Every finding on record at Ohman Family Living at Holly

Based on interviews, record review and review of facility policy, the facility failed to contain accurate information in medical records. This affected three residents (#132, #180 and #181) out of three residents reviewed for medical record accuracy. The facility census was 80.Findings include: 1. Review of the medical record for Resident #132 revealed an admission date of 12/08/25 and his diagnoses included acute respiratory failure with hypoxia (low oxygen level) and hypercapnia (increased carbon dioxide in the blood stream), sepsis, heart failure, tracheostomy (a surgical procedure that creates an opening in the neck and inserts a tube into the windpipe to help a patient breathe) and dependence on respiratory mechanical ventilator (a life-support treatment using a machine to assist or replace spontaneous breathing when a person cannot breathe adequately on their own). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #132 had intact cognition and was dependent on activities of daily living (ADLs) including personal hygiene, rolling left and right and transfers. He had a tracheostomy and required an invasive mechanical ventilator. He also had oxygen and required suctioning. Review of February 2026 Physician Orders and Respiratory Treatment Record (RTR) revealed the following: Resident #132 had an order dated 12/08/25 for ventilator checks (a structured, documented evaluation of both the mechanical ventilator and the resident's response to the support) every six hours and as needed. The RTR was blank for the 5:00 A.M. check on 02/02/26, 02/03/26, 02/04/26, 02/05/26, 02/07/26, 02/11/26, 02/14/26, 02/15/26, 02/16/26, 02/17/26, 02/19/26, 02/21/26, 02/22/26, 02/24/26, 02/25/26, 02/27/26 and 02/28/26; for the 11:00 A.M. check on 02/04/26, 02/05/26, 02/09/26, 02/18/26, 02/19/26, 02/22/26 and 02/27/26; for the 5:00 P.M. check on 02/06/26, 02/08/26, 02/10/26, 02/22/26, 02/25/26 and 02/27/26; and for the 11:00 P.M. check on 02/01/26, 02/02/26, 02/10/26, 02/23/26, 02/24/26, 02/26/26 and 02/28/26. Resident #132 had an order dated 12/08/25 to replace his oxygen nasal cannula, nebulizer mask, water bottle, and storage bag including marking the date and time on the items and checking the oxygen magnet on the door every Monday night, and the RTR was blank on 02/02/26 and 02/23/26. Resident #132 had an order dated 12/08/25 for sodium chloride inhalation nebulizer solution (respiratory therapy aerosol treatment used to thin, loosen, and help clear thick mucus from the lungs) seven percent per four milliliters (ml) via tracheostomy two times a day for pneumonia. The RTR was blank on 02/09/26 for the A.M. dose and on 02/25/26 for the P.M. dose. Resident #132 had an order dated 12/08/25 to assess his cuffed number six tracheostomy every shift. The RTR was blank on 02/09/26 for the A.M. shift, on 02/25/26 for the evening shift, and on 02/01/26, 02/02/26, 02/10/26, 02/23/26, 02/24/26, 02/26/26 and 02/28/26 for the night shift. Resident #132 had an order dated 12/08/25 for budesonide inhalation suspension (steroid aerosol treatment) 0.5 milligrams (mg) per two ml via tracheostomy two times a day due to pneumonia. The RTR was blank on 02/09/26 for the A.M. dose and on 02/25/26 for the P.M. dose. Resident #132 had an order dated 12/09/25 for ipratropium-albuterol solution (aerosol treatment) 0.5 mg per three ml via tracheostomy two times a day due to respiratory failure. The RTR was blank on 02/09/26 for the A.M. dose and on 02/25/26 for the P.M. dose. Resident #132 had an order dated 12/09/25 for tracheostomy care twice daily and as needed. The RTR was blank on 02/08/26 and 02/09/26 for the A.M. and on 02/06/26, 02/08/26, 02/10/26, and 02/25/26 for the P.M. Resident #132 had an order dated 12/09/25 to change his disposable tracheostomy inner cannula daily and as needed. The RTR was blank on 02/09/26 for the day shift. Resident #132 had an order dated 12/18/25 for oxygen at three liters per minute (LPM) via tracheostomy collar during the day, evening and night shift to maintain an oxygen saturation rate greater than 88 percent. The RTR was blank on 02/04/26, 02/05/26, 02/08/26 and 02/09/26 on the day shift, on 02/25/26 for the evening shift, and on 02/01/26, 02/02/26, 02/10/26, 02/23/26, 02/24/26, 02/26/26 and 02/28/26 for the night shift. Resident #132 had an order dated 12/22/25 to change his tracheostomy collar set up every Monday on night shift. The RTR was blank on 02/02/26 and 02/23/26. Resident #132 had an order for a cough assist (a non-invasive medical device designed to help residents with weak muscles or impaired lung function clear secretions from their airways) 30 times for five cycles two times a day. The RTR was blank on 02/09/26 for the A.M. and on 02/06/26, 02/08/26, 02/10/26 and 02/25/26 for the P.M. Review of March 2026 Physician Orders and RTR revealed the following: Resident #132 had an order dated 12/08/25 for ventilator checks every six hours and as needed. The RTR was blank for the 5:00 A.M. check on 03/01/26, 03/02/26, 03/03/26, 03/04/26, 03/05/26, 03/07/26, 03/09/26, 03/12/26 and 03/15/26; for the 11:00 A.M. check on 03/04/26 and 03/06/26; for the 5:00 P.M. check on 03/17/26; and for the 11:00 P.M. check on 03/01/26 and 03/08/26. Resident #132 had an order dated 12/08/25 for sodium chloride inhalation nebulizer solution seven percent per four ml via tracheostomy two times a day for pneumonia. The RTR was blank on 03/05/26 and 03/13/26 for the P.M. dose. Resident #132 had an order dated 12/08/25 to assess his cuffed number six tracheostomy every shift. The RTR was blank on 03/05/26 and 03/13/26 for the evening shift, and on 03/01/26 and 03/08/26 for the night shift. Resident #132 had an order dated 12/09/25 for tracheostomy care twice daily and as needed. The RTR was blank on 03/05/26 and 03/13/26 for P.M. Resident #132 had an order dated 12/09/25 for ipratropium-albuterol solution 0.5 mg per three ml via tracheostomy two times a day due to respiratory failure. The RTR was blank on 03/05/26 and 03/13/26 for the P.M. dose. Resident #132 had an order dated 12/23/25 for a cough assist 30 times five cycles two times a day. The RTR was blank on 03/05/26 and 03/13/26 for P.M. Resident #132 had an order dated 12/18/25 for oxygen at three liters via tracheostomy to maintain oxygen saturation level of 88 percent or greater and to check oxygen saturation level every evening and night shift. The RTR was blank on 03/05/26 and 03/13/26 for the evening shift and on 03/01/26 and 03/08/26 for the night shift. Review of the care plan last revised 12/14/25 revealed Resident #132 required oxygen therapy, for his oxygen saturation rate to be monitored continuously and he was followed by Respiratory Therapy (RT). Interventions included administering medications as ordered, monitoring for respiratory distress and reporting to the physician as needed. Resident #132 had a tracheostomy, continuous oxygen saturation rate monitoring and he was followed by RT. Interventions included oxygen as prescribed, suctioning as needed, monitoring and checking respiratory rate, depth and quality every shift as ordered and documenting. Resident #132 was on a mechanical ventilator due to respiratory failure and stroke. He was dependent on staff for all his ventilator needs and he was followed by RT. Interventions included administering aerosols as ordered, assessing signs of hypoxia, monitoring oxygen saturation levels, and routine tracheostomy change as ordered. There was nothing in the care plan regarding ventilator checks every six hours. 2. Review of the closed medical record for Resident #181 revealed an admission date of 03/02/26 and discharge to the hospital on [DATE]. Her diagnoses included acute respiratory failure with hypoxia, heart failure, tracheostomy and dependence on a respiratory mechanical ventilator. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #181 was cognitively intact and dependent on ADLs including personal hygiene, rolling left and right and transfers. She had a tracheostomy and required an invasive mechanical ventilator. She also had oxygen and required suctioning. Review of March 2026 Physician Orders and RTR revealed the following: Resident #181 had an order dated 03/03/26 to have ventilator checks every six hours and as needed. The RTR was blank for 5:00 A.M. on 03/03/26, 03/04/26, 03/05/26, 03/07/26, 03/09/26 and 03/12/26, for 11:00 A.M. on 03/04/26 and 03/06/26, and for 11:00 P.M. on 03/08/26. Resident #181 had an order dated 03/03/26 for albuterol sulfate nebulization solution 2.5 mg per three ml inhale orally per nebulizer two times a day for shortness of breath. The RTR was blank on 03/10/26 for the A.M. dose and on 03/05/26 for the P.M. dose. Resident #181 had an order dated 03/03/26 for sodium chloride inhalation nebulization solution seven percent per four ml via tracheostomy two times a day due to thick secretions. The RTR was blank on 03/05/26 for the bedtime dose. Resident #181 had orders dated 03/03/26 to assess her cuffed tracheostomy, size number seven, every shift and oxygen at one to 15 LPM to maintain an oxygen saturation rate of 88 percent or greater. The RTR was blank on 03/05/26 for the evening shift and on 03/08/26 for the night shift for both orders. Review of the care plan dated 03/08/26 revealed Resident #181 had oxygen therapy related to acute and chronic respiratory failure with hypoxia and hypercapnia. She was followed by an RT at the facility. Interventions included administering medications as ordered by the physician and monitoring signs of respiratory distress. Resident #181 was ventilator dependent related to respiratory failure. Interventions included administering aerosol treatments as ordered, assessing for signs of hypoxia, maintaining ventilator settings as ordered, monitoring oxygen saturation levels while on mechanical ventilator every shift, monitoring and documenting to physician any signs of respiratory infection, and preventing accidental extubating by taping securely and checking every two hours. There was nothing in the care plan regarding ventilator checks every six hours. Resident #181 had a tracheostomy related to impaired breathing. Interventions included suctioning as needed, monitoring and documenting respiratory rate, depth, and quality every shift and giving oxygen as ordered. 3. Review of the closed medical record for Resident #180 revealed an admission date of 02/06/26 and discharge to the hospital on [DATE]. She was re-admitted to the facility on [DATE] and discharged back to the hospital on [DATE]. Her diagnoses included acute and chronic respiratory failure, congestive heart failure, type two diabetes mellitus, pneumonitis (inflammation of the lung), chronic obstructive pulmonary disease, interstitial (small spaces in the lungs) pulmonary disease, dysphagia (difficulty swallowing), myasthenia gravis (weakness in voluntary muscles), non-Hodgkin lymphoma (a cancer of the lymphatic system), dementia, and chronic kidney disease. The resident had a tracheostomy and dependence on a respiratory mechanical ventilator. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #180 had no cognitive impairment and was dependent on ADLs including personal hygiene, bathing, dressing, and substantial to dependent assistance with bed mobility and transferring. She had a tracheostomy, required an invasive mechanical ventilator, and oxygen therapy. Review of February 2026 and March 2026 Physician Orders and RTR revealed the following: Resident #180 had an order dated 02/06/26 to have ventilator checks every six hours and as needed. The order was discontinued on 02/19/26 after discharge, and a new identical order was initiated on 02/24/26 upon readmission to the facility. The RTR was blank on for the 5:00 A.M. check on 02/07/26, 02/11/26, 02/14/26, 02/15/26, 02/27/26, 02/28/26, 03/01/26, 03/02/26, 03/03/26, and 03/04/26; for the 11:00 A.M. check on 02/07/26, 02/08/26, 02/09/26, and 02/27/26; for the 5:00 P.M. check on 02/10/26, 02/25/26, and 02/27/26; and for the 11:00 P.M. check on 02/10/26, 02/26/26, and 02/28/26. Resident #180 had an order dated 02/08/26 for albuterol sulfate nebulization (aerosol treatment) solution 2.5 mg per three ml via ventilator two times a day for respiratory failure. The order was discontinued on 02/19/26 after discharge, and a new order started on 02/24/26 for ipratropium-albuterol solution (aerosol treatment) 0.5-2.5 mg per three ml inhale orally three times a day for respiratory failure. The RTR was blank on 02/09/26 for the A.M. dose, on 02/27/26 and 03/04/26 at 1:00 P.M., and on 02/25/26 and 02/27/26 at 9:00 P.M. Resident #180 had an order initiated on 02/06/26 for titration (adjustment of the level) of oxygen one to 15 LPM, to maintain peripheral capillary oxygen saturation (the percentage of oxygen-saturated hemoglobin in the blood) of 88 percent or greater every shift. The order was discontinued on 02/29/26 after discharge, and a new identical order started on 02/24/26 upon readmission to the facility. The RTR was blank on 02/09/26 and 02/27/26 for the day shift, on 02/25/26 for the evening shift, and on 02/10/26, 02/26/26, 02/28/26, and 03/01/26 for the night shift. Review of the care plan dated 02/07/26 revealed Resident #180 had a tracheostomy and was ventilator dependent related to acute respiratory failure with hypoxia. Interventions included administering aerosol treatments as ordered, suctioning as necessary, and monitoring and documenting respiratory rate, depth, and quality every shift. Interview on 03/17/26 at 11:14 A.M. with Assistant Director of Nursing (ADON) #200 and RT #307 revealed there was always an RT at the facility and the RT was to document on the RTR that the orders were completed, omitted, refused and/or any other reason the RT medication and/or treatment was not completed. They verified the blanks on the February and/or March 2026 RTRs for Residents #132, #180 and #181 and stated they felt the orders were completed but not documented accurately. They verified there was no other documentation that the RTs used including ventilator checks as they revealed the RTR was the only form utilized. Interview on 03/17/26 at 2:06 P.M. with the Director of Nursing (DON) verified she had reviewed the RTRs for Residents #132, #180 and #181 for February and/or March 2026 and verified there were blanks including ventilator checks, aerosol treatments, tracheostomy assessments, and oxygen as ordered. She stated the facility had recently started the ventilator program and they were working out the issues including documentation. She felt the orders were completed but were not documented accurately. She revealed a medication error form should have been completed for any treatment and/or medication omitted and then the facility would investigate why the order was not documented as completed. Interview on 03/17/26 at 2:20 P.M. with Director of RT #239 verified that she had noticed the blanks on the RTR for Residents #132, #180 and #181. She stated the RTs at the facility were just not used to documenting on the RTR and that she was just as guilty as she had not documented at times. She verified the RTR documentation was not accurate, but stated she believed the orders were completed just not documented. Review of facility policy labeled, Medication Errors dated 01/30/20 revealed a medication error/omission report was to be completed immediately after an error was discovered to ensure proper resident follow up. Review of facility policy labeled, Invasive Mechanical Ventilation dated 12/08/25 revealed the goals of mechanical ventilation was to sustain life, reduce morbidity and enhance quality of life. There was no reference in the policy regarding ventilator checks or the documentation of orders in the RTR. This deficiency represents non-compliance investigated under Complaint Number 2795617.

Based on observation, interview, and record review, the facility failed to ensure timely incontinence care was provided to Resident #2. This affected one resident (#2) of three residents observed and reviewed for incontinence care. The facility census was 80.Findings include: Review of Resident #2's medical record revealed an admission date of 09/15/25. Diagnoses included spondylosis (an age-related degenerative condition) of the lumbar spine, diabetes, and high blood pressure.Review of the care plan dated 09/16/25 revealed Resident #2 had self care deficits related to weakness and limited mobility. Interventions included one staff participation with toileting. Resident #2 had bladder incontinence and required assistance with hygiene and transfers. Interventions included check resident as required for incontinence. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had intact cognition and was dependent with toileting. Resident #2 was identified to be frequently incontinent of both bowel and bladder. Observation on 01/28/26 at 10:50 A.M. revealed an electronic call light system at the nurses station that indicated Resident #2's call light had been active and unanswered for 35 minutes. Observation further revealed two staff members seated at the nursing station while the call light system was alarming. Observation and interview on 01/28/26 at 10:52 A.M. with Resident #2 revealed she had turned her call light on for assistance with toileting. During the interview at 11:02 A.M., Certified Nursing Assistant (CNA) #175 had entered the resident's room and stated she was on her way to lunch, but she had observed Resident #2's call light on for 45 minutes and wanted to check to see what Resident #2 needed. Resident #2 informed CNA #175 she needed toileting assistance and she had already been incontinent in her bed because she had waited so long. CNA #175 proceeded to assist Resident #2 into her wheelchair and assisted Resident #2 into the bathroom. CNA #175 had then proceeded to assist Resident #2 with personal hygiene and had changed Resident #2's bedding because it was soiled with urine.Interview on 01/28/26 at 11:25 A.M. with CNA #194 revealed she worked for agency and was not assigned to Resident #2, however she was present at the nurse's station and had heard the call system alarming, however had not answered the call light. At time of interview, Licensed Practical Nurse (LPN) #195 revealed she was the assigned nurse for Resident #2, however she was not aware of who the aide was for that assignment. LPN #195 further stated she was present at the nurses station and had heard the call light system, however she had assumed the aides would answer the light and if she was needed the aides would inform her. This deficiency represents non-compliance investigated under Complaint Number 2708882.

Based on observation, interviews, record review and facility policy, the facility failed to ensure neutropenic guidelines and isolation were maintained for Resident #36 and the provider order was followed by staff to prevent the development and transmission of communicable diseases and infections to the immunocompromised resident. This affected one resident out of five reviewed for infection control. The census was 85.Review of the medical record for Resident #36 revealed an admission date of 10/27/25 with a diagnoses of Cauda Equina Syndrome (spinal cord injury of lower back), myeloblastic leukemia (a blood cancer), epileptic syndrome, diastolic heart failure, adult failure to thrive, depression, venous thrombosis and embolism (blood clots), and depression.Review of the physician's orders dated 10/27/25 revealed Resident #36 was ordered to have neutropenic transmission-based precautions due to being an immunocompromised resident with myeloblastic leukemia. Immunocompromised residents are at increased risk for numerous types of infections while receiving healthcare, specifically, fungal and bacterial infections. This included: signage outside of the room, wear N95 mask, shield, gloves and gown when entering the room. Removal of personal protective equipment (PPE) prior to leaving room and hand hygiene before and after entering room. Sanitize shared equipment between uses.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated Resident #36 was cognitively intact. The functional assessment revealed Resident #36 required maximum assistance with showering and personal hygiene and was dependent on staff for toileting and mobility using a manual wheelchair. Resident #36 was also incontinent of bowel and bladder.Observation on 12/08/25 10:36 A.M. of Resident #36 sitting comfortably in a chair in her room. PPE was hanging on the outside of the door for staff and included an ample supply of surgical masks, gowns, gloves, and hand sanitizer. No N95 masks were available for staff.Observation on 12/08/2025 1:10 P.M. revealed Resident #36 was outside of the room in the common area not wearing any mask and in close contact with other residents and staff.Observation on 12/08/25 at 2:11 P.M. of Licensed Practical Nurse (LPN) #413 entering Resident #36's room wearing a surgical mask only.Interview with LPN #413 on 12/08/25 at 2:20 P.M. revealed Resident #36 does not wear a mask outside of her room. LPN #413 also stated that staff do wear surgical masks when entering Resident #36's room but do not don all the PPE unless providing care to resident. LPN #413 also verified the provider order indicated anyone entering resident's room would wear an N95 mask, gown and gloves and perform hand hygiene upon entering and exiting the room, and the resident would wear a mask outside of her room.Interview with the Director of Nursing (DON) on 12/08/25 at 2:30 P.M. verified Resident #36's order and stated they have not been using N95 masks per the order. The DON also stated the provider should have been contacted after placing the order in October 2025 to change to surgical masks and not N95 masks.Interview with Resident #36 on 12/09/25 at 2:45 P.M. revealed she only wears a mask when in physical therapy and does not wear a mask in any other area of facility including common areas such as dining room and activities room.Review of Resident #36's labs dated 12/08/25 revealed a [NAME] Sedimentation Rate of 46 millimeters per hours (mm/hr.) (reference range 0-20 mm/hr.) which indicates chronic inflammation due to active leukemia.Review of the facility policy titled, Isolation: Transmission -Based Precautions, dated 01/04/25, revealed Reverse Isolation (Neutropenic) is for compromised residents and should include signage on door, protecting resident from everyone else; and in addition to standard precaution to wear a gown when coming into contact with resident; wear a mask when coming within six feet of resident; and place a mask on resident when outside of their room.Review of the Center for Disease Control (CDC) Guidelines for Infectious Disease, dated 2007, revealed for neutropenic precautions, healthcare staff typically wear gloves, gowns, and masks (surgical or N95), along with meticulous hand hygiene, to protect immunocompromised patients from germs by creating a barrier against blood, body fluids, and respiratory secretions, especially when entering the patient's room for direct care. Patients themselves often wear masks in public to protect their weakened immune systems from others' germs.

Based on closed medical record review, staff interview, policy review, and review of manufacturer's guidelines, the facility failed to ensure Resident #100 was transferred in a safe manner to prevent an injury during a mechanical (Hoyer) lift transfer. Actual Harm occurred on 01/31/25 at approximately 6:49 P.M. when Resident #100, who was dependent on staff for transfers, was injured during a Hoyer lift transfer when staff did not ensure Resident #100 cleared the air mattress's bolsters on the edge of the bed. As a result, the Hoyer lift tipped and struck Resident #100 on the top of the head. Resident #100 was transported to the hospital and diagnosed with a concussion and laceration to the head which required six staples to close the lacerated wound. This affected one resident (#100) of three residents reviewed for safe transfers. The facility identified two additional residents who required the use of a Hoyer lift for transfers on the 500-hallway. The facility census was 90. Findings include: Review of the closed medical record for Resident #100 revealed a re-admitted [DATE] with medical diagnoses including Parkinson's disease with dyskinesia, generalized muscle weakness, and chronic systolic heart failure. Resident #100 discharged from the facility on 02/09/25. Review of Resident #100's care plan revised on 01/27/25 revealed the resident had an activities of daily living (ADL) self-care performance deficit related to Parkinson's weakness, limited mobility, and increased tremors. Listed interventions included transferring the resident using two staff participation using a Hoyer (mechanical) lift and a pressure relief mattress to bed to help reduce pressure on fragile skin. An additional care plan focus revealed Resident #100 was at risk for pressure ulcer development related to limited mobility and incontinence. A listed intervention included applying an air mattress to the resident's bed. Review of Resident #100's Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident was cognitively intact. The assessment revealed Resident #100 was dependent on staff for transfers and required the use of a manual wheelchair. Review of a progress note dated 01/31/25 at 6:49 P.M. revealed the nurse was notified by two Certified Nursing Assistants (CNAs) that as they were lifting Resident #100 with the Hoyer lift into his bed, the Hoyer lift tipped over, and the top-heavy part struck Resident #100 in the middle of his head, near his hairline and forehead. A large hematoma and bleeding were noted around the area. The physician was notified and gave an order to send Resident #100 out to a local emergency room (ED) for evaluation. A subsequent note timed 7:12 P.M. revealed Resident #100's family was notified of the injury and transfer to the local ED. Review of a skin incident report dated 01/31/25 and timed 7:00 P.M. revealed Resident #100 obtained an injury during a Hoyer lift transfer. The report was prepared by Registered Nurse (RN) #224. RN #224 was notified by two (unnamed) CNAs that during a hoyer lift transfer, once Resident #100 was lowered into the bed, the Hoyer lift tipped over and struck Resident #100's head near his hairline. Resident #100 was bleeding and had a hematoma surrounding the area. Resident #100 was assessed to be at baseline mentation and alertness. The report listed Resident #100 as stating I got hit with the Hoyer lift as he was being transferred. Notifications were completed to the physician and Resident #100's family, and the resident was transferred to a local emergency department (ED) for treatment. Review of an ED After Visit Summary (AVS) dated 01/31/25 revealed Resident #100 was seen in the ED after sustaining a head injury to his scalp. The note listed the resident had received six staples in his head to close the laceration. Listed diagnoses for the ED visit were listed as a head injury and concussion. Resident #100 received a dose of Tylenol (an over-the-counter analgesic) and a tetanus vaccination. Resident #100 returned to the facility in the early morning hours of 02/01/25. Interview on 04/11/25 at 11:00 A.M. with the Director of Nursing (DON) revealed that the resident had previously been treated for moisture-associated skin damage (MASD) during a prior admission, so upon his re-admission on 01/29/25, an air mattress was placed on the resident's bed as a preventative measure. The DON stated after being made aware of Resident #100's Hoyer lift injury, she believed the air mattress contributed to the incident. Interview on 04/11/25 at 4:22 P.M. with CNA #158 revealed her and Agency CNA #227 transferred Resident #100 on 01/31/25 when he sustained an injury from the Hoyer lift. CNA #158 reported the transfer went well until the lift got to the resident's bed. CNA #158 stated the mattress was too tall for the Hoyer lift to clear. The legs of the hoyer lift were open, CNA #158 stated she had control of the Hoyer lift, and Agency CNA #227 was guiding the resident. CNA #158 stated the legs of the Hoyer lift were open, Resident #100 was a taller and bigger man, and was unsure why or how the Hoyer lift tipped. CNA #158 stated she and Agency CNA #227 stopped the Hoyer lift from tipping completely. Interview on 04/11/25 at 4:35 P.M. with RN #224 revealed she was on duty the night Resident #100 was injured during a Hoyer lift transfer. RN #224 reported she did not witness the transfer but was called to the room by an unspecified aide after the transfer and an injury occurred. RN #224 immediately responded to the resident's room and noticed an abrasion to the resident's forehead. She assessed the resident and determined Resident #100 needed to be evaluated at a local ED as he routinely took blood thinners. Interview on 04/11/25 at 4:42 P.M. with Agency CNA #227 revealed she was caring for Resident #100 the night he sustained an injury during a Hoyer lift transfer. Agency CNA #227 and CNA #158 transferred Resident #100 from his wheelchair to his bed. On Resident #100's bed was an air mattress with bolsters (raised edges). Agency CNA #227 recalled the transfer went well until the Hoyer lifting Resident #100 did not clear the bolsters of the mattress. When turning and maneuvering the resident, the Hoyer lift tipped to the side, causing the top part of the Hoyer lift to hit Resident #100's head. Resident #100 started bleeding from where the Hoyer lift made contact with the resident's forehead. The two CNAs lowered Resident #100 into the bed and immediately summoned the nurse on duty. A follow up interview on 04/14/25 with the DON revealed the facility investigated the incident and had attempted to recreate the incident. The DON reported she did a root cause analysis of the incident and determined the root cause of Resident #100's injury was a combination of the resident's weight (last recorded as 262 pounds), the resident not clearing the air mattress bolsters, and movement/positioning of Resident #100 while transferring the resident into bed. Following the incident, Resident #100's mattress was changed from an air mattress with bolsters to a regular pressure-reducing mattress per his request and for improvement of safe transfers between surfaces. Review of the manufacturer's guidelines for the Hoyer lift, dated 2015, revealed the Hoyer lift's maximum capacity was 400 pounds (lbs). The guidelines contained a warning that lifters can tip over, and to keep base widened for stability. Review of the policy Mechanical Lift: Hoyer Lift dated 11/20/24 revealed a mechanical lift is used to facilitate transfers of residents who are unable to bear weight. At least two (2) people are involved during transferring a resident with the lift. The procedure included ensuring the resident is safe and secure. This deficiency represents non-compliance investigated under Complaint Number OH00162876.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions for food storage and food service. This had the potential to affect all residents except one, Residents #43, who received nothing by mouth. The facility census was 76. Findings include: During the tour of the kitchen on 01/02/19 at 9:14 A.M. a rolling metal rack was observed a yellow bin with a long clear lid. It contained an opened, bulk bag of flour with a large silver scoop observed sitting directly in the flour. Next to this rolling rack was the stand mixer. The mixer was observed with dried tan food particles on the upper surface where the mixer utensils are inserted and also scattered on the back of the stand. There were dried food particles and crumbs stuck between the back of the stand and the adjustable arm portion that holds the mixing bowl. Interview on 01/02/19 at 9:29 A.M. with Dietetic Technician (DT) #15 verified the scoop in the open bulk bag of flour and the dried food particles and crumbs on the stand mixer. Observation on 01/02/19 at 12:24 P.M. with DT #15 of the ice machine located just outside of the kitchen, revealed this ice machine was used for the residents. There were scattered black spots observed on the inside of the ice machine, on the outside of the off-white plastic ice shoot where the ice is dispensed from. There was also a small reddish stain. DT #15 stated the black spots were mold and that she will dump the ice and clean the ice machine. Review of the facility policy titled, Food Storage, dated 2010 revealed scoops for bulk foods are not to be stored in the food but are to be kept covered in a protected area near the containers.

Based on observation, record review and interview, the facility failed to ensure medications were administered according to the physician orders [REDACTED].#48 and #54) of nine residents observed receiving medications with two errors in 35 opportunities resulting in a medication error rate of 5.7%. Findings include: 1. Review of Resident #54's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #54's physician orders [REDACTED]. Insulin was to be given according to the sliding scale: inject two units if the resident's blood sugar was 150 to 200; four units if the resident's blood sugar was 201 to 250; six units if the resident's blood sugar was 251 to 300; eight units if the resident's blood sugar was 301 to 350; ten units if the residents blood sugar was 351 to 400; twelve units if the resident's blood sugar was 401 to 450; fifteen units if the resident's blood sugar was 451 to 500; and if greater than 501 give 20 units and notify the physician. Observation on 01/03/18 at 7:36 A.M. with Licensed Practical Nurse (LPN) #801 of Resident #54's medication administration revealed the nurse administered four units of insulin with a Humalog Kwikpen for a blood sugar of 213. LPN #801 did not ensure the pen was primed with two units of insulin prior to dialing up the four units of insulin and administering the insulin to the resident. Interview on 01/03/18 at 8:09 A.M. with LPN #801 confirmed she was unaware the insulin Kwikpens required priming of two units prior to dialing up the correct insulin dosage and administering the insulin to Resident #54. Review of the undated Kwikpen manufacturer directions revealed the pen was to be primed by turning the knob to select two units. The pen was to be held with the needle pointing up and the cartridge holder was to be tapped gently to collect air bubbles at the top. With the pen held with the needle pointing up they are to push the dose knob in until it stops and a zero is seen in the dose window. Insulin should then be seen at the tip of the needle. This removes air from the needle and ensures the correct dose of insulin can then be administered. 2. Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #48's physician orders [REDACTED]. Observation on 01/03/18 at 8:08 A.M. with LPN #801 of Resident #48's medication administration revealed the nurse administered 13 units of Humalog 75/25 insulin with an insulin Kwikpen. LPN #801 did not ensure the pen was primed with two units of insulin prior to dialing up 13 units of the insulin and administering the insulin to the resident. Interview on 01/03/18 at 8:09 A.M. with LPN #801 confirmed she was unaware the insulin Kwikpens required priming of two units prior to dialing up the correct insulin dosage and administering the insulin to Resident #48. Review of the undated Kwikpen manufacturer directions revealed the pen was to be primed by turning the knob to select two units. The pen was to be held with the needle pointing up and the cartridge holder was to be tapped gently to collect air bubbles at the top. With the pen held with the needle pointing up they are to push the dose knob in until it stops and a zero is seen in the dose window. Insulin should then be seen at the tip of the needle. This removes air from the needle and ensures the correct dose of insulin can then be administered. This affected two residents (Residents #48 and #54) of nine residents observed receiving medications with two errors in 35 opportunities resulting in a medication error rate of 5.7%.

Based on observation, interview and review of resident dietary records, the facility failed to ensure milk products were maintained at appropriate temperatures during meal service. This affected seven residents (Residents #66, #17, #32, #80, #68, #83, and #77) who received milk based drinks. Findings include : Kitchen observation on 09/04/14 at 11:27 A.M. revealed there was a silver cart in the kitchen which held numerous glasses with resident drinks. Dietary Aide (DA) #11 poured the drinks, but did not put them on ice. There were seven milk drinks on the cart. The cart was then wheeled into the dining room. The drinks belonged to Residents #66, #17, #32, #80, #68, #83, and #77. The temperature logs were reviewed and was no temperatures listed for the milk products. DA #11 stated she did not take the temperature of the milk products prior to placing them on the cart and putting them in the dining room.. On 09/04/14 at 11:45 A.M. the milk products remained on the cart in the dining room. DA #11 measured the temperature of the milk products. The milk was 58 degrees Fahrenheit (F) and the health shakes were 60 degrees F. The findings were verified with DA # 11 and the director of food services at the time of the temperature measurement. The director of food service disposed of the milk products.

Based on interview and record review, the facility failed to ensure Resident #26 had a medically appropriate [DIAGNOSES REDACTED]. This affected one of five residents reviewed for unnecessary medications. Findings include: Resident #26 was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was severely cognitively impaired. The resident had a physician order [REDACTED]. The listed [DIAGNOSES REDACTED]. The resident's behavior intervention monthly flow records for June, July and August 2014 were reviewed. The resident's listed behaviors were calling out (call son), anxiety, depression and resistant to care. There was no evidence the resident had a medical [DIAGNOSES REDACTED]. Registered Nurse #10 was interviewed on 09/03/14 at 3:11 P.M. and verified Resident #26 did not have an appropriate [DIAGNOSES REDACTED].

Based on record review and staff interview, the facility failed to ensure the clinical record reflected sufficient and accurate information related to two fall events that occurred in the past 30 days for Resident #44. This affected one of three records reviewed for accidents. Findings included: Review of the medical record revealed Resident #44 was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. Balance / walking assessments dated 06/24/14, 07/01/14, and 08/21/14 assessed Resident #44 to be unsteady upon standing but able to stabilize with staff support. The falls care plan initiated 02/14/14 related to an identified history of falls reflected current interventions of yellow cord tag to call bell system and low bed with floor mats as of 08/10/14. A falls risk assessment dated [DATE] revealed Resident #44 was assessed to be a high risk for falls. The September 2014 physician orders [REDACTED]. The nurse's note dated 08/10/14 at 6:30 A.M. revealed the resident was found on floor at 6:00 A.M. The nurse's note dated 08/17/14 at 4:00 A.M. revealed the resident was found on the floor on the mat on her buttocks next to the bed with mattress supporting her back. The director of nursing was interviewed on 09/03/14 at 3:51 P.M. She verified the nurses notes for 08/07/14 and 08/17/14 lacked detailed information to support care plan interventions were in place at the time Resident #44 was found on the floor. The DON verified the 8/10/14 note did not reflect any observations and conditions when the resident was found and the 08/17/14 note did not reflect if the new intervention of the low bed was in place. The DON commented: "The nurses are instructed to leave certain information out of their notes." On 09/04/14 at 9:00 A.M., interview of the charge nurse, Licensed Practical Nurse (LPN) #100 verified nurses were to complete nurse's notes that provided observed details of all resident incidents, including falls or being found on the floor. LPN #100 verified the two nurses notes identified above lacked accurate documentation of the events as witnessed or what the nurse observed. LPN #100 did state that she was the nurse who wrote the note dated 08/10/14. LPN #100 reported she only wrote something in the chart as the night nurse who was on duty when the resident was found on the floor failed to document a nursing note. LPN #100 stated, "I just wrote that (Resident #44) was found on the floor. I didn't know any of the details to put in the notes." On 09/04/14 at 9:25 A.M., the DON verified the nurse's notes in the clinical record for Resident #44 were incomplete.

Based on observation and interview, the facility failed to ensure the dumpster was properly covered with a lid. This had the potential to affect the 76 residents who live in the facility. Findings include : On 09/02/14 from 9:22 A.M. to 10:30 A.M. with the director of food service, the facility's dumpster was observed. There was no lid on the dumpster. There were numerous bags of garbage in the dumpster. The director of food service verified there was no lid on the dumpster at 9:35 A.M. The director of maintenance was interviewed on 09/02/14 at 9:40 A.M. The director of maintenance stated the refuse company stated they were not going to provide any more lids for the dumpster because they kept getting broken.

Based on observation, record review and interview, the facility failed to provide medications to two residents (Residents #74 and #56) without errors. Fifty-one opportunities were observed with 12 medication errors occurring. The error rate was 23.5%. This affected two of 14 residents observed during medication pass observations. The facility census was 74. Findings include: 1. During a medication pass observation for Resident #74, on 02/29/12 at 8:30 A.M., Licensed Practical Nurse (LPN) #122 retrieved 11 medications from the medication cart for the resident. The medications consisted of a narcotic opioid [MEDICATION NAME] ([MEDICATION NAME]) 50 milligrams (mgs), a skeletal muscle relaxant ([MEDICATION NAME]) 5 mgs, an anti-[MEDICAL CONDITION] medication ([MEDICATION NAME]) 20 mgs, a vitamin/mineral (folic acid) 1 mg, a diuretic medication ([MEDICATION NAME]) 25 mgs, a diuretic medication ([MEDICATION NAME]) 40 mgs, an anti-depressant medication ([MEDICATION NAME]) 50 mgs, a non-narcotic [MEDICATION NAME] (aspirin) 81 mgs, a stool softener ([MEDICATION NAME]) 100 mgs, a vitamin supplement (vitamin B-1) 100 mgs and another vitamin supplement (Vitamin D3) 2000 Units. LPN #122 put all 11 medications into the crush sleeve/pouch and a crushed them all together. She then poured the crushed medication into an eight-ounce plastic cup. She did not flick at the sleeve/pouch to get the entire contents of medication fragments into the cup. Upon discarding the sleeve/pouch the surveyor requested it. LPN #122 put 30 milliliters of warm water into the cup with a spoon and went into the resident's room. Resident #74 was lying in his bed, head of bed elevated and a nutritional tube feeding supplement (Fibersource HN) infusing at 65 milliliters per hour through his [MEDICAL CONDITION] feeding tube. LPN #122 shut off and disconnected the nutritional supplement. She inserted a little water into the resident's [MEDICAL CONDITION] tube and then poured the cup with the 11 medications into the [MEDICAL CONDITION] tube. She then flushed the [MEDICAL CONDITION] tube with a little water and reconnected the resident's nutritional tube feeding supplement to his [MEDICAL CONDITION] feeding tube. Upon discarding the plastic cup which held the 11 crushed medications, LPN #122 verified the bottom and sides of the cup had multiple fragments/particles of medications. Upon examination of the sleeve/pouch she used to crush the 11 medications, at this time, she verified an approximate 1/8-inch layer of medication particles/fragments lying inside along the bottom of the sleeve. Resident #74 had not received his entire dosage of the 11 medications that were ordered for him to receive. LPN #122 stated "it is our policy to pool the medications together to crush and give them." On 02/29/12 at 11:00 A.M., review of the facility policy and procedure on "Enteral Medication" dated 11/22/11 revealed the following: "Multiple medications may be administered together combined in a cocktail via feeding tube unless otherwise contrary to manufacturer's recommendations. No special order is required for this. It is the same principle as taking multiple medications by mouth." By administering all 11 medications together and being unable to identify the particles/fragments of medications not given to the resident, 11 medication errors occurred with the administration of medication to Resident #74. 2. On 02/28/12, at 3:50 P.M., Registered Nurse (RN) #128 prepared the medication for Resident #56 which was Pentoxyfilline ([MEDICATION NAME]) 400 milligrams (mg) ER (Extended Release) tablet. The nurse crushed the medication and mixed it into applesauce. The crushed medication was administered to Resident #56. Review of physician orders revealed Pentoxyfilline 400 mgER on e tab by mouth three times daily with food. Review of the pharmacy card instructions read "Swallow Whole" Do not crush. The pharmacy card was reviewed with RN #28. Interview with RN #128 verified the medication was extended release and should not be crushed.

Based on observation, record review, facility policy and procedure review and interview, the facility failed to provide infection control precautions for four residents (Residents #66, #83, #112 and #113) of four residents in isolation. The facility census was 74. Findings include: 1. Resident #66 was admitted into the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was moderately impaired in cognition for decision-making and required a moderate assistance by one staff member for transferring and locomotion on and off of the unit and required extensive assistance of one staff member for toileting. The MDS revealed the resident was continent of bowel and occasionally incontinent of bladder function. A plan of care dated 02/20/12 contained "extra-measures for[DIAGNOSES REDACTED]" and a plan of care dated 02/20/12 for "Droplet Precautions." Physician orders dated 02/21/12 indicated to add to [DIAGNOSES REDACTED]. During tour of the facility on 02/29/12 at 10:30 A.M., accompanied by the nursing supervisor, Registered Nurse (RN) #123, Resident #66 was found out of her room. A small stop sign was noted on the door to her room that indicated to please see the nurse. The resident shared a room with Resident #85. No personal protective clothing was available outside the resident's room, up entering the resident's room or anywhere inside of the room. This was verified by RN #123 who stated the personal protective equipment (PPE) was stored in the medication room for staff to go and get it if they need it. Resident #85's medical record was reviewed and indicated that she was not infected with[DIAGNOSES REDACTED] or with RSV infections and shared a room with a resident that was infected with both. On 02/29/12, at 12:30 P.M., both Residents #66 and #85 were found in the main dining room eating their lunch meals at the same table. Resident #66 appeared weak, somewhat lethargic but alert. The resident did not have a mask on her face at this time. A third resident was noted to be seated at the same table with the two residents. Nursing notes dated 02/24/12 at 10:40 A.M. revealed the resident was "coughing up sputum, blood tinged." Nursing notes on 02/27/12 at 2:00 P.M. and then again at 7:00 P.M. revealed the resident had temperature of 100 degrees Fahrenheit. At 7:00 P.M., was lethargic, unable to stay awake long enough to answer questions. The physician was notified and the resident was sent to the hospital. She returned to the facility at 1:45 A.M. Nursing notes also from 02/27/12 at 9:30 A.M. revealed, "discontinued droplet precautions-over contagious period. Plan reviewed with physician, POA and staff. May eat in main dining room for meals. Afebrile (no fever). Still moist cough with some production. Good at using Kleenex to cover her cough but needing re-enforcement." This notation was written by the facility director of nursing. No physician order was found to discontinue the droplet precautions. The facility policy and procedure "Infection Control Policy" revised last on 10/24/11 was reviewed. Attached to the policy was noted specific instructions for Droplet Precautions: 1. Face protection with close contact (within 3 feet). 2. Mask patient when out of room. 3. Wash hands before leaving room. Per CDC guidelines as retrieved above: Personal Protective Equipment such as masks, gowns, gloves, etc. should be available upon entrance into a resident's room with a known infection. The facility policy only indicated the wearing of gowns as a "may need" situation. Observation of Resident #66 on 03/01/12 at 9:10 A.M., revealed the resident was up in her wheelchair in the therapy gym doing exercises with a therapy staff member (PTA) #124. PTA #124 was sitting on a small rolling stool in front of the resident trying to have her arms go from side to side while holding a pole. During interview with PTA #124 at this time, he stated the resident "is still very weak." He verified the resident is "still coughing once in a while." He stated the resident is also working with speech therapy and is on thickened liquids. Further record review revealed that Resident #66 was toileted by staff and the bathroom in her room was shared by Resident #85 who was also toileted by staff. An "infection transmission risk assessment" for RSV dated 02/21/12 (discontinued on 02/27/12) indicated culture on 02/15/12, droplet precautions and wash hands frequently. The assessment indicated from (CDC) may be contagious three to eight days. An "Infection transmission risk assessment," dated 02/21/12 for[DIAGNOSES REDACTED], indicated contact precautions, bedside commode, contain soiled briefs in plastic bag, gloves for close contact with stool and other body substances example messy stools. The assessment further indicated "may require additional barriers when there is a potential for uniform contamination." 2. Resident #83 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital discharge/transfer summary dated 09/17/10 revealed the resident had a status [REDACTED]. She had a prosthesis infection with a status [REDACTED]. She returned to the hospital on [DATE] for right hip pain. She then had a post hip hemin-arthroplasty with drainage. An infectious disease physician was brought in and the resident was sent back to the facility on [DATE]. A hospital culture on 06/19/11 revealed rare staphylococcus aureus and MRSA. A significant change MDS dated [DATE] revealed the resident was severely impaired in cognition for decision-making, required an extensive assistance by two staff members for bed mobility, and by one staff member for transferring and toileting. physician progress notes [REDACTED]. Physician orders, dated 08/31/11, for contact precautions. February routine physician orders continued to indicate the physician's order from 08/31/11 for "contact precautions." A plan of care, dated 12/12/11, indicated the resident was frequently incontinent of bladder related to diuretic use and impaired mobility. The resident required assist to toilet for bowel and bladder needs. During tour of Resident #83's room, on 02/29/12 at 3:45 P.M., accompanied by the nursing supervisor RN #123, she verified the resident was in isolation. She verified there was no personal protective equipment (PPE) outside or inside the resident's room. She stated "we decided not to keep PPE outside of resident doors that are in isolation several years ago." She stated, "If staff need a gown, they have to go to the utility room to get one." She verified that Resident #83 shares a room with two other residents (Residents #38 and #115). A total of three residents resided in this room. She stated the other two residents are medical and are not isolation residents. She indicated that one of the residents uses the bathroom and is up walking around and has dementia. She stated the other resident is usually incontinent and has dementia also. She verified that Resident #83, in isolation, is sharing the room with the two other residents, and that the resident is on a toileting program. The surveyor requested to view the hip wound of Resident #83 at this time. At 4:05 P.M., RN #123 brought wound nurse, RN #126, who was dressed in her street clothes. She brought dressing supplies into the resident's room. No PPE was put on by RN #123 or RN #126. RN #126 put on a pair of gloves and rolled the resident onto her left side. A dressing was removed from the resident's right hip. The wound was approximately a 1.0 centimeter (cm) by 0.5 cm opening at top end of a healed incision on right hip. RN #126 verified a scant amount of serous drainage on the old dressing. She washed the area with a normal saline solution, patted it dry and applied a dressing onto the wound. She removed her gloves, washed her hands, and removed a small plastic bag with the old dressing and took it to the dirty utility room. The dirty utility room was searched by RN #126 for PPE. No PPE was found anywhere in the utility room. RN #126 verified "if I removed the dressing off of the resident and there was a sudden gush of drainage, I should have worn PPE." She stated, "per our DON, we only wear PPE if the resident has copious amounts of drainage." The medication room was then searched for PPE. No PPE was found in medication room. Both RNs #123 and #126 then checked the South Unit storage closet. No PPE was found in this room either. Both nurses verified there was no PPE available on the South Unit. 3. Resident #112 was admitted into facility on 02/17/12 with [DIAGNOSES REDACTED]. Physician orders dated 02/17/12, revealed the resident was to be given an antibiotic, [MEDICATION NAME] 250 mgs, four times a day for[DIAGNOSES REDACTED]. The resident was also to receive Lactobacillus/acidophilus two tablets three times a day. Review of a plan of care dated 02/17/12 for "extra-measures for[DIAGNOSES REDACTED] was found in the resident's medical record. Review of nursing notes, dated 02/18/12 at 12:30 P.M., revealed the resident required a mechanical lift (Hoyer lift) device for transfers and that generalized edema was present on the resident. Nursing notes dated 02/29/12 at 1:25 P.M. revealed the resident had 3+ pitting edema noted. During tour of the facility on 02/29/12 at 10:30 A.M., accompanied by the nursing supervisor, RN #123, Resident #112 was found lying in his bed with the head of the bed elevated. The resident shared a room with Resident #77. No stop sign was found on the entrance door to the room. RN #123 stated that the resident was in isolation and verified no alert sign on the door entering the resident's room. A small stop sign was found on the bathroom door inside of the room indicating to see the nurse before entering. No PPE was found inside or outside the room to apply before entering. This was verified by RN #123 at this time. 4. Resident #113 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician orders, dated 02/21/12 revealed an order for [REDACTED]. On 02/24/12 the physician again ordered a stool sample for[DIAGNOSES REDACTED], ova and parasite, salmonella, campylobacter, shigella and leucocytes. Laboratory results of 02/24/12 revealed the stool specimen was positive for[DIAGNOSES REDACTED] toxin. Physician orders on 02/27/12, indicated for the resident to begin an antibiotic medication [MEDICATION NAME] 500 mgs by mouth three times a day times 10 days and to initiate[DIAGNOSES REDACTED] precautions. Nursing notes dated 02/23/12 at 8:30 P.M., revealed the resident stated she had nine loose stools that P.M. Nursing notes, dated 02/24/12 at 6:40 A.M., revealed that the resident indicated she had two more loose stools. On 02/24/12 at 1:00 P.M., nursing notes revealed the resident had loose stools throughout shift. Physician orders dated 02/25/12 were noted for the treatment of [REDACTED]. A plan of care, dated 02/27/12, revealed "extra measures for[DIAGNOSES REDACTED]" noted. Interventions included to toilet with the limited assistance of one staff member. During tour of the facility on 02/29/12 at 10:30 A.M., accompanied by the nursing supervisor, RN #123 and Resident #113 was observed sitting up in a wheelchair in her room. The resident had a roommate (Resident #116) who was also noted in the room, laying in her bed. A small stop sign was noted on the door upon entering the resident's room but no PPE was found outside or anywhere inside of the resident's room. This was verified with RN #123 who stated if staff need a gown they need to go to the utility room to retrieve one. Record review for Resident #113 and her roommate revealed that both she and her roommate shared the bathroom in her room and that they both were on toileting programs. The record also revealed that the resident's roommate did not have a [DIAGNOSES REDACTED].

Based on observation, record review, and interview, the facility failed to re-assess the use of merri-walker device for one resident (Resident #50) with multiple falls. This affected one of three residents reviewed for accidents. The facility census was 74. Findings include: Resident #50 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was moderately impaired in cognition for decision-making and had both long and short term memory impairment. The MDS revealed the resident required extensive assistance by one staff member for bed mobility, transferring and toileting. The MDS revealed that the resident had sustained a fall in the facility since her admission with no injury. The resident was assessed as a high risk for falls on 01/22/11 and on 09/26/11. Physician orders [REDACTED]. The resident was to be removed every two hours, repositioned, re-apply the device. Physician orders [REDACTED]. During interview with the south unit charge nurse, Licensed Practical Nurse (LPN) #127 on 02/29/12 at 3:00 P.M., she stated that Resident #50 had a recent fall from her merri-walker. She had got down in the walker and got "entangled in the strap" and fell on the floor. She stated no injury was noted. During observation of Resident #50 on 02/29/12 at 3:30 P.M. and 5:30 P.M. she was up in a wheelchair, in the television/lounge area of the South Unit with an alarm device secured to her wheelchair. The resident was not talkative. She was looking around the room and appeared confused and disoriented. Record review revealed nursing notes with the following falls: On 01/08/11 at 7:00 P.M. nursing notes indicated the resident was found sitting on floor in front of the wheelchair between the television/lounge area in the front lobby. The resident stated "I was trying to get out of this chair." No injury was noted. On 02/22/11 at 2:05 P.M. the resident was seen lowering herself under the front bar of the merri-walker and onto the floor. No injury was noted. On 05/30/11 at 6:45 A.M. while being assisted off the toilet the resident stumbled forward and was lowered to the floor by a state tested nursing assistant (STNA). No injury was noted. On 10/29/11 at 10:45 A.M. the resident was found on a floor mat in Room 208 next to another resident's bed. The merri-walker was tipped, lying on left side. A scant amount of bleeding was noted to the resident's right side of her nose. On 11/27/11 at 10:30 A.M. staff alerted the nurse that the resident was in the merri-walker and it tipped over at the doorway edge. The resident was observed on the floor on her left side with the left side of her forehead bleeding. No loss of consciousness was noted. The resident was sent by emergency squad (911) to the emergency room and returned 11/27/11 at 3:30 P.M. with an edematous left eye and eight sutures in her forehead. Review of nursing notes dated 12/13/11 (no time indicated) revealed "reviewed pros and cons of allowing resident to ambulate in merri-walker without supervision. "I want her to walk" (unsure who quoted statement from) demonstrated probable cause of last fall being that the old merri-walker fit sideways through the door. Ordered new, longer merri-walker at the resident's power of attorney's (POA's) request. Review of nursing notes dated 01/12/12 (no time indicated) revealed the resident discovered on the floor in merri-walker immediately inside doorway of other resident's room. The merri-walker was laying sideways on the floor with the resident's lower half of body still inside the walker. The resident was laying on her side holding her shoulders and head up with left hand. The resident was bleeding from left brow and her glasses were laying on floor by her head and left arm. The glasses were broken. Steri strips were applied to the resident's left brow. The resident was sent to the hospital, 911 and returned the same date with a clear adhesive closure to the left brow. Small ecchymosis was noted on the left shin and redness to the left shoulder. Neuro checks were implemented. Reveal of nurses notes revealed on 02/24/12 at 10:30 A.M. housekeeping staff member observed the resident entangled in a black strap attached to the merri-walker. She summoned a STNA immediately. The resident apparently slid out of the merri-walker to the floor with straps and latches intact on the walker. On 03/01/12 at 2:00 P.M. review of the nursing notes revealed that the nurse heard "help" yelled out from down the hall. The resident was noted on the floor on her left side in the merri-walker in the doorway of Room 218. The resident was assessed. She had a left eye laceration with mild red drainage (bloody drainage). The resident's eyebrow was washed and treated and an ice pack was applied to the area. During observation of Resident #50 on 03/01/12 at 4:35 P.M. the resident gotten off her bed and placed into a wheelchair by two STNAs. An alarm device was noted intact on the wheelchair. A small two-inch dressing was on the left side of her face half over left eye and left eyebrow. Slight redness was noted to the skin around the left eye. The left eye appeared teary. The resident was non-verbal and would not speak to the surveyor. At 4:50 P.M. the resident's power of attorney (POA) arrived and took the resident over to the main dining room in her wheelchair. The medical record provided no evidence the merri-walker was reassessed for safety concerns for Resident #50.

Based on observation and interview, the facility failed to secure multiple vials of insulin, failed to maintain one secured medication cart out of three medication carts and failed to ensure that prepared medications was identified and administrated as ordered. The facility census was 74. Findings include: 1. During a medication pass observation on 02/29/12 at 8:00 A.M., for Resident #23, Licensed Practical Nurse (LPN) #122 obtained a small basket of 11 insulin vials from the nursing station and placed it on top of her medication cart. She retrieved a vial of Lantus insulin for the resident and drew up 50 units into a syringe. She took the resident into her room to administer the insulin to the resident. LPN #122 did not secure the 11 vials of insulin from on top of the medication cart and did not lock or secure the medication cart. While in the resident's room, administering the insulin to Resident #23, another resident (Resident #14) was left in the hallway in her wheelchair next to the medication cart. Upon return to the medication cart with the surveyor, LPN #122 verified that she had not locked up and secured the 11 vials of insulin and did not lock her medication cart. 2. On 02/29/12 at 8:25 A.M., during a medication pass observation on the 200 unit, Licensed Practical Nurse (LPN) #129 removed a plastic medication cup containing what appeared to be crushed medications with applesauce from the top drawer of the cart and placed it on top of the medication cart. An interview with LPN #129 at that time verified the plastic medication cup contained crushed medications and applesauce, and was left in the top drawer of the night shift cart. She stated that the plastic cup was not labeled and was probably for the night shift medication pass, but was not sure who left it there. LPN #129 stated that she did not know what medications were in the cup or what resident was supposed to receive the medications. LPN #129 verified that the facility policy was to administer medications when prepared, stating "It should not have been left there." A review of the facility policy and procedure form titled: Administration and Documentation of Medication, dated 11/24/11, contained the following notations: 2. Medication is prepared at the time of administration. 3. Medication is administered within one hour of the scheduled administration time unless scheduled daily. 8. Medication administration records are utilized during administration of medications. 9. The licensed nurse initials medication administration records (MAR) immediately after pouring the medication or after medication administration. If medication is refused or not administered, initials are to be circled and appropriate explanation recorded on the back side of the MAR. During an interview with the director of nursing on 02/29/12 at 10:30 A.M. she stated that "It's standard nursing practice that you don't leave medications unsecured and unattended."

Based on observation, review of policy and procedures and interview, the facility did not ensure that the dishwashing procedure was carried out in a manner that prevents cross-contamination between the handling of the dirty dishes, pots and pans, and the clean dishes, pot and pans. This affected 70 residents who received food trays. The facility census was 74 at the time of the survey. During the initial tour of the main kitchen, conducted on 02/18/12 between 9:00 A.M. and 9:40 A.M., the surveyor and the food service director observed Dietary Aide #121 working in the dish area. She was rinsing the dirty pots and pans and placing them in the rack to be put through the dish machine. She was wearing a plastic disposable apron and disposable gloves during this process. The water and waste from the rinsing was splashing onto the apron. Once the wash and rinse cycles were completed, the dietary aide opened the door to the machine, pulled the rack from the machine onto the drain board of the clean side of the machine. She was still wearing the gloves she used while rinsing the dirty pots and pans. The surveyor inquired if she was the only person assigned to the dish washing area and she replied, "Yes." She said there was only one dietary aide assigned all of the time. She did change her gloves and was going to proceed to unload the clean items, however, she did not wash her hands before she donned the clean gloves. She continued to wear the same apron while taking the pots and pans from the dish rack to the storage rack. She said she did not think to change her apron, too, nor did she realize she had to wash her hands after she removed the soiled gloves before donning clean gloves. The facility policy reads that gloves should be removed and wash hands before removing the clean dishes from the racks.

Based on observation, interview and record review, the facility failed to provide planned interventions to prevent the spread of infection from one resident (#69) to his roommate (#70), and failed to clean a bedside glucose testing device to prevent cross contamination after being used by one resident (#46). This affected two residents within a sample of 15. Findings include: 1. Resident #69 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident's plan of care for the infection included physician orders for oral antibiotics ([MEDICATION NAME]), and included contact precautions to prevent the spread of infection. An Infection Risk assessment dated [DATE] indicated that the resident could be in a room with a non infected resident because the staff would use "BSI" (body substance isolation) and "C-Diff special precautions". The assessment indicated the resident's roommate did not use the bathroom and was not on antibiotics. A review of the facility policy associated with[DIAGNOSES REDACTED] Special Precautions indicated that the resident was to have a sign on his bathroom door alerting visitors to check with the nurse before assisting the resident to the bathroom. The precautions indicated that the resident was to use a bedside commode which was to be kept in the bathroom. On 12/28/10 at 9:00 A.M., Resident #69's room was observed. The room had a purple dot sticker on the door frame indicating the resident had[DIAGNOSES REDACTED]. There was no sign for visitors and no bedside commode in the bathroom. On 12/28/10 at 2:50 P.M., Resident #69's room was observed with the director of nursing (DON). The DON verified the room lacked a bedside commode and the lack of any signs advising visitors to check with the nurse. During the observation Resident #69 was interviewed. The resident indicated that he had his room changed on 12/27/10 and that he had used the toilet in this room twice since then for bowel movements. A review of the bowel records of Resident #69's roommate, Resident #70, for December 2010 indicated that the resident had also used the toilet for bowel movements twice since 12/27/10. 2. On 12/30/10 at 11:05 A.M., Licensed Practical Nurse (LPN) #1 was observed during the bedside glucose testing (accucheck) for Resident #46. The nurse took the testing device from the medication cart to the resident's room with her supplies. She placed the testing device on the arm of the resident's recliner in his room while she used the lancet device to get a blood sample from the resident's finger. Following the testing the nurse returned the testing device to the top drawer of the medication cart without cleaning it as required to prevent cross contamination. LPN #1 verified she had not cleaned the glucometer after use.

Based on observation and interview, the facility failed to ensure that bedside glucose testing devices (accucheck machines) had required quality control testing. This affected one of six residents (#46) who had his glucose tested during the medication pass. Findings include: On 12/28/10 at 11:05 A.M., Licensed Practical Nurse (LPN) #1 was observed during medication pass. The nurse used a bedside glucose testing (accucheck) device to test the glucose level of Resident #46. Following the test the nurse was asked to provide the log of quality control tests done for the machine. The nurse indicated she had not tested the machine and did not know where the log was. On 12/28/10 at 11:25 A.M., the director of nursing (DON) was interviewed. The DON indicated she did not think there was a log of the quality control tests of the accucheck machine but would investigate. At 3:30 P.M., the DON indicated that the supervisor who took care of the accucheck machines had gone on sick leave in late November 2010. She indicated that she found no record of the accucheck testing.