture of T 11-T 12 vertebra, displaced intertrochanteric fracture of left femur, cardiac arrhythmia's, dementia, depression, hypertension, pain, and unspecified fall. Review of the Minimum Data Set (MDS) assessment, dated 05/23/24, revealed the resident had severe cognitive impairment. Resident #196 required extensive assistance for activities of daily living. Review of baseline care plan dated 05/19/24 revealed no mention of the use of bed rails/mobility bars to the bed. Review of care plan revealed on 05/29/24 in Resident #196 profile care guide was added for walking/mobility devices: may use mobility bars as enabler for safe transfers or increased mobility. No care plan was added to address the actual use of mobility bars and interventions as to what to monitor. During interview on 05/30/24 at 2:45 P.M., MDS Support #147 verified enabler/mobility bars was not checked on the baseline care plan on admission. Review of policy titled Comprehensive Care Plan Guideline revised on 05/22/18 revealed a 48-hour baseline care plan will be completed within 48 hours of admission and will be the temporary working care plan until the comprehensive care plan is completed per guidelines.

Based on record review, observation, interview and manufacturer's instruction review, the facility failed to prime an insulin pen prior to administration, resulting in a signficant medication error. This affected one (Resident #23) of five residents observed during medication pass. The facility census was 39. Findings include: Review of medical record for Resident #23 revealed admitted [DATE] with diagnoses including type two diabetes. During an observation on 05/29/24 at 11:27 A.M., Licensed Practical Nurse (LPN) #115 was preparing to give Resident #23 six units of lispro insulin. LPN #115 dialed up six units of insulin without priming the insulin pen. LPN #115 then administered the insulin to Resident #23. During an interview on 05/29/24 at 11:35 A.M., LPN #115 verified she did not prime the insulin pen prior to administering the insulin to Resident #23. LPN #115 stated she did not know that she was supposed to prime the pen. Review of insulin lispro KwikPen insert on accessdata.fda.gov/drugsatfda_docs/label revealed prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime the pen, turn the dose knob to select 2 units. Hold the pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top, continue holding the pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count slowly to 5. You should see insulin at the tip of the needle. If you do not see insulin, repeat the priming steps, but not more than 4 times. If you still do not see insulin, change the needle and repeat the priming steps.

Based on record review, observations, resident and staff interviews, and policy review, the facility failed to provide residents with assistance with activities of daily living (ADL) including oral care and/or bathing services. This affected two (#30 and #35) out of six residents reviewed for ADL/personal hygiene. Facility census was 42. Findings include: 1. Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include displaced fracture of base of neck of right femur, cerebral ischemia, celiac disease, anxiety disorder, aphasia, and unspecified nausea with vomiting. Review of the admission minimum data set (MDS) dated [DATE] revealed the resident was cognitively intact, had no behaviors, and required assistance from staff for ADL's. Interview with Resident #30 on 12/05/23 at 11:40 A.M. revealed the resident stated she was supposed to have a shower the day before but it did not happen and she could not remember why. Resident #30 stated she had not had any assistance to clean her teeth since her admission on 11/28/23. Observation of Resident #30's room and interview with state tested nursing assistant (STNA) #355 on 12/05/23 at 11:50 A.M. confirmed there were no supplies (toothbrush, toothpaste mouth wash, or emesis basin) in the room or bathroom to brush the Resident #30's teeth. STNA #355 verified Resident #30 was on her assignment and she had not provided oral care to the resident on this day. STNA #355 verified there were no supplies in Resident #30's room for providing oral care to the resident. While in the room with STNA #355, Resident #30 asked why she did not get her shower on the day before and STNA #355 stated you did not feel well and did not want the shower and we washed you up in bed instead, the resident replied oh that's right. STNA #355 verified Resident #30's teeth had not been brushed on the prior day. Interview with STNA #315 on 12/06/23 at 11:10 A.M. confirmed oral care should be provided every morning to the residents, and showers are provided twice weekly or as desired by the resident. 2. Review of Resident #35's medical record revealed 35 the resident was admitted [DATE]. Diagnoses include traumatic subarachnoid hemorrhage without loss of consciousness, diffuse traumatic brain injury, protein calorie malnutrition, obesity, dementia, and type two diabetes. Review of the admission MDS dated [DATE] revealed the resident was cognitively impaired, had no behaviors required assist from staff for ADL's. Review of Resident #35's bathing documentation revealed the resident had no shower/bathing service documented at the facility from 11/03/23 through 11/10/23. Interview with STNA #315 on 12/06/23 at 11:10 A.M. confirmed showers are provided twice weekly or as desired by the resident. Interview with the Director of Nursing (DON) on 12/06/23 at approximately 4:30 P.M. confirmed Resident #35 had no documented shower or bathing services from 11/03/23 through 11/10/23 verifying that seven days without being washed up was too long. Review of a facility policy titled Guidelines for Bathing Preference, dated 05/11/16 last revised 12/31/22 revealed the purpose is to establish a personal preference bathing routine. The resident will be advised of Trilogy's guidelines for residents to self-determine their plan of care and schedule during their stay in the campus. Bathing shall occur at least twice a week unless resident preference states otherwise. This deficiency represents non-compliance investigated under Complaint Number OH00147793.

Based on medical record review, observations and staff interviews, the facility failed to provide a resident with medication as ordered by the physician which resulted in a significant medication error when the resident was provided a medication he was not ordered and the medication was listed as a mediation the resident was allergic to. This affected one (#45) out of two residents observed for medication administration. Facility census was 42. Findings include: Review of Resident #45's medical record revealed the resident was admitted to the facility on [DATE]. Diagnosis include fractured femur, chronic respiratory failure, type two diabetes, cardiomyopathy, peripheral vascular disease, asthma and hypertension. Resident #45 had allergies listed as Atorvastatin (statin) with reaction of severe weakness stating statin's other than Rosuvastatin (statin) cause problems, Liraglutide (incretin mimetics) reaction nausea and vomiting, Nortriptyline (antidepressant) dizziness. Review of Resident #45's orders revealed the resident had orders for Rosuvastatin 10 mg daily for hyperlipidemia, daily 7:00 P.M.-10:00 P. M. dated 11/23/23. Further record review revealed there was no order in Resident #45's medical record for Atorvastatin 40 mg. Resident #45 had an order that indicated may use generic equivalents unless otherwise stated dated 11/22/23. Review of Resident #45's physician progress note dated 11/24/23 at 10:36 P.M. revealed the resident had a hospital stay related to a left femoral fracture, pain, muscle weakness, nausea, and diabetes. The fracture occurred as result of a fall and he was medically stabilized and transferred to the nursing facility for ongoing care and therapy. Observation of medication pass on 12/06/23 revealed Resident #45 was provided Atorvastatin (statin) 40 mg at 8:29 A.M. by Licensed Practical Nurse (LPN) #400. During the medication pass LPN #400 removed one medication Lasix (diuretic) 20 mg as the resident was leaving for an appointment and the family requested the medication to be administered when the resident returned from the appointment. LPN #400 verified no other medications were removed from the morning medication pack. Interview on 12/06/23 at 9:45 A.M. with Clinical Nurse Consultant (CNC) #375 confirmed Atorvastatin 40 mg was not ordered for Resident #45. Observation of the 12/06/23 morning medication pack for Resident #45, CNC #375 confirmed the pack had Atorvastatin 40 mg listed as included in the pack which was administered to the resident on 12/06/23. Observation of the medication cart with CNC #375 on 12/06/23 at 10:00 A.M. confirmed the medication packs supplied from pharmacy for Resident #45 had Atorvastatin 40 mg in the morning medication packs, and the evening medication packs did not contain Rosuvastatin 10 mg. Observation of Resident #45's medication administration record (MAR) with CNC #375 on 12/06/23 at 10:05 A.M. confirmed the staff were documenting Resident #45 was receiving Rosuvastatin 10 mg every night however the medication was not in the medication packs that were available in the medication cart to administer to the resident, and there was no record of an order for Atorvastatin for Resident #45 which was the medication included in his morning medication packs and was observed to be administered to the resident on 12/06/23 at 8:29 A.M. Interview with CNC #375 on 12/06/23 at 10:45 A.M. revealed the pharmacy had a therapeutic interchange for Rosuvastatin to be changed to Atorvastatin for residents in the facility. It was asked if the pharmacy routinely interchanged medication when the resident was documented as allergic to the medication. CNC #375 stated she would not think so but the Atorvastatin was documented to cause weakness in Resident #45. CNC #375 verified there was no documentation in the medical record indicating Resident #45's practitioner was asked if Resident #45 could have Atorvastatin administered instead of Rosuvastatin. CNC #375 confirmed Resident #45 was at the facility to receive therapy services after a fall at home. Interview on 12/06/23 at 1:26 P.M. with Certified Nurse Practitioner (CNP) #350 revealed she would expect pharmacy to not complete a therapeutic interchange and provide a resident medications they were allergic to. CNP #350 verified she had not been asked if she wanted or if it was ok to change the Rosuvastatin to Atorvastatin for Resident #45. CNP #350 verified Resident #45's hospital paperwork revealed all statin's except Rosuvastatin caused issues for Resident #45. CNP #350 verified Resident #45's facility medical chart including his pharmacy orders listed Atorvastatin as an active allergy for the resident. CNP #350 verified Resident #45 was at the facility to gain strength after a fall with a fracture occurred at his home. This deficiency represents non-compliance investigated under Complaint Number OH00147793.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, and facility policy review, the facility failed to provide the required physical assistance for a resident during incontinence care. This resulted in Actual Harm to Resident #34 when one staff person (instead of the required two staff) attempted to provide incontinence care and the resident fell out of bed resulting in the resident sustaining fractured ribs. This affected one (Resident #34) of three residents reviewed for falls. The total facility census was 32. Findings Include: Review of the medical record for Resident #34 revealed he was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease, acute and chronic respiratory failure, congestive heart failure, atrial fibrillation, atherosclerotic heart disease, depression, diverticulitis, Type II diabetes, benign prostatic hyperplasia, dependence on supplemental oxygen, muscle weakness, and dysphagia. Review of Resident #34's Minimum Data Set (MDS) assessments, dated 07/28/22 and 10/28/22, revealed the resident needed extensive assistance of two person physical assistance for bed mobility. The MDS assessment, dated 10/28/22, revealed the resident was cognitively intact. Review of Resident #34's care plan, dated 01/10/22, revealed the care plan did not specify how many staff were required to assist the resident during bed mobility tasks. Review of Resident #34's Activities of Daily Living (ADL) Point of Care documentation, dated 09/01/22 to 10/30/22, revealed 40 bed mobility opportunities in which two staff were present, and 63 bed mobility opportunities in which one staff was present. This information identified that 38.9 percent of the bed mobility opportunities were completed as indicated on the MDS assessments of 07/28/22 and 10/28/22. Review of Resident #34's Investigation Summary, dated 10/28/22, revealed that Resident #34 was in his bed when one staff [State tested Nursing Aide (STNA) #400] requested his assistance when they were performing incontinence care in his bed. Resident #34 reached for his grab bar to assist with turning, missed the grab bar, and fell out of his bed. Resident #34 was transferred to the hospital, where it was determined he had three fractured ribs. Interview with the Director of Health Services (DHS) and Regional Director #300 on 11/19/22 at 12:24 P.M. and 1:30 P.M. confirmed there was only one staff person in Resident #34's room completing incontinence care at the time of the fall on 10/28/22. DHS and Regional Director #300 confirmed Resident #34's MDS assessments since admission, but specifically on 07/28/22 and 10/28/22, identified that he was to have two staff in his room providing assistance during bed mobility activities. They confirmed Resident #34 had a mixture of one and two person physical assistance with bed mobility in the last two months, but the documentation did support the MDS assessments that identified Resident #34 required two person physical assistance. Review of the facility Fall Management Program Guidelines, dated 03/16/22, revealed the facility strives to maintain a hazard free environment, mitigate fall risk factors, and implement preventative measures. A fall is considered to be a unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Should the resident experience a fall, the attending nurse shall complete the fall event. This includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions. The deficiency was corrected on 11/02/22 when the facility implemented the following corrective actions: On 10/28/22 at 5:45 A.M., Resident #34 was sent to the hospital for further assessment of potential injuries. It was determined he had three fractured ribs. On 10/28/22, Assistant Director of Health Services (ADHS) #109 provided education to State tested Nursing Aide (STNA) #400 that was directly involved with providing incontinence care for Resident #34 by herself. Education included ensuring the bed wheels are locked, if resident needs two person assist, call for help, and resident bed should not be in the high position during care. On 10/28/22 and 10/29/22, MDS Coordinator #127 provided education to all nursing staff regarding proper incontinence care while residents are in bed, and an update for Resident #34's care to be two person assistance for bed mobility tasks. On 10/30/22, the facility completed full resident audits of MDS and functional assessments to determine accuracy. All resident assessments were updated on that day if they needed to be changed. On 11/02/22 through 11/19/22, audits were completed of five residents per week who needed two person assistance with bed mobility for three weeks. No issues were identified. There were no identified incidents or injuries regarding lack of required assistance provided to residents between 10/28/22 and 11/19/22, the time of the onsite complaint investigation. This deficiency represents non-compliance investigated under Complaint Number OH00137187.

Based on observations, closed medical record review, staff interviews, medical staff interviews, and manufacturer's document review, the facility failed to ensure Resident #14 was free from accident hazards when she sustained [CONDITION(S)] to her bilateral groin areas and right anterior hip area, caused by the hot coffee provided within the facility. Actual harm occurred to Resident #14 when Resident #14 transported her coffee without using a lid and the coffee spilled on her lower extremities, resulting in second degree [CONDITION(S)] (involves the first two layers of skin and may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin) to her bilateral groin, abdomen, and right anterior hip areas. Subsequently, Resident #14 presented to the Burn Clinic with third degree [CONDITION(S)] (a type of burn that destroys the skin and may damage the underlying tissue. They are more severe than first and second [CONDITION(S)] and always require skin grafts). This affected one (#14) of three residents reviewed for accident hazards. The facility census was 16. Findings include: Review of the closed medical record for Resident #14 revealed an admitted [DATE]. Diagnoses included localized-related symptomatic [CONDITION(S)] and epileptic syndromes with simple partial seizures, type II diabetes mellitus with [CONDITION(S)] and diabetic polyneuropathy, and personal history of [CONDITION(S)] (TIA) and cerebral infarction without residual deficits. Review of Resident #14's face sheet revealed Resident #14 had a legal guardian in place due to brain surgery (removal of frontal lobe) and [CONDITION(S)]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/24/22, revealed Resident #14's Brief Interview for Mental Status (BIMS) score was 12, which indicated she had impaired cognition. Review of Resident #14's progress notes, dated 01/28/22, revealed Resident #14 was observed in the hallway with a full cup of coffee in her hands and no lid. Staff asked if she wanted a lid and she declined vigorously, stating she would not spill her coffee. Review of Resident #14's progress notes, dated 01/31/22, revealed on 01/31/22 between 12:25 P.M. and 1:00 P.M., Registered Nurse (RN) #121 heard Resident #14 yell and immediately went to the dining room area to find Resident #14 with hot coffee around her mid-section. Resident #14 was taken to her room, had her pants/undergarments removed to have her groin, abdomen, and hip areas assessed. RN #121 documented the areas were red, skin was peeling, and beginning to blister. Certified Nurse Practitioner (CNP) #161 was contacted immediately and provided new orders to treat her [CONDITION(S)]. Review of the facility's witness statement, written by Housekeeping Director #134, dated 01/31/22, revealed Housekeeping Director #134 saw Resident #14 at the coffee machine on 01/31/22. Housekeeping Director #134 went to assist Resident #14 by taking her cup, dispensing the coffee into her cup, and placing it on the counter. Housekeeping Director #134 was then going to assist Resident #14 with putting the creamer in her coffee, when Resident #14 grabbed the coffee cup (without a lid on it), placed it between her legs, and wheeled her wheelchair away. Shortly after doing this, Housekeeping Director #134 heard a yell and saw that Resident #14 had spilled coffee on her lap area. That was when RN #121 came out and assisted Resident #14 to her room to be cared for. Review of the physician orders, dated 01/31/22, revealed an order for [MEDICATION(S)] cream 4% apply topically as needed three times per day for pain, [MEDICATION(S)] 50 milligrams (mg) every six hours as needed for severe pain, ibuprofen 600 mg every six hours for mild to moderate pain, and [MEDICATION(S)] four mg every six hours as needed for nausea/vomiting. Review of Resident #14's initial undated care plan revealed no problem areas, goals, or interventions related to the resident's safety, and assistance with coffee until 01/31/22. On 01/31/22, the facility implemented a care plan related to Resident #14's safety and getting coffee. The facility will assist Resident #14 with getting coffee, encourage her to use a lid at all times when coffee was in her cup, place a couple ice cubes in the coffee to lower the temperature, and continue to provide education about safety with hot coffee. Review of Resident #14's skin assessment, dated 02/01/22, revealed Resident #14 had the following burn areas: second degree [CONDITION(S)] to her bilateral groin areas, right outer thigh and abdomen, and a first degree/superficial burn to the top of her right hand. There were no other assessments of the wound currently, including measurements and description of the wounds. Review of Resident #14's progress notes, dated 02/01/22, revealed an interdisciplinary team (IDT) meeting was held to review and discuss Resident #14's accident on 01/31/22. The IDT will follow CNP #161's orders for treating with pain medication and monitoring the burn for changes with weekly rounding. The IDT made the following additions to her care plan: Staff to add a few chips of ice to coffee to decrease the temperature, therapy to evaluate the resident for appropriate cup, and allow staff at times to assist with getting coffee. Review of Resident #14's progress notes, dated 02/08/22, revealed Physician #160 was in to see Resident #14 and the physician examined Resident #14's [CONDITION(S)]. He prescribed new orders for antibiotic therapy for two weeks and follow up with the burn clinic. Physician #160 reported Resident #14 as having dark, red eschar to inner thighs and groin and right outer hip area. Areas to inner thighs softening and having an odor. The facility made an appointment with the burn clinic for 02/18/22; the burn clinic reported they would call if something became available sooner. Review of Resident #14's physician orders, dated 02/08/22, revealed new orders for [MEDICATION(S)] (antibiotic) 100 mg once daily, [MEDICATION(S)] (antibiotic) 500 mg once daily, vital signs every shift for 72 hours, and [MEDICATION(S)] (topical antiseptic) to burned areas in groin twice daily. Review of Resident #14's progress notes, dated 02/12/22, revealed Resident #14's daughter was in to visit that day and saw her wound and she noted odor and a brown dressing with pus. Resident #14's daughter made the request to send Resident #14 to the hospital and the facility notified the physician and agreed to send Resident #14 to the hospital. Resident #14 was transferred from the facility to the emergency room for further evaluation and treatment. Review of Resident #14's hospital admission documentation, dated 02/12/22, revealed Resident #14 spilled hot coffee in her lap 12 days ago and it was described as a thermal burn. The hospital ordered multiple blood work labs. Resident #14's white blood cell (WBC) count was 7.29, which was within normal limits, indicating possibly no infection. After being in the emergency room for six hours, Resident #14 was transferred to another hospital with a burn clinic. Review of Resident #14's hospital/burn clinic documentation, dated 02/13/22, revealed Resident #14 was in a facility and spilled hot coffee on her thighs two weeks ago. She presented with third degree [CONDITION(S)] (a type of burn that destroys the skin and may damage the underlying tissue. They are more severe than first and second [CONDITION(S)] and always require skin grafts) with foul smelling eschar. In addition to her routine medications, she was started on [MEDICATION(S)] (parameters not documented), [MEDICATION(S)] 220 mg at night (once daily), [CONDITION(S)] [MEDICATION(S)] 250 units once, [CONDITION(S)], [MEDICATION(S)] and acellular [MEDICATION(S)] vaccine 0.5 milliliter. The assessment/recommendations revealed the third degree [CONDITION(S)] to the bilateral thighs will need excision and due to the delayed presentation will need to stage the procedure and first cover with allograft (a tissue graft from a donor). The plan for Resident #14 while in the burn clinic hospital was as follows: admit to burn unit for specialized burn care, intravenous (IV) and by mouth medications for hydrotherapy (use of water for pain relief) and breakthrough pain, medical/surgical status vitals every four hours, monitor wound for [CONDITION(S)] or signs of infection, there was no indication for antibiotics at this time, wash wound daily with soap and water and apply [MEDICATION(S)] to wounds, and plan for operating room tomorrow (02/14/22) for excision and allograft. Interview with Physician #160 on 02/17/22 at 12:13 P.M. confirmed he assessed Resident #14 [CONDITION(S)] on 02/08/22. He ordered antibiotics to be started immediately due to his assessment that the [CONDITION(S)] were infected (smell, drainage, etc.). He also ordered for the facility to contact the burn clinic to have the burn wounds assessed for further treatment. The facility told him they were able to get her an appointment on 02/18/22. Interview with RN #121 on 02/17/22 at 12:32 P.M. revealed she was in the private dining room and heard a yell from the dining area. She ran out and saw that Resident #14 had coffee spilled on her pants. RN #121 immediately took Resident #14 to her room, assisted her with getting her pants off and saw the reddened areas on her abdomen/groin area. She also noticed that skin was coming off, due to the [CONDITION(S)]. Resident #14 was claiming she was in pain, so RN #121 put cold, wet rags on the red areas. This was not the first time Resident #14 tried to get coffee without using a lid. She was not sure exactly what happened this time to cause the burn, but she knew that Resident #14 does not like to use a lid and she will take it off. Observation on 02/17/22 at approximately 1:30 P.M. reveled the facility has one self-serve hot coffee, tea, and hot water machines in the dining room area. The machine was always turned on, which allowed any resident to go to the machine and pour their own hot beverage at any time. The coffee temperature from the coffee machine was obtained at 174 degrees Fahrenheit (F). After one minute, the temperature was 170 degrees F. After three minutes, it was 160 degrees F. And after six minutes, it was 155 degrees F. Interviews with Director of Health Services (DHS) and Regional Director of Clinical Services (RDCS) #163 on 02/17/22 from 11:30 A.M. and 2:00 P.M. confirmed there was not a specific care plan in place prior to the burn incident on 01/31/22. They also confirmed the only assessment they had completed with Resident #14 about hot coffee and coffee safety was the education that was provided to her and verified they had not completed a formal risk/safety assessment. Interview with Housekeeping Director #134 on 02/17/22 at 2:23 P.M. revealed she was walking in the dining room when she saw Resident #14 at the coffee machine, starting to pour her own coffee. She walked over, told Resident #14 she would help, and then Housekeeping Director #134 pushed the button to pour the coffee from the self-serve machine. After the coffee was poured to the near top of the coffee cup, Housekeeping Director #134 moved the cup from the coffee machine deck to the counter, to put creamer in the coffee for Resident #14 per the resident's preference. While Housekeeper Director #134 grabbed for the creamer, Resident #14 grabbed her coffee cup (with no lid), put it between her legs and started to wheel away without saying a word. Then Resident #14 spilled her coffee in her lap. The nurse came very quickly and treated her. This was the first time Resident #14 had grabbed her coffee cup before the creamer was put in. She was aware the staff need to assist her with getting coffee for her safety, which was why she did it for her. Interview with Physician Assistant (PA) #164 from the Burn Clinic on 02/24/22 at 2:20 P.M. revealed Resident #14 presented to the hospital with third degree [CONDITION(S)] to her abdomen, thigh, and groin area. She was placed on antibiotic medication and topical treatment. She had lab work completed, and the white blood cell (WBC) count was within normal range. She stated that even if the WBC count was within normal limits, Resident #14 still could have an infection. She stated that it was normal for third degree [CONDITION(S)] to have two skin surgeries; one to prepare the skin and one to apply a skin graft for healing. Review of the manufacturer assessment and guidelines for the facility's self-serve coffee maker, dated 02/16/22, revealed when they dispensed the coffee on that date, it was 176.6 degrees F at the initial dispensing. The report stated the temperature of the coffee dropped by 10 degrees after 45 to 60 seconds after dispensing, which would still make the coffee 166.6 degrees F after one minute. The manufacturer identified no issues with the coffee maker. This deficiency substantiates Complaint Number OH 252.