Every finding on record at Ohio Living Rockynol

Based on observations, interview and policy review, the facility failed to ensure safe food handling to prevent cross contamination. This had the potential to affect all 27 residents receiving meals from the kitchen. The facility did not identify any residents who did not eat by mouth. Findings include: Observation was conducted on 08/08/23 at 11:30 A.M. of the lunch tray line. The cook serving on tray line was observed grabbing plates on the tray line then using the same gloved hand to grab sandwich buns out of a plastic bag. After throwing away the plastic bag in the trash can, the cook proceeded to touch another sandwich bun out of a new plastic bag with the same gloved hands. The cook then changed into new gloves without performing hand washing before applying the new gloves and proceeded to use her gloved hands to grab more buns, fresh lettuce and fresh tomato slices for sandwiches for the residents. Observation was conducted on 08/09/23 at 11:45 A.M. of the luch tray line, and it was noted the tray line cook used a gloved hand to grab a hamburger bun out of a plastic bag then touched loose potato chips , a serving scoop handle and another hamburger bun. After discarding a plastic bag in the trash can, the cook proceeded to touch loose open chips for serving to residents with the same gloved hand. The cook made no attempt to wash her hands or change into clean gloves when moving between touching the food items and touching the scoop handles and plastic bags. Interview was conducted on 08/09/23 at 12:00 P.M. with Culinary Director (CD) #338 whoverified the tray line cook did not practice proper glove usage or proper hand hygiene. CD #338 revealed the cook should have used tongs to grab the buns and other food items instead of directly touching the food with her gloved hands that had also touched utensils and plates. Review of the Ohio Living Rockynol Cross Contamination Dietary policy, undated, revealed all employees must wash hands when changing jobs.

Based on record review, observation and interview, the facility did not ensure Resident #19's room was free from safety hazards that could potentiate fall risk. This affected one resident (#19) of four residents reviewed for accident hazards. The facility census was 27. Findings include: Medical record review was conducted for Resident #19 revealing a diagnosis of pain, malnutrition, and debility. Resident #19 had altered visual depth perception and was a fall risk. Observation of Resident #19's room on 08/07/23 at 3:32 P.M., 08/08/23 at 8:30 A.M. and 08/09/23 at 9:43 A.M. revealed both wooden doors to her clothing closet full of her clothing were off track at the bottom and leaning against her clothing. The top of the wooden closet doors were attached to the closet door frame, but the bottom of the doors swung loosely back and forth upon opening and there was no bottom track placement to safety secure the doors. Interview was conducted on 08/08/23 at 9:47 A.M. with STNA #301 who stated Resident #19 made her own choices and was able to go into her own closet to pick out her own clothes. Interview was conducted on 08/08/23 at 9:57 A.M. with Maintenance Director #332 who verified Resident #19's closet doors were not safely secured at the bottom so there was nothing to prevent the doors from falling out. Interview was conducted on 08/09/23 at 9:43 A.M. with Physical Therapy Assistant #335 who verified the loose closet doors and added this was not safe for Resident #19 because she was at risk for falls.

Based on observation, staff interview, and review of the resident council minutes, the facility failed to ensure the carpeting in the resident hallways and resident rooms was maintained in a clean manner and in good condition. This had the potential to affect all 27 residents residing in the facility. Findings include: An environmental tour was conducted on 08/09/23 between 8:00 A.M. and 3:30 P.M. The tour revealed carpeting in the hallways throughout the facility, resident common areas and the carpet leading into resident rooms contained multiple and significantly large stains of brown and other various colors, and multiple areas with a buildup of dust and debris. The carpeting was also noted in numerous areas to be pulling away from the floor in the center of the hallways leading to resident rooms indicating a lack of proper adhesion of the carpet to the floor. Interview was conducted on 08/09/23 at 3:22 P.M. with Corporate Registered Nurse (RN) #334 who verified the condition of the carpeting. Interview was conducted on 08/09/23 at 3:26 P.M. with Resident #19 who stated the carpet by the nurses stations needed to be removed and the facility needed new carpeting. An interview with Housekeeper # 333 on 08/09/23 at 3:28 P.M. stated they told told management a long time ago about the carpet stains. Interview with The Administrator on 08/09/23 at 3:53 P.M. revealed the carpet had not been replaced due to planned move of all residents off the first floor to the second floor. Interview was conducted on 08/09/23 at 4:48 P.M. with Resident #2 who voiced complaints that the carpet in her room was dirty and her room smelled bad from the dirty carpet. Observation and interview on 08/10/23 at 11:00 A.M. with the Administrator of the second floor of the facility revealed no evidence of remodeling in progress for the move of residents to the second floor. The Administrator stated there was no start date set for the remodeling. Record review of Resident Council minutes revealed January 2023 environmental concerns were reported about dirty carpets.

Based on observation, interview, and record review the facility failed to maintain shower rooms located on the first and second floor in a clean and sanitary manner. The facility also failed to ensure hot water was available in the shower of the first floor. This affected one resident (#15) and had the potential to affect 27 residents (#2, #6, #10, #15, #17, #18, #22, #23, #26, #32, #36, #38, #47, #48, #49, #51, #52, #53, #56, #57, #63, #64, #66, #158, #313, #314, and #315). The facility census was 56. Finding include: Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included [CONDITION(S)], age related [CONDITION(S)], and obesity. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and bathing activity did not occur. Interview with Resident #15 on 08/09/21 at 10:04 A.M. revealed the shower rooms looked awful and the water was too cold in the alcove shower room. Resident #15 stated the shower rooms were not in good shape. Interview on 08/11/21 at 1:57 P.M. with Director of Environmental Services (DEVS) #403 and Assistant Director of Environmental Services (ADEVS) #402 revealed there was only one shower room in use on the first floor which was located near the rehab unit. Observation of this shower room revealed the tub looked dirty and was stained. Wash cloths and towels were being stored in the tub. The shower curtain behind the tub also looked dirty and stained. Interview on 08/11/21 at 2:02 P.M. with DEVS #403 verified the observation of the tub and shower curtain. DEVS #403 stated the tub was maintained by a contracted company. On 08/11/21 at 2:07 P.M., ADEVS #402 turned on the hot water to the shower located in the first floor shower room and let it run. The water felt cold to touch. ADEVS #402 confirmed the water felt cold and stated it had been recently fixed. Further observation with DEVS #403 on 08/11/21 at 2:08 P.M. revealed a black rectangular trash bin located near the tub was filled about halfway with water and plastic gloves. Observation of the second floor shower room on 08/11/21 at 2:34 P.M. revealed it was cluttered with shower chairs and unlined trash bins with trash bags hanging on sides. One unlined trash bin contained used plastic gloves and a tied off trash bag with soiled incontinence briefs was on the floor. The bath tub was stained. These observations were confirmed with ADEVS #402 at the time of the observations. Review of the Resident council minutes dated 07/26/21, under the area of environmental services, revealed the shower room on the first floor needed attention, deep cleaning, and upkeep. Residents #2, #6, #10, #15, #17, #18, #22, #23, #26, #32, #36, #38, #47, #48, #49, #51, #52, #53, #56, #57, #63, #64, #66, #158, #313, #314, and #315 resided on the first and second floors and utilized the shower rooms. This deficiency substantiates Complaint Number OH 874.

Based on observation, interview, record and policy review, the facility failed to ensure a pressure sore was identified and treated in a timely manner for one resident (Resident #62). Actual Harm occurred when Resident #62 was found with a necrotic left heel wound. In addition the facility did not ensure on-going skin assessments for one resident (Resident #52). This affected two of four residents reviewed for pressure ulcer/skin impairment. The facility census was 72. Findings include: 1. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission assessment, dated 02/23/19, indicated the resident had non-[MEDICAL CONDITION] of the left leg. Review of the skin assessment, dated 03/05/19, indicated Resident #62 was at moderate risk for the development of pressure ulcers. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 03/15/19, indicated the resident had moderate cognitive impairment and was at risk for but had no pressure sores. Review of the physician's orders [REDACTED].#62's skin was to be checked every Friday. Review of the progress note, dated 03/30/19 at 3:41 A.M., revealed the resident had swelling to her left lower extremity. The left heel had a black spot that left dried blood on the sheet. This was the first documented evidence of the wound. Review of the wound management note, dated 04/02/19 at 6:26 P.M., indicated the pressure sore on the left heel measured 5.2 centimeters (cm) by 5.7 cm that was described as 100% eschar tissue. Eschar is slough or piece of dead tissue cast off from the surface of the skin. The wound management note, dated 04/09/18 at 3:15 P.M., indicated the left heel measured 4.8 cm by 5.2 cm. The area was noted to be 100 percent eschar tissue. The edges/margins were calloused and firm. Review of the plan of care, initiated on 04/04/19, revealed an unstageable pressure ulcer to the left heel. According to the National Pressure Ulcer Advisory Panel (NPUAP), an unstageable pressure ulcer is defined as,full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound. Interventions included: consult a wound nurse, management of tissue loads, nutrition assessment, heel protecting boots at all times, reposition every two hours and as needed, and a low air loss mattress. Interview with Registered Nurse (RN) #320, the wound nurse, on 04/11/19 at 8:03 A.M. indicated she was upset that Resident #62's pressure sore was not identified until it was necrotic (black or eschar). She said weekly skin assessments were to be completed but were not reviewed by her. Review of the skin monitoring comprehensive state tested nurse aide (STNA) shower sheets dated 03/14/19 and 03/23/19 identified no skin impairment. Interview with the Director of Nursing (DON) on 04/11/19 at 1:40 P.M. indicated she could only find the two shower sheets. The DON verified the pressure sore should have been identified prior to it being necrotic. Observation was made of Licensed Practical Nurse (LPN) #39 changing Resident #62's pressure sore dressing on 04/11/19 beginning at 1:45 P.M. When LPN #39 began to take off the heel protector, sock and dressing the resident vocalized a painful moan. LPN #39 continued to change the dressing. The resident was asked by LPN #39 if she had pain and she said it hurt. LPN #39 continued the dressing and described the pressure sore as a large black area measuring 6.0 cm by 5.5 cm. LPN #39 rested the resident's left heel directly on the foot rest of her wheelchair. The resident continued to vocalize a painful moan. LPN #39 asked the resident if she was having pain, and the resident said yes. LPN #39 said she would get her some Tylenol. LPN #39 continued to cleanse and dress the pressure sore without providing pain medication. Review of the Prevention, Detection and treatment of [REDACTED]. ability and when transferred or discharged . At least daily staff will observe and report potential and actual changes in skin condition. Skin condition would be observed and reported by the nurse or the nursing assistant with every bath. Weekly skin condition evaluations were to be done. 2. Review of the medical record of Resident #52 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the record revealed on 01/22/19, a fluid filled blister was noted to the resident's left foot arch area. A note from the facility wound nurse on 01/22/19 revealed the blister was fluid filled and measured 2.5 centimeters (cm) by 1.0 cm. The resident was seen by the physician with an order to cleanse the area with normal saline and cover with a bordered foam dressing every three days. Review of the record revealed measurements to the left foot arch area were documented on 01/29/19, 02/05/19, 02/12/19 and 02/19/19 indicating the blister was resolving, with no fluid noted. The measurements of the area remained the same on all notes. The next note after was 02/19/19 was dated 03/05/19 and indicated the area was a scab but was healed. Further review of the record for Resident #52 revealed he was found with a deep tissue injury to his right heel on 02/05/19. The area measured 2.4 cm by 1.0 cm and with no further description. A treatment was ordered for skin prep to be applied to the area and to cover it with bordered foam every three days. Review of the record revealed assessments of right heel on 02/12/19, 02/19/19, 02/26/19, 03/05/19 and 03/19/19. All notes indicated the area was the same measurement of 2.4 cm by 1.0 cm and described as a scab/dry callous. An observation of the right heel with LPN #301 on 04/12/19 at 10:30 A.M. revealed a 0.2 by 0.2 cm red area to the right heel. There was no evidence of a scab or dry callous. An observation of the left foot arch with LPN #301 on 04/12/19 at 10:30 A.M. revealed a foam dressing in place. When the dressing was removed, a small amount of bloody drainage was noted on the dressing. The area appeared as a blistered area with the top layer removed, and with a small amount of serosanguineous drainage (containing both blood and liquid). It measured 2.0 cm by 1.2 cm with the top layer of skin missing for a depth of 0.1 cm. The treatment for [REDACTED]. The DON was interviewed on 04/12/19 at 10:45 A.M. She verified the two skin areas had not been assessed since the dates noted, and that the assessments were not accurate as to the observations of the surveyor on 04/12/19.

Based on observation, interview and record review, the facility failed to ensure medications were stored in a secured area. This had the potential to affect ten cognitively impaired, independently mobile residents (Resident #'s 15, 26, 28, 40, 41, 42, 50, 53, 56 and 62) who resided on the second floor of the facility. The facility census was 72. Findings include: Initial observation of the second floor unit on 04/09/19 at 9:00 A.M., revealed a large nursing station in the center of the unit, near the elevator. The station had glass windows, and a door that opened into a common area where residents were noted to sit in their wheelchairs. The medication carts were generally parked outside the nursing station and residents were observed as they approached staff to ask for medications or other care concerns, and the area was also adjacent to the entrance to the second floor dining room and activity room. Staff were observed to go in and out of the nurse's station frequently, and staff, visitors and residents were observed approaching the door of the nurse's station at times to talk with nursing staff. The door was noted open at times with no staff in the room during observations during the survey. On 04/09/19 at approximately 4:00 P.M., the surveyor was reviewing records in the second floor nursing station. Other staff were present in the room, including the Director of Nursing (DON). The DON approached the surveyor and stated that she was leaving the nursing station, and as no other staff were present at that time in the nursing station, the door would be closing and locking behind her. The surveyor left the nursing station with the DON. An observation by another surveyor on 04/10/19 at 11:40 A.M. revealed two gray boxes of medications in the nursing station. One box contained [MEDICATION NAME]es (pain medications), [MEDICATION NAME] (breathing treatments), Hydrogen Peroxide and a bottle of Senna (laxative). The other box had blister packs of pills. The surveyor was alone in the nurses station, and the door to the station was open. The surveyor observed the nursing station on 04/10/19 from approximately 12:30 P.M. to 2:45 P.M. At 12:30 P.M., the nursing station door was open, with no nursing staff in the room or in the common area. One gray box could be seen on the floor of the nursing station, but the surveyor did not enter the room at that time. Observations revealed staff in and out of the nursing station, with the area unattended at times. At approximately 2:30 P.M., a resident, later identified as Resident #26, was seen wheeling up to the open door in her wheelchair and attempting to go into the station. Staff redirected her to the common area. This was verified with another surveyor. On 04/10/19 at 2:45 P.M., the DON was interviewed regarding the security of medications and the nursing station. She indicated the nursing station door should remain closed and locked when staff were not in the room. She verified that one gray box of medication cards still remained on the floor in the nursing station. The box contained 36 blister packs of medications, which included [MEDICATION NAME] (a blood thinner), [MEDICATION NAME] (a medication for [MEDICAL CONDITION]), several antibiotics ([MEDICATION NAME] and [MEDICATION NAME]) and [MEDICATION NAME] (a blood pressure medication). The DON stated the medications were in the nursing station unsecured, as they were to be returned to the pharmacy, but verified several residents on the unit were cognitively impaired and able to independently move about on the unit. She verified the door to the medication room was not always closed when staff left the room, and the medications, which were in the box sitting on the floor directly inside the room, should have been more secured. Review of the facility policy on storage of medications, revised on 04/05/19, revealed that all medications should be secured stored in a locked cabinet or cart or locked medication room that was inaccessible by residents and visitors.

Based on interview and document review, the facility failed to inform the resident or his or her legal representative in writing why specific skilled services may not be covered and of the resident's/beneficiary's potential liability for payment for the non-covered services for two residents (Residents #38 and #62) of three residents (Residents #38, #62, and #73) reviewed for liability notices for residents who remained in the facility. The facility census was 72. Findings include: 1. Review of the Centers for Medicare and Medicaid Services (CMS) form indicated Resident #38 was cut from skilled nursing services, and services would end on 02/06/19. The form was not signed by the resident/representative. The Skill Nursing Facility Advance Beneficiary Notice (SNFABN) form was provided. The form indicated the estimated cost was room, board and any therapy services. No specific dollar amount was provided. This form was not signed by the resident/representative. Review of the note authored by Licensed Social Worker (LSW) #41 indicated he spoke with the representative on 02/04/19 at 2:30 P.M. 2. Review of the CMS form indicated Resident #62 was cut from skilled nursing services, and services would end on 03/21/19. The form was not signed by the resident/representative. The SNFABN form was provided. The form indicated the estimated cost was room, board and any therapy services. No specific dollar amount was provided. This form was not signed by the resident/representative. Review of the note authored by LSW #41 indicated he spoke with the representative on 03/19/19 at 11:20 A.M. informing him that skilled services would end on 03/21/19. The note indicated the representative would appeal the decision. Interview with the Administrator on 04/10/19 at 11:49 A.M. verified the type of skilled services being cut was not specified, the SNFABN's did not have estimated costs identified, and there was no evidence the resident/representatives were notified in writing of the decision and appeal rights.

Based on observation, interview and record review, the facility failed to ensure standards of practice were maintained for Resident #9 regarding a dressing change. This affected one of four residents reviewed for pressure areas. The facility census was 72. Findings include: Review of the medical record of Resident #9 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed he was seen weekly at an outside wound clinic for wound management. Review of the orders and treatment records revealed an order dated 03/12/19 to treat his right foot near his heel and right foot near his great toe with a padded dressing wrapped with Kerlix (a gauze wrap) to be changed every day and as needed. The treatments were signed off every day from 03/12/19 through 04/09/19, when the order was discontinued and an order was written for a treatment to the left foot near the great toe. An observation of the dressing change was made with Licensed Practical Nurses (LPN) #305 and #307 on 04/10/19 at 2:00 P.M. The dressing change was completed to the resident's left foot area near his great toe. An interview with the Director of Nursing on 04/11/19 at 5:00 P.M. confirmed the documentation in the treatment record had indicated the dressing change was to be done to the right foot from 03/12/19 through 04/09/19, when the order was corrected to the left foot. She verified the resident did not have any skin impairments to his right foot at any time, and the nurses who had completed the order should have noted the error was written for the wrong foot and corrected the order.

Based on interview and record review, the facility failed to ensure Resident #6, who received [MEDICAL TREATMENT] three times weekly, was provided a physician ordered [MEDICATION NAME] binding medication with meals. Failure of taking a [MEDICATION NAME] binder could lead to bone pain, pruritis (itching) and worsening secondary [MEDICAL CONDITION] (overactive [MEDICAL CONDITION]). This affected one resident reviewed for [MEDICAL TREATMENT] and one resident of five residents reviewed for unnecessary medications. Findings include: Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 03/08/19, indicated she was alert, oriented and independent in daily decision making. She rejected care on one to three days of the seven-day assessment period. She was marked to receive [MEDICAL TREATMENT] services. Review of the [MEDICAL TREATMENT] plan of care indicated she was non-compliant at times with going to [MEDICAL TREATMENT]. Review of the [MEDICAL TREATMENT] communication revealed the resident refused four of the last 18 treatments. Review of the physician's orders [REDACTED]. A [MEDICATION NAME] binder should be taken three times a day with meals to help to control phosphorous levels in the body. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. Review of the progress notes lacked indication why the phosphorous binding medication was not administered. Interview with Resident #6 on 04/10/19 at 10:05 A.M. said she was supposed to get a phosphorous binder with food. She said the nurses try to give it to her way before or way after she ate her meals. She said that was a big problem. Interview with the Director of Nursing (DON) on 04/10/19 at 02:22 P.M. verified there was no documented evidence the phosphorous binding medication was administered to Resident #6 as ordered and confirmed there were no corresponding progress notes.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than five percent. The facility had an error rate of 12%, three errors in 25 opportunities, affecting Resident #7 and Resident #8. The facility census was 72. Findings include: 1. Observation of the medication pass for Resident #8 on 04/10/19 at 9:38 A.M. with Licensed Practical Nurse (LPN) #300 revealed him prepare an iron supplement, a multivitamin and a laxative ([MEDICATION NAME]) for the resident, who took all of the medications without concern. Review of the record of Resident #8 revealed she was also ordered Calcium 500 milligrams (mg) with Vitamin D3 400 mg to be given every day during the morning medication pass, which had been ordered on [DATE]. An interview with LPN #300 on 04/12/19 at 12:30 P.M. confirmed he had not administered the Calcium/Vitamin D3 medication as ordered. 2. Observation of medication pass for Resident #7 on 04/10/19 at 9:50 A.M. revealed LPN #300 prepared all the medications for the resident. He went into the resident's room with a cup of medications. She stated to him that she preferred to have the medications crushed and put into yogurt. LPN #300 called for the unit manager, LPN #305, who went into the resident's room, and then told LPN #300 to crush the medications. Both nurses identified two gel caps, Vitamin A and Vitamin E, that were not able to be crushed, and the resident stated that she could take those two medications one at a time with a bite of yogurt. LPN #300 crushed the other medications he had prepared for the resident, which included Potassium Chloride, 20 milliequivalents. He administered the crushed medications to the residents in yogurt, including the two gel cap vitamins. Review of the resident's orders revealed she was to receive Vitamin D3 2000 units, ordered on [DATE] every day during the morning medication pass. An interview with LPN #300 on 04/10/19 at 12:30 P.M. confirmed he had not given the Vitamin D3 as ordered. He also confirmed at that time that he had crushed all the resident's medications, including the Potassium, and had only administered two vitamins to the resident as a whole capsule, as they could not be crushed. Review of the facility list of medications that should not be crushed, dated (MONTH) (YEAR), confirmed Potassium Chloride should not be crushed. An interview with LPN #305 on 04/10/19 at 4:00 P.M. confirmed the Potassium Chloride should not have been crushed prior to administration. This was specifically confirmed with LPN #300 on 04/10/19 at 5:00 P.M. The Director of Nursing (DON) confirmed on 04/11/19 at 5:00 P.M. that three medication errors had occurred, including two missed medications and crushing a medication that should not have been crushed.

Based on interview and record review, the facility failed to ensure Resident # 9 and Resident #28 had been assessed for their need or desire for influenza and pneumococcal vaccinations on admission. This affected two of five residents reviewed for immunizations. The facility census was 72. Findings include: Review of the record of Resident #9 revealed he was admitted to the facility on [DATE]. There was no evidence that he or his representative were provided with education or asked if he wanted to receive an influenza or pneumococcal vaccine. Review of the record of Resident #28 revealed he was admitted to the facility on [DATE]. There was no evidence he or his representative were provided with education or asked if he wanted to receive an influenza vaccine. Review of the facility policy Influenza and Pneumococcal Vaccines, revised in (MONTH) (YEAR), revealed all residents would be given education regarding the vaccines and offered an influenza immunization between (MONTH) 1 and (MONTH) 31. Residents would also be asked at least once if they would like the pneumococcal vaccine. The policy indicated the resident's medical record would contain documentation of the education provided and the consent or refusal of the vaccines. An interview with the Director of Nursing (DON) on 04/12/19 at 9:30 A.M. confirmed the above findings. She stated Resident #9 would be receiving the pneumonia vaccine on 04/12/19.

Based on observation, interview and record review, the facility failed to ensure urinary catheter bags were maintained in a private, dignified manner. This affected two (Residents #30 and #65) of four residents observed with urinary catheters. Findings include: #1. On 03/26/19 at 10:43 A.M., Resident #65 was observed ambulating the length of the first floor hallway. Resident #65 was using a walker. Certified Occupational Therapy Assistant (COTA) #101 and Physical Therapy Assistant (PTA) #102, were walking with Resident #65 and providing instruction and stand-by assistance. A urinary catheter tubing was extending from under the resident's pant leg to a urinary catheter bag. The bag was attached and hanging from the resident's walker. The catheter bag was fully exposed and approximately 1/3 full of dark, yellow-brownish, cloudy, urine. Record review revealed Resident #65 was being treated for [REDACTED]. Resident #65 walked to the large common area adjacent to the dining room and therapy room. Several residents, staff and visitors were walking through the area. Resident #65, COTA #101 and PTA #102 entered the therapy room. Eleven residents and five staff were observed in the therapy room. An interview was completed with COTA #101 and PTA #102 immediately following the observation. COTA #101 and PTA #102 verified they were aware a privacy bag should be used to cover the catheter bag. However, both revealed there were no privacy bags available in the facility. Therefore, they usually attached a pillowcase around the catheter bag when they brought residents to the therapy department but did not remember to do so, on that morning. #2. On 03/26/19 at 3:09 P.M., Resident #30 was observed sitting in a wheelchair in the middle of the 200 unit hallway. A urinary catheter bag was observed on the floor in front of the resident's wheelchair. The bag was not covered and contained urine. STNA #103 verified the observation at the time it occurred.

Based on observation, interview and record review, the facility failed to ensure Resident #72 was transferred from the bed to a wheelchair with the assistance of two staff, and failed to ensure Resident #72 was wearing non-skid socks. This affected one of three residents reviewed for falls. Findings include: #1. Resident #72 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of a Brief Interview for Mental Status (BIMS) dated 06/06/18 and 02/05/19, revealed Resident #72 had severe cognitive impairment. Review of the facility Incident/Accident log revealed Resident #72 had a fall dated 06/05/18 at 10:02 A.M. Review of the facility Investigative Summary of the same date, revealed a state tested nurse aide (STNA) was transferring Resident #72 from her bed to a wheelchair. The resident's legs buckled and the STNA lowered Resident #72 to the floor. The new intervention to prevent another fall required two staff to transfer Resident #72. However, review of the Minimum Data Set (MDS) assessment dated [DATE], the most current assessment prior to the fall, revealed Resident #72 already required two staff for a bed to chair transfer. An interview was completed with the Director of Nursing (DON) on 03/25/19 at 6:01 P.M. The DON verified two staff should have been transferring Resident #72 on 06/05/18. #2. Review of a Fall Risk assessment dated [DATE] revealed Resident #72 was at a high risk for falls. Review of a Plan of Care of the same date, revealed an intervention to provide adaptive equipment for resident use, as needed. However, the same care plan did not identify the adaptive equipment. On 03/26/19 at 11:19 A.M., Resident #72 was observed sitting in her wheelchair in a common area on the resident unit. Resident #72 was wearing striped, fuzzy socks. Resident #72 was not wearing shoes and her feet were flat on the floor. The bottom of her socks were not visible. State tested Nurse Aide (STNA) #100 was observed passing through the hallway. When asked if the resident's socks were non-skid socks. STNA #100 lifted the resident's foot and verified the socks were not non-skid socks. STNA #100 continued down the hallway. Resident #72 was awake, alert and confused. Resident #72 easily engaged in conversation. Resident #72 revealed she was looking for a job and asked to be hired. Approximately three minutes later, the DON arrived with non-skid socks, verified the observation and applied the socks. This deficiency substantiates Master Complaint Number OH 281and Complaint Number #OH 179.

Based on record review, observation and interview the facility did not ensure that care plans were updated for positioning interventions for Resident #24, safety supervision for Resident #47, pressure relieving interventions for Resident #53 or for a pressure ulcer for Resident #31. This affected four residents (Resident #24, Resident #31, Resident #47 and Resident #53) out of 23 residents whose care plans were reviewed Findings include: 1. Resident #24 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #24 relied on the staff for all of her care and she would eat in her room while sitting upright in bed. Review of the medical record for Resident #24 revealed a physician order [REDACTED]. Review of the care plan developed for Resident #24 revealed the problem area of activities of daily living related to her decreased ability to perform activities due to a stroke with paralysis. None of the current care plans for Resident #24 contained the intervention of positioning her properly with the use of the specified pillows. An observation on 02/26/18 9:52 A.M. revealed Resident #24 was finished eating her lunch meal and was sitting in her bed with the head of the bed elevated. Resident #24 was bent at the waist and leaning to the left and her head was almost touching the side rail. A large body pillow was in place on the left side of the resident but was not positioned in a way to help support Resident #24 and prevent the abnormal posture. Further observations conducted on 02/26/18 at 11:46 A.M., 02/27/18 at 5:10 P.M. and 5:45 P.M., and on 02/28/18 at 9:45 A.M. and 11:00 A.M. revealed Resident #24 to be positioned in the upright position with the body pillow placed on the left side of the body and functioning in a way which did not support proper positioning. These observations and findings were verified with the Administrator on 02/28/18 at 3:30 P.M. 2. Resident #47 was admitted to the facility on [DATE]. The primary [DIAGNOSES REDACTED]. Resident #47 was diagnosed with [REDACTED]. The resident could ambulate with the use of a walker. Observations on 02/27/18 at 12:15 P.M. during the lunch meal revealed Resident #47 would attempt to stand while at the dining table as if she was getting up to go somewhere. The daughter of Resident #47 was present at the meal and would gently remind her to sit down. Observations included the staff reminding the resident to sit down while she was seated in the common area by the nursing station and dining room. The medical record documented two falls (02/11/18 and 02/21/18) since Resident #47 had been admitted to the facility. Investigations into the reason for the fall and what interventions would be appropriate for the resident were completed. These interventions included orders dated 02/22/18 in the treatment record for the staff to not leave the resident unattended when she is up in her recliner within her room as she had fallen when attempting to stand from her recliner. The second intervention was to have Resident #47 sit in the common areas to maximize supervision while awake. This order was also placed on the treatment record. Review of the care plan for Resident #47 revealed a problem area, At risk for accident, injury, fall, last revised 02/12/18. This care plan was not updated and did not include the interventions for staff to not leave Resident #47 alone while in her recliner in her room or for staff to keep the resident in a supervised areas while she was awake to maximize supervision. These findings were reviewed and verified with the Administrator and Director of Nursing (DON) on 02/28/18 at 3:30 P.M. 3. Resident #53 was admitted to this facility on 01/02/18. His admitting [DIAGNOSES REDACTED]. The minimum data set (MDS) assessment dated [DATE] showed this resident was cognitively intact. Functionally he needed extensive assistance from staff for bed mobility, dressing, toilet use and personal hygiene. He was totally dependent on staff for transfers. Resident #53 did have a deep tissue injury on his right buttocks and a stage II pressure ulcer on his left buttocks. One of the physician orders [REDACTED].#53 to have a pressure redistribution cushion in his chair and wheelchair. They were to use a ROHO cushion, a type of pressure relieving cushion in his wheelchair. Review of the care plan showed an intervention for the redistributing cushion in chair and wheelchair but did not show the ROHO cushion which was specifically ordered for the wheelchair. Interview with the DON and the Assistant Director of Nursing (ADON) on 02/28/17 at 4:00 P.M. verified Resident #53's care plan was not updated to include the ROHO cushion. 4. Resident #31 was admitted to this facility on 04/13/05. Her admitting [DIAGNOSES REDACTED]. The minimum data set (MDS) 3.0 assessment dated [DATE] indicated Resident #31 had memory problems and refused to answer the questions. Functionally, this resident was dependent on staff for bed transfers, needed extensive assistance from staff for toilet use and needed limited assistance from staff for bed mobility, dressing and personal hygiene. The skin assessment section on this MDS revealed Resident #31 had a stage 3 pressure ulcer, a full thickness loss of skin involving damage to or death of subcutaneous tissue that may extend down to the underlying fascia and may include tunneling and/or undermining, measuring 1.5 centimeters (cm) by 0.7 cm by 0.1 cm on her left heel. Review of Resident #31's current care plans revealed a care plan for risk for skin breakdown related to [MEDICAL CONDITION], impaired mobility and incontinence. The interventions were focused on preventing pressure ulcers and did not address the care, treatments and other interventions to heal and prevent complications for her actual left heel pressure ulcer. Interview with the assessment nurse, Registered Nurse #505, on 02/28/18 at 4:00 P.M. verified there was no care plan to address Resident #31's left heel pressure ulcer.

Based on record review, and interview the facility failed to ensure physician orders [REDACTED].#163. This affected one of 23 residents whose physician orders [REDACTED]. Findings include: Resident #163 was admitted to this facility on 02/15/18. Her admitting [DIAGNOSES REDACTED]. According to the 48-hour care plan Resident #163 was alert and oriented to person, place and time. She needed assistance of one staff for all activities of daily living. Review of physician orders [REDACTED]. Staff were to notify the physician if her temperature was greater than 100 degrees, her hear rate was greater than 100, if her systolic blood pressure was less than 90 or if she had new or worsening symptoms. Review of the nursing documentation from 2/16/18 to 02/26/18 revealed Resident #163 did not have her vital signs taken every shift as ordered on [DATE], 02/19/18, 02/20/18, 02/22/18, 02/23/18, 02/24/18, and 02/26/18. Interview with the Director of Nursing (DON) on 02/28/17 at 4:00 P.M. verified Resident #163's vital signs were not taken according to the physician's orders [REDACTED].

Based on interview and record review, the facility failed to ensure communication between a [MEDICAL TREATMENT] center and the facility was implemented and maintained. This affected one resident (Resident #163) out of one resident reviewed for [MEDICAL TREATMENT]. Findings include: Resident #163 was admitted to this facility on 02/15/18. Her admitting [DIAGNOSES REDACTED]. According to the 48-hour care plan this resident was alert and oriented to person, place and time. She needed assistance of one staff for all activities of daily living. Resident #163 was dependent on [MEDICAL TREATMENT] and had a contract with a local [MEDICAL TREATMENT] center. Interview on 02/28/17 at 9:30 A.M. with Licensed Practical Nurse (LPN) #503 revealed the facility makes sure the resident is ready to go to [MEDICAL TREATMENT]. They also make sure that the resident has a lunch to take if they will be there during lunch time. LPN #503 said they did not send anything else or any information to the [MEDICAL TREATMENT] center staff. LPN #503 said the [MEDICAL TREATMENT] center staff did not send us any paperwork or information related to the care provided to Resident #163 while at the [MEDICAL TREATMENT] center. LPN #503 said if there were any issues or concerns while at [MEDICAL TREATMENT] they would call the facility. Interview with the Administrator and the Assistant Director of Nursing (ADON) on 02/28/17 at 11:00 A.M. revealed that the [MEDICAL TREATMENT] center would fax them a report about the resident's care and status during [MEDICAL TREATMENT] treatments. The ADON was not able to provide any documentation or reports from the the [MEDICAL TREATMENT] center for Resident #163. Interview with the [MEDICAL TREATMENT] center staff, Registered Nurse (RN) #504, on 02/28/17 at 2:00 P.M. revealed they have not sent any paperwork or information back with Resident #163. He said that if something abnormal happened at the [MEDICAL TREATMENT] center they would call the facility. He further stated that the facility would have to initiate the exchange of information if they needed that. Interview with the Director of Nursing, the Administrator, and the ADON on 02/28/17 at 4:00 P.M. verified they have not been exchanging information/communicating with the [MEDICAL TREATMENT] center related to Resident #163 to ensure ongoing collaboration for care and services and continuity of care.

Based on observation and interview, facility failed to follow proper infection control procedures when administering medications. This affected one resident (Resident #169) of four residents observed for medication pass. Finding include: Observation of the medication pass on 02/27/18 at 8:15 A.M. was conducted for Resident #169. Registered Nurse (RN) #513 gathered the medications for Resident #169 and included the bubble packed medication cards and over the counter medications contained in white plastic bottles. No hand washing or alcohol rub was observed after gathering the medications. RN #513 placed two [MEDICATION NAME] tablets into the medication cup and returned the [MEDICATION NAME] to the drawer in the cart. A tablet of aspirin was placed in the medication cup and the aspirin bottle was returned to the cart. RN #513 obtained the bubble card containing calcium with vitamin D and popped out pill. The pill fell and landed on the back of another medication card laying on the top of the medication cart. RN #513 picked up the pill with her bare right thumb and forefinger and placed the pill in the medication cup. No hand washing or alcohol rub was utilized before picking up the pill. RN #513 proceeded to obtain a [MEDICATION NAME] pill from an over the counter bottle and placed the pill in the medication cup. RN #513 dropped the [MEDICATION NAME] bottle on the floor and picked the container up off the floor and placed it into the medication cart. No hand washing or alcohol rub was utilized. RN #513 picked up the card containing the [MEDICATION NAME] (heart medication) and attempted to pop the pill out of the back of the card into the medication cup. The pill would not release from the card so RN #513 picked the pill out of the card with her right thumb and forefinger and placed it into the medication cup. In an interview with RN #513 on 02/27/18 at 8:25 A.M., she verified she touched two medications for Resident #169 with her bare hand and had not completed proper hand hygiene and infection control practices while preparing the medications. This included dropping a pill on her medication cart and other items then picking it up, picking up a bottle of medication off of the floor and then pulling a pill from the bubble card. Review of the document titled, General Dose Preparation and Medication Administration, last revised on 01/01/13 directed nurses to not touch the medications when opening a bottle or unit dose packages.

Based on observations and staff interview the facility failed to ensure the prevention and control of spreading infection when the treatment cart was taken into a resident's room. This cart was used for other residents as well. This affected one (Resident #3) of one resident observed for a dressing change. Findings include: During observations on 08/07/17 at 1:40 P. M., Licensed Practical Nurse (LPN) #11 was observed to wash her hands, don clean gloves and remove the soiled dressing from Resident #3's left foot. She cleansed the foot with normal saline, sanitized her hands, donned clean gloves and applied a clean dressing to the left foot. The treatment cart was observed to be placed at the foot of the resident's bed as she obtained supplies from it and used the top of the cart to place her supplies used to dress the wound. During an interview with LPN #11, on 08/07/17 at 2:00 P. M., it was revealed that the top of the treatment cart was sanitized each time it was used prior to taking it into other residents' rooms. She verified that the entire cart was not cleaned prior to taking it into other rooms. During an interview with the director of nursing (DON), on 08/07/17 at 4:00 P. M., it was revealed that their policy states that it is ok to take the treatment cart into resident rooms and this had not been a problem in the past. Review of the facility's policy, Clean Techniques for Dressing Changes or Applications, revealed that it was fine to take the treatment cart with one in the resident's room and that the top of the cart should be clean and neat. This deficiency substantiates Complaint Number OH 639.

Based on staff interview and record review the facility failed to document evidence that a treatment was performed as ordered by the physician on a resident . This affected one (Resident #1) of three resident records reviewed. Findings include: Review of the treatment administration record (TAR) for Resident #1 revealed that there was no documented evidence that the following treatment was performed for Resident #1 on the following dates: 06/05/17, 06/11/17, 06/26/17, 06/29/17, 07/02/17, 07/05/17, 07/08/17, 07/11/17, 07/14/17, 07/20/17, 07/23/17, 07/26/17 and 07/29/17. Review of the physician's orders [REDACTED].#1 was to have an Allevyn (soft gel adhesive) dressing applied to pad and protect the healed left ankle pressure area. The left ankle was to be cleansed with normal saline and the dressing was to be changed every third day and as needed. This treatment was originally ordered on [DATE]. During an interview with the director of nursing (DON), on 08/07/17 at 4:00 P. M., it was verified that staff failed to document that this treatment ordered by the physician was applied as ordered as noted on the above dates. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She also received treatment to a blister on the right breast and right arm as she was under the care of the wound physician. During an interview with the DON, it was revealed that these areas had healed. Resident #1 was under the services of hospice as of 08/01/17. She was observed seated in the dining room during the lunch meal on 08/07/17 at 12:30 P. M. This deficiency substantiates Complaint Number OH 639.

Based on observation, interview and record review the facility failed to ensure infection control was maintained during a dressing change for Resident #65. This affected one of one reviewed for wounds and dressing change. This had the potential to affect eight residents the facility identified to have a wound with a dressing change. The census was 76 at the time of the survey. Findings Include: Observation on 12/14/2016 at 11:50 A.M. of wound dressing to bilateral feet for Resident #65 revealed that Licence Practical Nurse (LPN) #20 did not sanitize hands after removing soiled dressing and applying new dressing. LPN #21 was assisting LPN #20 with the dressing change for Resident #65. LPN #20 washed hands, applied gloves removed old dressing to right foot and cleansed foot with soapy water. LPN #20 patted foot dry, took off gloves and applied new gloves and did not wash hands or sanitized hands prior to applying clean dressing. Interview on 11/15/16 at 11:09 A.M. with LPN #20 verified that she did not wash hands/sanitize hands prior to applying clean dressing. Review of undated policy named Dressing-Clean Technique revealed that wash/sanitize hands, put clean gloves on and remove soiled dressing, place soiled dressing in a plastic bag, cleanse wound with wound cleanser, normal saline or as specified by physician, remove gloves, sanitize hands and apply clean gloves.