Every finding on record at River Run Healthcare of Portsmouth

Based on record review, review of hospital records, policy review, review of local police reports, staff interview, resident interview and interview with the Long-Term Care Ombudsman, the facility failed to provide a safe and proper discharge to an appropriate location for Resident #25. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] when Resident #25, who had diagnoses including type two diabetes mellitus with two chronic ulcers, adult failure to thrive, functional quadriplegia, nicotine dependence, deep vein thrombosis, personality disorder, psychoactive substance abuse, anxiety, depression, and viral Hepatitis C, was discharged to an unknown location without housing, medications, or arrangements for ongoing care. Resident #25 was discharged without evidence of continuity of care related to medical care and services in place to address the resident's medical and mental health diagnoses. Resident #25 required 24-hour care for medication and behavior monitoring. This affected one (Resident #25) of three residents reviewed for discharge. The facility census was 22. On [DATE] at 1:45 P.M., the Administrator, Chief Clinical Officer (CCO) #500 and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when Resident #25, who resided in the facility for 12 days, was discharged to an unknown location without evidence he had a safe location in which to discharge to and without evidence of coordination of care to ensure the resident's medical and psychosocial needs were met resulting in the resident being hospitalized two days later. The Immediate Jeopardy was removed on [DATE], when the facility implemented the following corrective actions: - On [DATE] at 2:30 P.M., CCO #500 reviewed and revised the facility policy for transfer and discharge. The revisions included collaborating with the Ombudsman and community resources as indicated, ensuring discharge location meets the resident's needs, medications are given along with instructions and follow up for medical care. - On [DATE] at 2:45 P.M., CCO #500 educated the Administrator and the DON on the revised transfer and discharge policy. Education included the following components of the policy: during the appeal process of any 30-day discharge issued, the resident will not be discharged ; If an emergency occurs, the facility will confer with the Ombudsman, Medical Director #800 and company leadership to establish a safe discharge location to ensure the resident needs will be met; and the facility will notify the Ombudsman prior to discharge and after-hours voicemail will be left. 1. The Ombudsman will be notified by the Administrator immediately of any 30-day or emergency discharge as required. The Administrator or designee will confer with the Ombudsman to assist as necessary in resolving resident care concerns or facility barriers to meeting resident needs.2. Medical Director #800 will be notified by the DON of any 30 day or emergency discharge immediately upon the residents receiving documents, including rationale for discharge, location of discharge, ongoing needs and plan for medical follow up. - On [DATE], Corporate Minimum Data Set (MDS) Coordinator #700 audited all 22 in-house residents discharge care plans. All 22 care plans were reviewed and revised as indicated. - On [DATE] at 3:00 P.M., CCO #500 educated Social Services Designee #410 via the telephone on the facility's revised transfer and discharge policy and procedure.- On [DATE], the Director of Nursing reviewed the three residents (#27, #28, and #29) who were discharged in the past 30 days to ensure the discharge location was safe, met the residents' needs, follow up medical care was arranged, medications and discharge instructions were given. There were no negative findings.- On [DATE], the DON educated nine of the ten licensed nurses on the facility's revised policy on transfer and discharge. The one licensed nurse who was not educated will be unable to work until the in-service is completed. - On [DATE] at 3:30 P.M., the Administrator and the DON reviewed all 22 residents and documented their current discharge plan in each resident's medical record. There were no other 30-day notices at this time and there have been no other emergency discharges within the past six months.- On [DATE], an AD HOC Quality Assurance Performance Improvement (QAPI) meeting was conducted to discuss the deficiency, the revision component of the transfer and discharge policy, the actions to correct the deficiency, and the ongoing monitor of like residents. The attendees were Chief Clinical Officer #500, the Administrator, and Medical Director #800. - On [DATE], Resident #25 is now residing in another nursing facility and declined to return to the facility.- Beginning [DATE], the DON or designee will audit any discharge/pending discharge weekly for four weeks then monthly for two additional months to ensure ongoing safe proper discharges. Results of audits will be submitted weekly to QAPI committee for review and further recommendations.Although the Immediate Jeopardy was removed on [DATE], the deficiency remains at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Closed record review for Resident #25 revealed the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus with two chronic ulcers, adult failure to thrive, functional quadriplegia, nicotine dependence, deep vein thrombosis, personality disorder, psychoactive substance abuse, anxiety, depression, and viral Hepatitis C. Resident #25 involuntary discharged on [DATE].Review of the physician orders revealed Resident #25's scheduled medications included Aspirin (clot prophylaxis) 81 milligrams (mg) daily, lactulose (laxative) 10 gram (gm)/15 milliliters (ml) daily, loratadine (treats allergies) 10 mg daily, multivitamin (supplement) one tablet daily, Seroquel (antipsychotic) 100 mg twice daily, sennosides-docusate (laxative) 8.6-50 mg two tablets daily, apixaban (clot prophylaxis) five mg twice daily, duloxetine (antidepressant) 60 mg twice daily, Flonase (treats allergies) 50 micrograms per actuation one spray to both nostrils daily, magnesium oxide (supplement) 400 mg daily, MiraLAX (laxative)17 gm twice daily, Lyrica (anticonvulsant) 100 mg twice daily, baclofen (treats muscle spasms) 20 mg three times a day, and Oxycodone-Acetaminophen (treats severe pain) 5-325 mg every eight hours as needed.Review of the nursing notes from [DATE] through [DATE] revealed multiple behavioral issues including belligerence with staff, leaving the facility after signing himself out on multiple occasions and returning to the facility impaired, numerous refusals of care, and non-adherence to the facility smoking policy. According to the medical record, Resident #25's behavioral issues were not aimed at or targeted toward other residents.Review of the local police report dated [DATE] revealed Resident #25 was reported to have demonstrated threatening behavior toward staff and the facility wanted to discharge him due to his behaviors. The responding officer spoke to the long-term care (LTC) Ombudsman and advised Resident #25 and staff they could not make Resident #25 leave without notice and arranging transfer. The LTC Ombudsman arranged a meeting to come to a resolution. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was cognitively intact. Resident #25 was impaired on both sides to upper and lower extremities. Resident #25 was dependent on staff for personal hygiene, bathing, self-care, transfers, bed mobility, side-to-side movement, and dressing. Resident #25 utilized motorized wheelchair for mobility.Review of the Transfer Notice dated [DATE] revealed the facility provided Resident #25 with a written notice with multiple transfer locations listed and had 30 days to transfer out of the facility. Referrals were sent to multiple facilities in the Columbus and Cincinnati area. The reason for transfer was for the safety of the individuals in the home were endangered, and an emergency existed in which the safety of the individuals in the home were endangered. Appeal rights were also provided on the notice. There was no documentation provided by the facility on the status of the appeal, but the LTC Ombudsman was directly involved as of [DATE]. The LTC Ombudsman revealed Resident #25 was appealing this transfer.Review of the care plan, initiated on [DATE] revealed Resident #25 was receiving wound management care for left and right heel wounds along with coccyx and right gluteal wounds. Resident #25 was receiving anti-platelet therapy and was at risk of abnormal bleeding. Resident #25 was at risk for fluctuation in blood sugar levels related to diabetes mellitus. Resident #25 was incontinent with both bowel and bladder due to decreased mobility and functional quadriplegia. Resident #25 had an activity of daily living (ADL) self-care performance related to functional quadriplegia, activity intolerance, aggressive behavior, and utilized a motorized wheelchair for mobility.The care plan dated [DATE] revealed Resident #25's discharge planning was uncertain at the time and may be transferred to another nursing facility or to community. Interventions include allowing the resident to verbalize feelings regarding LTC placement, providing the resident with discharge information including his medications, durable medical equipment (DME) needs, follow up with physician visits and contact information, and provide Resident #25 with education before discharge as needed. There was no evidence in Resident #26's medical record this was completed at the time of Resident #25's emergency discharge on [DATE].The nursing note dated [DATE] at 9:45 A.M. revealed a fire alarm was sounding to Resident #25's room with smoke coming out of the resident's room. The resident had immediately left his room prior to this. The nursing note dated [DATE] at 3:01 P.M. revealed Medical Director #800 was notified of the incident and of Resident #25's immediate discharge.The nursing note dated [DATE] at 3:15 P.M. revealed the Administrator met with Resident #25 and issued an immediate discharge due to violating the safety of all residents in the facility. The resident only took his personal belongings with him and left the building.The immediate transfer notice dated [DATE] revealed the transfer location would be a homeless shelter (no address provided) in Portsmouth. The reason for the transfer was for the safety of individuals in the home was endangered and the health of individuals in the home would otherwise be endangered. The reason for the emergency was because an emergency existed in which the safety of the individuals in the home was endangered and an emergency existed in which the health of the individuals in the home would be otherwise endangered. The nursing note dated [DATE] at 3:20 P.M. revealed the LTC Ombudsman was notified of Resident #25's immediate discharge via email as the facility was unable to reach by telephone. A copy of the discharge information was also sent. The local police department report dated [DATE] revealed an officer was on standby at the facility as they gave Resident #25 an immediate notice of removal. The notice was provided to Resident #25 at 3:18 P.M.The local police report dated [DATE] at 11:03 A.M. revealed Resident #25 was found in a parking lot of a grocery store approximately 0.8 miles from the facility. The battery of his motorized wheelchair was completely dead. He was assisted at a local emergency room for evaluation.Review of the hospital records for Resident #25 dated [DATE] revealed Resident #25 arrived at the hospital and was disheveled and malodorous. He appeared chronically ill with infected conjunctiva, knuckles with infected-looking wounds, and excoriations of his skin. Resident #25 was transferred to Nursing Facility #800 on [DATE]. While at the hospital, the resident reported being kicked out of a nursing home. During an interview on [DATE] at 10:00 A.M., LTC Ombudsman #600 revealed she had been working with Resident #25 since [DATE]. She stated the facility attempted to provide the resident with an emergency discharge on that date ([DATE]) after he had left the facility for an extended period. A meeting was held with the resident and facility management on [DATE] to address the resident's behavior and a thirty-day discharge notice was issued, which the resident was planning to appeal. On [DATE], she was notified by the local police that Resident #25 was found at a local grocery store with his motorized wheelchair completely out of power and was taken to a local hospital. She stated the resident was transferred to another nursing facility on [DATE].During an interview on [DATE] at 12:30 P.M., the Administrator revealed Resident #25 was given an emergency discharge after the welfare and safety of the other residents were at risk on [DATE]. She stated he was given his belongings which he took with him. He left on his motorized wheelchair at 3:15 P.M.During an interview on [DATE] at 11:20 A.M., the DON verified Resident #25 was given an emergency discharge from the facility on [DATE]. She stated the resident left with his belongings and was not provided with any type of discharge instructions, wound care instructions, or medications.During a telephone interview on [DATE] at 1:20 P.M., Resident #25 stated the facility kicked him out for something he did not do (in reference to setting fire to his bed). He verified he was living on the streets after he was kicked out on [DATE] and his motorized wheelchair battery was dead two days later ([DATE]) and he was stuck in a grocery store parking lot. The facility did not give him anything but his belongings and he denied receiving instructions or medications. He stated he does not want to return to this facility.During a telephone interview on [DATE] at 10:50 A.M., the Administrator stated the facility notified the local police for assistance with giving the resident an immediate removal from the facility. Resident #25 was escorted off the facility's property by a police officer. He left the property in his motorized wheelchair. The Administrator stated they were attempting to find placement in a homeless shelter when Resident #25 left the facility.Review of the facility policy titled Transfer and Discharge Policy dated [DATE] revealed the facility's transfer/discharge notice will be provided to the resident in a language and way they can understand. The notice will include all the following at the time it is provided: this includes the specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged .The revised version of the Transfer and Discharge Policy dated [DATE] revealed prior to any facility-initiated discharge, the facility will review as an interdisciplinary team (IDT) and confer with senior leadership. Facility will collaborate with the Ombudsman to facilitate resolution to care concerns, barriers to care. Ombudsman will be contacted prior to emergency discharge. The facility will collaborate with the area Ombudsman and other community resources to assist with discharge as indicated.This deficiency represents non-compliance investigated under Complaint Number 2992143.

Based on observations, staff interviews, and resident interviews, the facility failed to provide an effective pest control program. This had the potential to affect all 21 residents residing in the facility. The facility census was 21. Findings include: Observation on 08/24/23 at 10:12 A.M. revealed five flies were observed on the window of the exit door located at the end of the hallway by room [ROOM NUMBER]. An unknown number of flies were observed flying in the hallway. More than 30 dead flies were observed on the ledge located between the walls and hand rails along the 100 and 200 halls. Observation and interview with Licensed Practical Nurse (LPN) #200 on 08/24/23 at 10:55 A.M. verified two flies were observed to be crawling on Resident #5's face and pillowcase while the resident was sleeping in bed and multiple flies were observed flying around in the room of Resident #10. LPN #200 stated flies were definitely a problem at the facility. Observation on 08/24/23 at 11:50 A.M. revealed Resident #5 was observed to be eating her lunch tray in her room and flies were landing on the residents food. Observation on 08/24/23 at 12:00 P.M. revealed residents were sitting in the dining area eating their lunch meals while multiple flies were flying around them and landing in their food. Interviews with three residents (#4, #7, and #9) at the time of the observation verified the flies were an issue at the facility and stated they had to fight to keep the flies off their food. Interview with Housekeeping Supervisor #777 on 08/24/23 at 12:15 P.M. revealed there was a problem with flies in the facility. Observation on 08/24/23 at 2:28 P.M. revealed there were eight flies observed on the window of the exit door by room [ROOM NUMBER]. Interview with Resident #20 on 08/24/23 at 2:35 P.M. revealed flies were a horrible problem at the facility.

Based on review of daily staffing sheets, review of employee time clock punches and staff interview the facility failed to ensure a Registered Nurse was on-duty and present in the facility for at least eight hours daily as required. This had the potential to affect all 22 residents residing in the facility. Findings include: Review of the facility sheets titled Report of Nursing Staff Directly Responsible for Resident Care, dated 05/02/22 and 05/03/22, revealed documentation a Registered Nurse (RN) was only present for six hours each day at the facility. Review of the employee time clock punches for 05/02/22 and 05/03/22 revealed there was not an RN clocked in for work on 05/02/22 or 05/03/22. Review of the facility list provided by Business Office Manager #350 titled Agency Staffing/Hours and Other Buildings, not dated, revealed on 05/02/22 and 05/03/22 RN #805 was documented to have worked at the facility from 4:00 P.M. to 10:00 P.M. for a total of six hours each day. On 05/12/22 at 3:00 P.M. interview with the Administrator verified the facility only had an RN present in the facility for six hours each day on 05/02/22 and 05/03/22. The Administrator revealed here had been issues with the RN who was the Director of Nursing on those days and was therefore not present in the facility.

Based on record review and staff interview the facility failed to ensure all required members of the Quality Assessment and Assurance (QAA) committee attended meetings at least quarterly. This had the potential to affect all 22 residents residing in the facility. Findings include: Review of the QAA committee meeting minutes, dated 04/20/22 revealed the absence of the signature of the Director of Nursing (DON) to indicated the DON's presence at the meeting. On 05/12/22 at 3:00 P.M. interview with the Administrator verified the DON had not been in attendance at the QAA meeting held on 04/20/22 due to another work commitment.

Based on record review and staff interview the facility failed to timely initiate a significant change Minimum Dat Set (MDS) 3.0 assessment after a change in Resident #10's condition and discharge from Hospice services. This affected one resident (#10) of one resident reviewed for Hospice services. Findings include: Record review for Resident #10 revealed the resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 03/18/22 revealed the resident had mildly impaired cognition with a Brief Interview for Mental Status (BIMS) score of 11 out of 15. The resident was assessed to require limited assistance from one staff member for bed mobility, extensive assistance from one staff member for transfers and limited assistance from one staff member for eating. This resident was assessed to have received Hospice care while residing in the facility. On 05/10/22 at 8:45 A.M. interview with the Director of Nursing (DON) revealed Hospice services were discontinued for Resident #10 on 04/05/22. Review of the MDS assessments for Resident #10 revealed there was no evidence a significant change MDS 3.0 assessment was completed timely following the discontinuation of Hospice services for the resident. The MDS assessment was not initiated until 05/09/22. On 05/10/22 at 9:54 A.M. interview with Registered Nurse (RN) #121 verified a significant change MDS assessment was not initiated for Resident #10 timely after being discharged from Hospice services on 04/05/22. RN #121 verified the MDS was not initiated until 05/09/22.

Based on record review and staff interview the facility failed to accurately code medications on the Minimum Data Set (MDS) 3.0 assessment for Resident #5. This affected one resident (#5) of five residents reviewed for unnecessary medication use. Findings include: Record review for Resident #5 revealed the resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS 3.0 assessment, dated 03/04/22 revealed the resident was assessed to have received an anti-psychotic medication seven of seven days in the assessment reference period. Review of the active and discontinued physician's medication orders, dated 02/25/22 through 05/10/22 revealed the resident was not prescribed any anti-psychotic medication(s). On 05/11/22 at 9:10 A.M. interview with the Director of Nursing (DON) verified Resident #5 had not received any medications classified as an anti-psychotic while residing at the facility. The DON revealed staff had most likely coded an anti-psychotic medication on the admission MDS assessment, dated 03/04/22 due to receiving the medication [MEDICATION(S)], which the DON verified was classified as being an anti-convulsant medication.

Based on observation, record review and interview the facility failed to ensure ongoing communication with a Hospice provider regarding the care needs and services provided to Resident #10 and failed to ensure a treatment order for Resident #16 was specific to detail the actual treatment required or being provided to the resident. This affected one resident (#10) of one resident reviewed for Hospice services and one resident (#16) of three residents reviewed for change in condition. Findings include: 1. Record review for Resident #10 revealed the resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident was receiving Hospice services at the time of admission to the facility. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 03/18/22 revealed the resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15. The resident was assessed to require limited assistance from one staff member for bed mobility, extensive assistance from one staff member for transfers and limited assistance from one staff member for eating. This resident was assessed to have received Hospice care while residing in the facility. Review of the Hospice care plan, dated 03/18/22, revised on 05/09/22 and resolved on 05/10/22 revealed the resident received Hospice services. Interventions included to consult with Hospice team to ensure needs were met. Record review revealed Resident #10 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/10/22 at 8:45 A.M. interview with the Director of Nursing (DON) revealed the facility had no Hospice communication notes or documentation available in the facility for review prior to the Hospice provider faxing them to the facility on [DATE]. The DON revealed upon calling the Hospice provider for Resident #10 on 05/09/22 (as part of the survey process), it was discovered the resident's Hospice services had been discontinued on 04/05/22. The DON stated facility staff were unaware the resident had not been receiving Hospice services from 04/05/22 through 05/09/22 while residing in the facility. On 05/10/22 at 9:54 A.M. interview with Registered Nurse (RN) #121 revealed Resident #10 had previously received Hospice services but believed they were discontinued after the resident went to the hospital a few weeks prior. On 05/10/22 at 10:00 A.M. interview with State tested Nursing Assistant (STNA) #127 revealed Resident #10 was currently receiving hospice services. 2. Record review for Resident #16 revealed the resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment, dated 04/12/22 revealed the resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 06 out of 15. The resident was assessed to require extensive assistance from two staff members for bed mobility, was dependent upon two staff members for toileting and transfers and required limited assistance from one staff member for eating. Review of the active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR) from 04/27/22 through 05/09/22 revealed documentation by nursing staff the ordered treatment apply bilateral lower extremities every shift had been completed as ordered. On 05/10/22 at 10:00 A.M. observation of Resident #16 revealed the resident was lying in bed with no treatments or devices observed to be in place to the bilateral lower extremities. On 05/10/22 at 10:07 A.M. interview with Registered Nurse (RN) #121 revealed the active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #121 verified staff had documented the ordered treatment as being completed per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/10/22 at 10:05 A.M. interview with the DON verified the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure ongoing assessments/monitoring of pressure ulcers, pressure ulcer interventions and treatments were provided for Resident #10 who was admitted to the facility with pressure ulcers. This affected one resident (#10) of two residents reviewed for pressure ulcers. Findings include: Record review for Resident #10 revealed the resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a facility Admission Nursing Observation Form, dated 03/11/22 revealed documentation the resident had pressure ulcers located on the coccyx, left heel and right heel. Review of the active physician's order, dated 03/12/22 revealed an order to cleanse the pressure ulcer to the resident's coccyx with normal saline or wound cleanser, apply Med Honey ointment and cover with a foam dressing every day at bedtime. Review of the care plan, dated 03/13/22 (revised 04/08/22) revealed the resident had impaired skin integrity. Interventions included to apply barrier cream/ointment after each incontinent episode as needed, encourage fluids, inspect skin daily during routine daily care, pressure reduction devices if ordered, turn and reposition as ordered, elevate heels off mattress and treatments per order. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 03/18/22 revealed the resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11 out of 15. The resident was assessed to require limited assistance from one staff member for bed mobility, extensive assistance from one staff member for transfers and limited assistance from one staff member for eating. The assessment revealed the resident was at risk for pressure ulcer development. Review of the Certified Nurse Practitioner (CNP) wound care note, dated 03/25/22 revealed the resident had a Stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) pressure ulcer to the right heel and an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the left heel. The plan of care for the areas of pressure included off-loading boots, float heels while in bed and keep pressure off heels as much as possible. Review of the CNP wound care note, dated 04/15/22, revealed the resident continued to have areas of pressure located to the right and left heel. The plan of care included to continue prevalon offloading boots, float heels while in bed and keep pressure off heels as much as possible. Review of CNP wound care note, dated 04/26/22, revealed the resident continued to have areas of pressure located to the right and left heel. The plan of care included to continue prevalon offloading boots, float heels while in bed, keep pressure off heels as much as possible and to follow up with resident in one week. Review of the Treatment Administration Record (TAR) for 05/2020 revealed there was no documentation of the ordered treatment to the pressure ulcer located on the coccyx of Resident #10 being completed on 05/05/22, 05/06/22, 05/07/22, 05/08/22 or 05/09/22. On 05/09/22 at 9:16 A.M. Resident #10 was observed lying in bed on her back with her left and right heel directly against the mattress. There were no prevalon boots applied to the left or right heel or observed in the resident's room. There was one pillow observed on the resident's bed which was located under her head. On 05/09/22 at 3:00 P.M. Resident #10 was observed lying in bed on her back with her left and right heel directly against the mattress. There were no prevalon boots applied to the left or right heel or observed in the resident's room. There was one pillow observed on the resident's bed which was located under her head. On 05/10/22 at 9:54 A.M. interview with Registered Nurse (RN) #121 verified Resident #10 had pressure ulcers to the coccyx, left heel, and right heel present upon admission to the facility on [DATE]. On 05/10/22 at 10:00 A.M. Resident #10 was observed lying in bed with no prevalon boots observed on the left or right heel. Observation of care being performed revealed the resident had no pressure ulcer dressing observed to the coccyx or in the garbage bag being used while incontinence care was being completed. On 05/10/22 at 10:00 A.M. interview with State tested Nursing Assistant (STNA) #127 during the observation verified there had not been a foam dressing in place to the coccyx of Resident #10 at that time. STNA #127 revealed the resident did not utilize prevalon boots to either heel and there were none located in the resident's room. On 05/10/22 at 1:55 P.M. Resident #10 was observed lying in bed on her back with her left and right heel directly against the mattress. There were no prevalon boots applied to the left or right heel or observed in the resident's room. There was one pillow observed on the resident's bed which was located under her head. On 05/11/22 at 9:20 A.M. Resident #10 was observed lying in bed on her back with her left and right heel directly against the mattress. There were no prevalon boots applied to the left or right heel or observed in the resident's room. There was one pillow observed on the resident's bed which was located under her head. On 05/11/22 at 3:00 P.M. interview with the Administrator verified the plan of care documented on the CNP wound care notes dated 03/25/22, 04/15/22, and 04/26/22 included to float heels while in bed, prevalon off-loading boots and keep pressure off the heels as much as possible. The Administrator verified there were no orders for prevalon off-loading boots to be applied to the resident's left and right heels or care planned interventions for prevalon off-loading boots to be worn by the resident. The Administrator verified there was no evidence of an assessments of the pressure ulcer to the resident's coccyx since 03/11/22 and also verified there was not evidence of weekly wound assessments being completed for the areas of pressure located on the residents left and right heels. Review of the facility policy titled Wound Care, revised 12/2020 revealed wounds would be evaluated when they were observed and weekly until resolved. Wounds were to be monitored for location, size, undermining, tunneling, exudates, necrotic tissue and the presence or absence of granulation tissue and epithelization. Wound evaluations were to be documented weekly and as needed.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure appropriate indwelling urinary catheter care was provided for Resident #18 to prevent urinary tract infections when staff failed to appropriately clean the resident's catheter. This affected one resident (#18) of two residents reviewed for catheters. Findings include: Record review for Resident #18 revealed an admitted [DATE] with most recent admission of 01/31/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 04/09/22 annual Minimum Data Set (MDS) 3.0 assessment revealed Resident #18 was cognitively intact and required total dependence from staff for bed mobility, transfers, dressing, eating, toilet use, bathing and personal hygiene. The resident required extensive assistance for locomotion on and off unit. The resident used a wheelchair to aid in mobility, had an indwelling urinary catheter and was always incontinent of bowel. On 05/12/22 at 1:31 P.M. State tested Nursing Assistant (STNA) #127 was observed to empty the resident's urinary catheter bag and stated she had completed catheter care for Resident #18. The surveyor then asked the STNA to actually clean the resident's catheter (catheter care). STNA #127 gathered supplies, washed her hands and applied gloves. STNA #127 had a damp washcloth with soap and water and a washcloth with water for cleaning the catheter. The STNA cleaned the indwelling urinary catheter from the clear tubing area down to the collection bag. STNA #127 did not remove the resident's pants and did not clean the latex portion of the catheter where it was inserted into the resident's penis. On 05/12/22 at 1:52 P.M. interview with STNA #127 verified she did not clean the catheter around the area where it was inserted into the resident's penis or the tubing around the insertion area. ON 05/12/22 at 3:19 P.M. interview with the Director of Nursing revealed the facility policy does not indicate where to clean the catheter. The DON said her expectations would be for the catheter to be cleaned at least three to four inches from the insertion site (penis) down the tubing. Review of the 02/01/22 facility Catheter Care Policy and Procedure document revealed it was the policy to provide urinary catheter care that keeps the resident free from infection and cross contamination. Clean catheter in only one direction away from the body using a clean area of the cloth from each stroke.

Based on record review and interviews the facility failed to ensure dietary recommendations were implemented and/or failed to ensure resident weights were obtained as ordered. This affected two residents (#10 and #16) of the three residents reviewed for nutrition. Findings include: 1. Record review for Resident #10 revealed the resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan, dated 03/15/22 revealed the resident had protein malnutrition. Interventions included 30 milliliters (ml) of ProStat (a protein supplement) twice a day and an 1,800 ml fluid restriction. Review of the dietary progress note, dated 03/15/22 revealed a recommendation to add 30 ml of ProStat twice a day and implement an 1,800 ml fluid restriction due to [CONDITION(S)]. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 03/18/22 revealed the resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11 out of 15. The resident was assessed to require limited assistance from one staff member for bed mobility, extensive assistance from one staff member for transfers and limited assistance from one staff member for eating. There was no weight or height documented in the assessment as a dash was documented where the information was to be located. Review of documented weights for Resident #10 revealed the resident weighed 176.6 pounds on 04/11/22. No other weights were available for review. On 05/10/22 at 11:51 A.M. interview with the Director of Nursing (DON) verified there were not any weights available for Resident #10 except for the one documented on 04/11/22. The DON verified there was no follow up completed for the dietary recommendations dated 03/15/22 for an 1,800 ml fluid restriction or 30 ml of ProStat twice a day. On 05/11/22 at 10:15 A.M. interview with Registered Dietitian (RD) #800 verified the dietary recommendations made for Resident #10 on 03/15/22 had included 30 ml of ProStat twice a day to assist in wound healing and an 1,800 ml fluid restriction daily due to documented [CONDITION(S)]. RD #800 verified no weight or height had been documented on the admission MDS assessment dated [DATE] as there was not a height or weight available. RD #800 verified it was very difficult to accurately assess a resident's nutritional status without documentation of weights or height. 2. Record review for Resident #16 revealed the resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan, dated 10/13/15 (revised 02/17/22) revealed the resident had the potential for/alteration in nutrition and hydration. Interventions included to weigh at the same time of day and record as ordered, provide and serve diet as ordered and obtain and monitor lab/diagnostic work as ordered. Review of a dietary progress note, dated 08/31/21 revealed a recommendation for a low concentrated sweets diet with Juven (a protein supplement taken by mouth) twice a day to aid in wound healing and prevent elevated blood glucose and weight gain. Review of the resident's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order had been in place since 09/2021. Review of the dietary progress note, dated 01/12/22 revealed a recommendation to discontinue Juven twice a day. There was no evidence this recommendation was followed up or changes to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/12/22 revealed the resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 06 out of 15. The resident was assessed to require extensive assistance from two staff members for bed mobility, was dependent upon two staff members for toileting and transfers and required limited assistance from one staff member for eating. On 05/11/22 at 10:35 A.M. interview with Registered Nurse (RN) #121 revealed orders for Juven would be put in the computer and administration would be documented by the nurse. RN #121 verified Resident #16 had not been receiving Juven as ordered.

Based on record review, facility policy and procedure review and interview the facility failed to timely address pharmacy recommendations for Resident #20. This affected one resident (#20) of five residents reviewed for unnecessary medication use. Findings include: Record review for Resident #20 revealed the resident was admitted to the facility on [DATE] and had diagnoses including unspecified [CONDITION(S)], anxiety, major depressive disorder and [CONDITION(S)]. Review of the Consultant Pharmacist Recommendation for Provider, dated 07/08/21 revealed a recommendation to evaluate and consider tapering off [MEDICATION(S)] at the time. The recommendation contained no documentation of the review of the recommendation. There were no documented signature(s) by the physician or facility staff present on the recommendation. Review of the Consultant Pharmacist Recommendation for Provider, dated 09/13/21 revealed the recommendation to evaluate and consider tapering off [MEDICATION(S)] at the time. The recommendation contained no documentation of the review of the recommendation. There were no documented signature(s) by the physician or facility staff present on the recommendation. Review of the Consultant Pharmacist Recommendation for Provider, dated 03/11/22 revealed the recommendation to evaluate and consider tapering off [MEDICATION(S)] at the time. The recommendation was signed and dated as being reviewed by the Cerified Nurse Practitioner on 05/11/22. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/13/22 revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15 out of 15. The resident was assessed to require extensive assistance from one staff member for bed mobility, was dependent on two staff members for transfers, required extensive assistance from two staff members for toileting and required supervision with setup assistance only for eating. On 05/10/22 at 11:30 A.M. interview with the Director of Nursing (DON) verified the pharmacy recommendations dated 07/08/21 and 09/13/21 contained no evidence they had been reviewed and the 03/11/22 recommendation was not addressed until 05/11/22 (two months later). Review of the facility policy titled Pharmacy: Pharmacy Recommendations Policy, dated 01/01/16 revealed the DON or Assistant DON would review the recommendations with the physician and/or Medical Director, implement any changes into the medical record within 30 days, and the recommendations would be marked on the recommendation form by the intials of the DON or Assistant DON to show it had been completed.

Based on record review and interview the facility failed to ensure the anti-histamine medication, [MEDICATION(S)] (for anxiety/agitation) was administered to Resident #11 with a current physician's order to ensure the medication was necessary. This affected one resident (#11) of five residents reviewed for unnecessary medication use. Findings include: Record review for Resident #11 revealed an admitted [DATE] with diagnoses including type two diabetes mellitus, altered mental status, [CONDITION(S)], malignant neoplasm of prostate, dementia without behaviors, displaced intertrochanteric fracture of right femur, protein calorie malnutrition, dehydration and pneumonia. Record review revealed a physician's order, dated 04/21/22 for [MEDICATION(S)] ([MEDICATION(S)]), an anti-histamine medication sedative hypnotic medication 25 milligrams (mg) every eight hours as needed (PRN) for anxiety/agitation. The order for the medication was for 14 days. Review of the medication administration record Resident #11 received the [MEDICATION(S)] on 05/10/22 at 9:48 P.M. On 05/12/22 at 11:00 A.M. interview with the Director of Nursing (DON) verified the [MEDICATION(S)] order was for 14 days and should have ended on 05/04/22. The resident did not have a physician order for the medication at the time it was administered on 05/10/22.

Based on observation, record review, medication insert review and interview the facility failed to maintain a medication error rate of less than five percent (%). The medication error rate was calculated to be 7.14% and included two medication errors of 28 medication administration opportunities. This affected two residents (#6 and #9) of three residents observed for medication administration. Findings include: 1. Record review for Resident #9 revealed an admitted [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/11/22 at 8:46 A.M. Registered Nurse (RN) #121 was observed administering medications to Resident #9. RN #121 obtained a blister pack containing the medication [MEDICATION(S)] 250 mg and administered a half of a tablet (125 mg). On 05/11/22 at 9:52 A.M. interview with RN #121 verified she only administered Resident #9 one half tablet of the [MEDICATION(S)] 250 mg (125 mg) instead of a full tablet. RN #121 revealed the resident was to receive one tablet in the morning and half a tablet at bedtime. RN #121 revealed there was not a blister pack with a full tablet of 250 mg [MEDICATION(S)] in the medication cart. 2. Record review for Resident #6 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If blood sugar less than 70 call physician, for blood sugar of 150 to 200 give two units, for blood sugar 201 to 250 give four units, blood sugar 251 to 300 give six units, blood sugar 301 to 400 give nine units, blood sugar 402 to 450 give 12 units and for blood sugar 451 or above, call physician. On 05/12/22 at 10:32 A.M. Licensed Practical Nurse (LPN) #333 was observed during medication administration. At the time of the observation, the LPN was observed to obtain Resident #6's Insulin [MEDICATION(S)] insulin pen and turned the dial to 23 units to administer insulin to the resident. At the time of the observation, LPN #333 failed to first prime the insulin pen prior to administering the dose of insulin. On 05/12/22 at 10:42 A.M. interview with LPN #333 verified she did not prime the insulin pen prior to administrating Resident #6 insulin. LPN #333 revealed she did not know how to prime an insulin pen. Review of the Insulin [MEDICATION(S)] [MEDICATION(S)] medication insert, dated 11/01/19 revealed before each injection small amounts of air may collect in the cartridge. To avoid injecting air and to ensure proper dosing, turn the dose selector to select two units. Hold the [MEDICATION(S)] with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect to the top of the cartridge. Keep the needle pointing upwards, press the push button all the way in. The dose selector returns to zero. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times. If you do not see a drop of insulin after six times, do not use the Insulin [MEDICATION(S)] [MEDICATION(S)].

Based on medical record review, staff interview, and facility policy review, the facility failed to provide Resident #2 and Resident #5 sufficient supervision to prevent potential drug overdoses. This affected two residents (Resident #2 and Resident #5) of three residents reviewed for drug overdoses. Findings Include: 1. Resident #2 was admitted to the facility on [DATE]. His diagnoses were [CONDITION(S)], urinary tract infection, other neuromuscular dysfunction of bladder, [CONDITION(S)], polyneuropathy, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], lack of coordination, muscle wasting, other psychoactive substance abuse (uncomplicated), anxiety disorder, [CONDITION(S)], [CONDITION(S)] disorder, and [CONDITION(S)]. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was intact. Review of Resident #2 functional assessment, dated 11/01/21, and his medical diagnoses, revealed he was a quadriplegic, and needed total physical assistance with all of his activities of daily living (ADLs) and administration of medication, and he was not physically able to put medication into his mouth independently. Review of Resident #2 physician orders revealed he was not to have unsupervised visits and was not to have anyone in his room alone with him. Review of Resident #2's progress notes, dated 11/19/21, revealed staff answered a call light in Resident #2 room. When they arrived at his room, Resident #6 was beside his wheelchair, and Resident #2 was bluish in color and unresponsive. The nurse was immediately called and both staff started to treat his symptoms with sternal rubs, cool cloths and trying to arouse him. When that did not arouse him, the nurse administered [MEDICATION(S)]. As all of this treatment was occurring, staff contacted Emergency Medical Services (EMS) to get emergency services help. As EMS arrived, he started to arouse. He was transported to the hospital, was assessed, and returned. Due to the hospital not being able to access their electronic medical records, it was unknown what Resident #2 ingested, but the evidence supported the use of [MEDICATION(S)] at the facility aroused him. Resident #2 and Resident #6 had a history of substance abuse. Interview from 11/22/21 at 2:00 P.M. to 11/23/21 at 2:00 P.M. with Regional Director of Clinical Services (RDCS) #101, Administrator, Director of Nursing (DON), State tested Nursing Aide (STNA) #103, and Registered Nurse (RN) #102 revealed Residents #2 and Resident #6 were drug seeking, and in this facility due to a history of drug abuse. They all confirmed documentation supported Resident #2 was not to have anyone in his room, by himself or any unaccompanied visits. They all confirmed that the drug seeking population' in the facility was very difficult. The residents are very creative in their ways to get drugs. Unless they searched each visitor that came into the facility, there was no way they would know who brings drugs to the residents. Interview from 11/22/21 at 2:00 P.M. to 11/23/21 at 2:00 P.M. with STNA #103 and RN #102 both confirmed there are days they do not have enough staff in the building to visually supervise all the residents appropriately. Interview from 11/22/21 at 2:00 P.M. to 11/23/21 at 2:00 P.M. with RDCS #101 and Administrator confirmed they did an investigation for each resident who was administered [MEDICATION(S)] and they were not able to confirm what substance they ingested to need the use of [MEDICATION(S)]. They also confirmed [MEDICATION(S)] was used for an overdose of opioids. They confirmed Resident #2 would need another person to put any drugs into his mouth as he was not physically able to do so. They know he was not able to have anyone in his room without supervision (including other residents), but stated is was very difficult to monitor. 2. Resident #5 was admitted to the facility on [DATE]. His diagnoses were extradural and subdural abscess, chronic [CONDITION(S)] C, other psychoactive substance abuse (uncomplicated), [CONDITION(S)], neuromuscular dysfunction of bladder, [CONDITION(S)], antisocial personality disorder, [CONDITION(S)], muscle weakness, bacteremia, [CONDITION(S)], and anxiety disorder. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] revealed his cognition was intact. Review of Resident #5 medical records revealed on 11/13/21, Resident #5 was in his room with Resident #3 when Resident #5 fell out of his wheelchair. Staff heard the noise and went to his room immediately. They asked if he was fine; he stated he was, so they attempted to assist him back into his wheelchair. As they were assisting him back into his wheelchair, he became unresponsive. The nurse was immediately called and EMS was alerted. The staff attempted multiple measures to arouse him, but nothing worked until he was administered [MEDICATION(S)]. After a few minutes, EMS arrived and Resident #5 became aroused. He argued and adamantly disagreed with going to the hospital, so EMS did not transport him. After this incident was clear and Resident #5 was stable, a search of his room found a glass tube/pipe with a black tarry substance inside the pipe in his bed. He would not confirm he ingested any illegal substances to cause the overdose. Interview from 11/22/21 at 2:00 P.M. to 11/23/21 at 2:00 P.M. with Regional Director of Clinical Services (RDCS) #101, Administrator, Director of Nursing (DON), State tested Nursing Aide (STNA) #103, and Registered Nurse (RN) #102 revealed Residents #3 and Resident #5 were drug seeking, and in this facility due to a history of drug abuse. They all confirmed that the drug seeking population' in the facility was very difficult. The residents are very creative in their ways to get drugs. Unless they searched each visitor that came into the facility, there was no way they would know who brings drugs to the residents. Interview from 11/22/21 at 2:00 P.M. to 11/23/21 at 2:00 P.M. with STNA #103 and RN #102 both confirmed there are days they do not have enough staff in the building to visually supervise all the residents appropriately. Interview from 11/22/21 at 2:00 P.M. to 11/23/21 at 2:00 P.M. with RDCS #101 and Administrator confirmed they did an investigation for each resident who was administered [MEDICATION(S)] and they were not able to confirm what substance they ingested to need the use of [MEDICATION(S)]. They also confirmed [MEDICATION(S)] was used for an overdose of opioids. Review of facility policy titled, Substance Abuse Policy and Procedure, dated 04/24/18, revealed substance abuse was defined as long term pathological use of alcohol or drugs characterized by frequent intoxication, inability to reduce consumption, and impairment in social or occupational functioning; broadly, alcohol or drug addiction. The purpose of the policy was to ensure the safety of the residents, staff, visitors, and other residents residing in the facility, the facility will identify residents at risk for or with a history of substance abuse and implement a plan of care. The facility will assess residents on admission and identify risk for and/or history of substance abuse. Facility will implement a plan of care for residents identified as at risk for any/or history of substance abuse. Facility will review plan of care quarterly and with significant changes. Residents identified as at risk and/or history of substance abuse will receive a copy of facility drug and alcohol policy. Residents identified as at risk and/or history of substance abuse will sign and receive a copy of Substance Abuse Resident Agreement. This deficiency substantiates Complaint Number OH 518.

Based on observation, policy review and staff interview the facility failed to ensure food was served at a temperature that was palatable. This affected one resident (#6) and had the potential affect all 20 residents who resided in the facility. Findings include: On 01/12/21 observation of midday meal service revealed the following: At 11:37 A.M. the midday meal cart arrived on the quarantine unit. The food for all residents were on the cart and the meals were all served in disposable Styrofoam containers. The first tray was served at 11:40 A.M. At 11:45 A.M. State tested Nursing Assistant (STNA) #101 delivered Resident #6's meal tray. STNA #101 placed the food on the over bed table across the room from the resident. The resident was unable to access the meal on her own. The last resident was served their meal at 12:20 P.M. On 01/12/21 at 12:30 P.M. STNA #101 went into Resident #6's room to feed the resident. The temperature of the food items were obtained by STNA #101 at the surveyors request. The food items were cold. The resident's pureed hot dog was 83.7 degrees Fahrenheit (F) and the mashed potatoes were 87.1 degrees F. The temperatures were verified by the STNA and Director of Nursing (DON). On 01/12/21 at 12:33 P.M. interview with the DON revealed the Styrofoam containers do not keep the food hot. On 01/12/21 at 12:34 P.M. interview with STNA #101 revealed all resident meal trays were placed on the cart at the same time because that was the way it was always done. STNA #101 revealed the food was not served hot like it used to be. Review of the Food Service policy, dated October 2017 revealed each resident would be served food that was palatable.

Based on observation, staff interview, review of Centers for Disease Control and Prevention (CDC) Strategies for Optimizing the Supply of Eye Protection and policy review the facility failed to implement an effective infection prevention and control program to prevent the spread of COVID-19 when the facility failed to ensure staff properly changed personal protective equipment (PPE), failed to ensure staff properly cleaned/disinfected face shields between resident care, improperly transferred a container from one resident room to another resident room without first disinfecting it and failed to use the correct disinfectant for the shared glucometer. This has the potential to affect all 20 residents residing in the facility. Findings include: On 12/30/20 from 12:22 P.M. until 1:10 P.M. observations in the facility revealed all facility residents were identified to be in quarantine due to possible exposure to COVID-19. 1. Observations and interviews completed on 12/30/20 revealed the following infection control concerns: a. State tested Nursing Assistant (STNA) #101 was observed assisting Resident #16 in her room. The STNA was wearing gloves, a gown and goggles. At 12:50 P.M. STNA #101 exited Resident #16's room, did not remove her gown, disinfect her goggles or perform hand hygiene after removing her gloves. STNA #101 then entered Resident #11's room at 12:52 P.M., applied gloves assisted the resident. Upon exiting the room at 12:55 P.M., STNA #101 did not remove her gown or disinfect her goggles. Interview with STNA #101 at 12:57 P.M. revealed she only changed her gown after providing residents with personal care. The STNA revealed she should disinfect her goggles between residents and use either alcohol based hand rub (ABHR) or soap and water to wash her hands between residents. b. At 12:58 P.M. Registered Nurse (RN) #102 was observed to exit Resident #20's room carrying a metal pan. At the time she exited the room, RN #102 did not change her gown or goggles or clean her goggles. RN #102 set the metal pan down at the nurse's station without disinfecting it. Observation of the metal pan revealed it contained a glucometer, multiple vials of insulin, syringes and slips with residents' names who received insulin. RN #102 took the metal pan into Resident #16's room, used the glucometer to test her blood sugar, administered insulin and exited Resident #16's room at 1:02 P.M. RN #102 did not change her gown, disinfect her goggles or disinfect the metal pan. RN #102 then set the metal pan on the night stand in Resident #17's room. RN #102 removed her gloves, obtained new gloves from the pocket of her uniform that was under her gown and applied the gloves. RN #102 checked Resident #102's blood sugar, disposed of used supplies, removed her gloves, obtained gloves from her uniform pocket and applied them without first performing hand hygiene. At 1:10 P.M. RN #102 exited Resident #17's room without removing her gown or disinfecting her goggles. RN #102 took the metal pan to the nurse's station without disinfecting it and then washed her hands and goggles with soap and water. Interview with RN #102 at 1:15 P.M. revealed she placed the glucometer, all diabetic resident's syringes and insulin in the metal pan because she did not know how else to diabetic resident's blood sugars could be checked and insulin administered timely. She stated it took too long to go back to the nurse's stations between residents to obtain new diabetic supplies and insulin. RN #102 revealed she only changed her gown if it was soiled and stated she should disinfect her goggles between residents but does not always do that. RN #102 stated she disinfected the glucometer with alcohol wipes but stated she should use the purple topped wipes but did not have them with her. c. Observation of Cook #105 at 1:50 P.M. revealed she had arrived to the facility at that time but was not wearing any type of mask. At the time of the observation, Cook #105 could not find a pen to sign in to the facility with and proceeded to walk from the entry area down the hall to the offices without a mask on. Interview with Cook #105 at 1:53 P.M. confirmed she did not wear a mask into the facility as she was going to the kitchen. d. At 1:55 P.M. Occupational Therapist (OT) #103 was observed to exit Resident #12's room wearing a gown, gloves and goggles. OT #103 walked from the end of the hall, passed other resident rooms, the nurses station and the dining room wearing the same gown, gloves and goggles. Interview with OT #103 at 1:55 P.M. revealed she did not remove her gown or disinfect her goggles as she was leaving. OT #103 revealed she would remove them before she exited the building. e. At 2:03 P.M. Licensed Practical Nurse (LPN) #106 and STNA #107 were observed as they walked to the facility from the parking lot. Neither staff member was wearing a mask and they did not adhere to social distancing. The two staff members entered the building, were screened for COVID-19 and then applied PPE. Observation of LPN #106 at 2:30 P.M. revealed she exited Resident #14's room wearing her gown and goggles. Interview with LPN #106 at 2:33 P.M. revealed she only changed her gown when it was soiled. LPN #206 revealed she washed her goggles with soap and water between residents. At 2:31 P.M. STNA #107 was observed in Resident #13's room passing snacks. The containers for PPE waste were by the resident's room, across the room from the door. STNA #107 walked past the resident after she had removed her gown and gloves. On 12/30/20 at 2:45 P.M. interview with the Director of Nursing (DON) revealed since all the residents in the facility were under quarantine, goggles should be disinfected between each resident encounter with the purple topped wipes, not alcohol or soap and water. Gowns should be removed in the resident room after an encounter with the resident. The metal pan should not be used, it would need to be disinfected after being in a residents' room. The glucometer should be disinfected with the purple topped wipes between residents. 2. The following observations and interviews were conducted on 01/12/21: At 11:40 A.M. STNA #102 was observed to apply a surgical mask over her N95 respirator mask. However, the ear loops of the mask got caught on her face shield. With her gloved hands, she touched the front of her face shield. Once she freed the ear loop she did not change her gloves or perform hand hygiene. At 11:44 A.M. STNA #102 exited Resident #4's room, removed her gown first then her gloves in the hall outside the room. She took her face shield off while holding it in one hand she used a wipe to wipe the outside of the shield and then the inside of the shield. The manner in which she cleaned her face shield contaminated areas she had cleaned with her potentially contaminated fingers. At 11:45 A.M. STNA #102 applied a gown, then gloves and entered Resident #6's room to deliver her meal tray. The STNA then exited the room, removed her gown then gloves, and disinfected her face shield as she did before. At 11:50 A.M. STNA #108 removed her face shield after being in a quarantined resident's room, disinfected the outside of the face shield then the inside while holding it and potentially contaminating the shield with her fingers. On 01/12/21 at 12:55 P.M. interview with the DON revealed the facility did not have a procedure for disinfecting face shields or goggles. Review of the facility donning and doffing procedure of PPE (issued by the CDC) revealed gowns and gloves were to be removed inside the resident's room and goggles (removed) outside the resident's room. Additionally, gloves should be the last item donned and the first item doffed. The document revealed if the face shield or goggles were reusable, they should be placed in the designated receptacle or discarded. This document also revealed the front of the face shield was contaminated and if your hands become contaminated, wash or use ABHR immediately. Review of CDC Strategies for Optimizing the Supply of Eye Protection, updated 12/22/20 revealed while wearing gloves, the inside of the face shield or goggles were cleansed followed by the outside and fully air dried (air dried or use clean absorbent towels).

Based on observation, medical record review, policy review and interview, the facility failed to provide adequate supervision to ensure safety during smoking, prevent falls, and prevent injuries from resident care equipment. Actual Harm occurred on 01/01/2020 when the facility failed to have effective interventions in place and provide Resident #7, who was at high risk for falls and had a history of [REDACTED]. This affected one resident (#7) of three residents reviewed for accidents. Additionally, one resident (#11) of one sampled resident reviewed for smoking was not provided adequate supervision during smoking, and one resident (#13) of three residents reviewed for accidents did not have their wheelchair modified to prevent injuries. Findings include: 1. Review of Resident #7's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's fall risk assessment dated [DATE] revealed she was at high risk for falls. Review of Resident#7's progress notes revealed on 11/13/2019 at 5:45 P.M. the resident fell from her bed onto the floor. Resident #7 was unable to answer questions due impaired cognition and communication. A floor mat was placed on the floor beside her bed. Review of Resident #7's plan of care regarding falls initiated on 11/27/2019 revealed she was at risk for falls and to have commonly used articles within easy reach, maintain a clear pathway and her bed locked. Review of Resident #7's Minimum Data Set (MDS) 3.0 assessment, dated 11/29/2019 revealed her speech was clear, sometimes she was understood, sometimes she understands, her short-term and long-term memory was impaired, she had no recall and her decision making was severely impaired. Resident #7 had no indicators of [MEDICAL CONDITION], no behaviors and did not reject care. Review of Resident #7's progress notes revealed on 01/01/2020 the resident was found on the floor of her room. There was no evidence a floor mat was in place at the time of the fall (as implemented after the 11/2019 fall). The note stated Resident #7 was encouraged to eat meals in dining area, educated on proper use of call light, and encouraged to ask for help. It could not be determined what fall safety interventions were in place prior to and at the time of the fall and following the fall it could not be determined that new interventions were individualized and effective for the resident. Resident #7's fall resulted in a skin tear to right inner and outer knee, right forearm and right elbow. On 01/02/20 at 1:45 P.M. Resident #7 complained to the Hospice nurse that she had left leg and hip pain. The Hospice nurse directed the staff to send the resident to the emergency department. Resident #7 was assessed to have a fractured left hip and pelvis. Review of the POS [REDACTED].M., Resident #7 fell when she tried to get out of her wheelchair. The investigation failed to include evidence of effective and individualized fall safety interventions being in place at the time of the fall. Following the fall, new interventions were to educate and encourage Resident #7 to use her call light and encourage her to eat in the dining area. (However, the resident was assessed to have severely impaired decision making skills, no recall ability and long and short term memory impairment). Record review revealed Resident #7 sustained a fall on 01/11/20. Review of the POS [REDACTED].M. the resident had fallen from the bed to the floor. There was no evidence the fall mat was in place to the floor at the time of the fall. A new intervention was added for half side rails and a new wheelchair with working brakes. Review of Resident #7's undated post fall investigation revealed on 01/28/2020 at 4:23 P.M. the resident fell from her wheelchair trying to self-transfer to her recliner chair. There was no evidence of any fall safety interventions being in place and effective at the time of the fall. Following the fall, the new safety intervention was Resident #7 being educated on the use of the call light and to ask for help. However, again the resident was assessed to be cognitively impaired and this interventions would not be effective or individualized for the resident. Observation of Resident #7 on 02/10/2020 at 1:15 P.M. revealed her feet were off the footrest of her wheelchair and Resident #11 asked the Director of Nursing (DON) to reposition Resident #7 as she looked uncomfortable. The DON placed Resident #7's feet on the footrest but her feet were then hanging over the footrest. The DON pushed Resident #7 back to her room telling her they would bring her back out. At 1:20 P.M. the DON went to the administrative area and Resident #7 was still in her room. At 1:37 P.M. Resident #7 was observed in her room in her recliner chair with her feet elevated. Her call light was not within reach. Observation of Resident #7 on 02/12/2020 at 9:57 [NAME]M. revealed she was in her room in her recliner chair, asleep, leaning to the right and her feet were elevated. Resident #7's call light was not in reach. Interview with the DON on 02/12/2020 at 10:08 [NAME]M. confirmed Resident #7's call light was not in reach (which was a safety intervention for the resident). The DON gave the call light to Resident #7 and instructed her to use it to call for help, asked the resident if she needed pain medication or to be repositioned. Resident #7 was sleepy and did not respond. Interview with Licensed Practical Nurse (LPN) #105 on 02/12/2020 at 10:51 [NAME]M. revealed she was not aware of Resident #7 using a call light. LPN #105 revealed staff needed to check on the resident a lot when she was no in a common area (due to her fall risk and inability to use her call light for assistance). Interview with State tested Nursing Assistant (STNA) #135 on 02/12/2020 at 11:26 [NAME]M. revealed Resident #7 did not use a call light. STNA #135 revealed staff assisted the resident to bed to sleep at night and the resident frequently sat in her recliner chair during the day. Interview with Corporate Registered Nurse #115 on 02/12/2020 at 3:00 P.M. confirmed educating Resident #7 on the use of the call light to prevent falls was not an appropriate intervention for her. Corporate Registered Nurse #115 confirmed limited interventions to prevent falls were implemented with Resident #7 and also verified Resident #7 sustained a fall with fracture on 01/01/20 due to a lack of adequate supervision and effective and individualized fall safety interventions being in place for the resident. Review of the facility assistive device and equipment policy, dated (MONTH) (YEAR) revealed the facility would address the appropriateness of devices and equipment for each resident to avoid the risk of injury. 2. Review of Resident #13's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's quarterly MDS 3.0 assessment, dated 08/28/2019 revealed her speech was clear she was rarely/never understood, usually understands, her short- and long-term memory was impaired, she had no recall and her cognition was severely impaired. Resident #13 required extensive assistance of two staff for bed mobility, was dependent on two staff to transfer, she did not walk and she was dependent on two staff for locomotion and used a wheelchair for mobility. Resident #13 had no falls and no skin problems. Review of Resident #13's progress notes revealed on 02/03/2020 at 11:16 [NAME]M. an order was obtained for an x-ray of the right lower leg and right foot related to bruising. Resident #13's medical record had no evidence of what caused the resident's right leg and foot bruising. Observation of Resident #13 on 02/10/2020 at 11:29 [NAME]M. and 1:17 P.M. revealed she was seated in wheelchair at table in dining room and her feet were dangling with no support. On 02/11/2020 at 8:55 [NAME]M. and 3:14 P.M., Resident #13 was observed in her wheelchair and her feet were dangling. Resident #13 was observed on 02/12/2020 at 8:54 [NAME]M. and on 02/13/2020 at 9:53 [NAME]M. seated in her wheelchair and her feet were dangling with no support. There were no footrests on the resident's wheelchair. Interview with LPN #105 and Corporate Registered Nurse #115 on 02/13/2020 at 4:38 P.M. revealed on 02/3/2020, Resident #13's leg and ankle were caught between the receiving lever for the footrest and the front wheel of the chair on the right side, about a 4-inch gap. This accident resulted in bruising of the lower leg and foot. An x-ray was obtained with no signs of a fracture. These staff members confirmed there was no documentation in the medical record of the incident, no evidence of monitoring of the leg and ankle bruising, and there were no preventive measures were put into place to prevent Resident #13 from being injured again. Review of the facility assistive device and equipment policy, dated (MONTH) (YEAR) revealed the facility would address the appropriateness of devices and equipment for each resident to avoid the risk of injury. 3. Review of Resident #11's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #11's speech was clear, she understands, was understood and her cognition was intact. Resident #11 had no indicators of [MEDICAL CONDITION], had no behaviors, and did not reject care. Resident #11 required limited assistance of one staff for bed mobility and to transfer. Review of Resident #11's smoking assessment dated [DATE] revealed the resident can carry her own lighter and cigarettes. Observation of Resident #11 on 02/09/2020 at 5:50 P.M. revealed the resident went outside to smoke with STNA #137. Resident #11 pulled cigarettes and lighter out of her [NAME]et pocket. Interview with LPN #139 on 02/09/2020 at 6:03 P.M. revealed Resident #11 and #8 kept their cigarettes and lighters on them. Interview with the DON on 02/10/2020 at 3:05 P.M. revealed residents were not supposed to keep lighters or cigarettes on them. The DON stated the lighters and cigarettes were kept at the nurse's station and a STNA would give them to the resident and goes out with the resident to smoke. She stated this had changed a month ago or so (residents not being permitted to maintain possession of cigarettes and/or lighters). Review of the facility smoking policy, dated 08/22/2019 revealed residents must store smoking materials with staff, except when they are under the supervision of staff.

Based on record review and interview the facility failed to ensure annual performance evaluations and in-service education was completed as required. This affected two employees, STNA #116 and #120 who had worked in the facility for more than one year and had the potential to affect all 19 residents residing in the facility. Findings include 1. STNA #116 started to work at the facility on 02/03/16. Review of STNA #116's personal file revealed an employee evaluation dated 02/01/19, however it was not signed by STNA #116 indicating agreement with or review of the evaluation. The Assistant Director of Nurses (ADON) confirmed on 02/13/20 at 10:35 [NAME]M. that STNA #116's evaluation had not been signed by the employee as required. Review of the facility policy, titled Performance Evaluation, dated 06/2010 revealed performance evaluations would be completed after 90 days of employment, yearly, and would be dated and signed by the employee acknowledging receiving the evaluation. In addition, review of STNA #116's annual in-service training documentation revealed no evidence the employee completed at least 12 hours of in-service training between 02/03/19 and 02/03/20. On 02/13/20 at 10:35 [NAME]M. during an interview with the Assistant Director of Nursing (ADON) she reported she had not kept record of STNA in-service training/hours and could not produce documentation of STNA #116 completing at least 12 hours of in-service annually as required. 2. STNA #120 started to work at the facility on 08/01/18. Review of STNA #120's personal file revealed the file did not contain a yearly performance evaluation. The Assistant Director of Nurses (ADON) confirmed on 02/13/20 at 10:35 [NAME]M. STNA #120 did not have a yearly evaluation completed and maintained in the employee's personal file. Review of the facility policy, titled Performance Evaluation dated 06/2010 revealed performance evaluations would be completed after 90 days of employment, yearly, and would be dated and signed by the employee acknowledging receiving the evaluation. In addition, review of annual in-service training documentation revealed no evidence the employee completed at least 12 hours of in-service training between 08/01/18 and 08/01/19. On 02/13/20 at 10:35 [NAME]M. during an interview with the Assistant Director of Nursing (ADON) she reported she had not kept record of STNA in-service training/hours and could not produce documentation of STNA #120 completing at least 12 hours of in-service annually as required.

Based on observation, menu review and staff interview the facility failed to ensure the written menu was followed. This had the potential to affect all 19 residents residing in the facility. Findings include: Observation of the preparation of the ground chicken on 02/11/2020 at 11:00 [NAME]M. revealed Cook #106 placed 12.8 ounces of chicken in the food processor to chop. According to the menu 21.2 ounces were needed for four servings of chicken for the lunch meal. Observation of tray line at 11:33 [NAME]M. revealed Cook #106 served residents a four-ounce serving of chicken. Review of the menu revealed residents on a mechanical soft diet should receive 5.3 ounces. The menu did not identify the serving size for the chicken for the other diets served in the facility. Cook #106 served other diets a four-once portion. Interview with Dietary Supervisor (DS) #118 on 02/11/2020 at 12:00 P.M. confirmed the menus did not specify the serving size for chicken for the regular diet, the no added salt diet, and the carbohydrate-controlled diet. The menu for mechanical soft diet called for 5.3 ounces of chicken not the 4 ounces that was served.

Based on observation and interview the facility failed to maintain the floor in the 100 hall and dining area in a clean and sanitary manner and to ensure the surface was safe for those who walk through this area. This had the potential to affect all 19 of 19 resident residing at the facility. Findings include: On 02/13/20 at 4:26 P.M. during tour of the facility with Registered Nurse (RN) #115 the flooring in the 100 Hall and part of the dining area was observed to be loose and in poor repair. Gaps between the laminate flooring up to two inches were noted, preventing cleaning due to exposure of the sub floor. The finish was coming off of some pieces of the laminate flooring exposing the particle board. Interview with RN #115 confirmed the above findings at the time of the observation.

Based on observation, record review, staff interview, family interview and review of the facility abuse policy and procedure the facility failed to ensure one resident (Resident #8) was free from mental and physical abuse. Resident #8 sustained actual harm when her head was taped to a wheelchair headrest and she was forced to wear a "sign of shame" claiming she was "bad". This affected one of three residents reviewed for abuse. The facility census was 23. Findings include: Review of the medical record revealed Resident #8's latest admission was 06/23/14 with [DIAGNOSES REDACTED]. Review of Resident #8's quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] revealed the resident sometimes made self understood and usually understood others. The MDS indicated Resident #8 had modified independence for cognitive decision making skills, required extensive assistance to being dependent on staff for activities of daily living (ADL) and was always incontinent of bowel and bladder. Review of a facility self-reported incident (SRI) dated 07/20/14 revealed State-tested Nurse Aide (STNA) #10 taped a sign on the back of Resident #8's wheelchair which read "I am so bad that I have to have my own sign of shame. (Resident #8's name) sign of shame." In addition the SRI indicated STNA #10 applied scotch tape to Resident #8's head and attached the scotch tape to the resident's wheelchair headrest because Resident #8's head kept sliding off the headrest. STNA #10 was suspended immediately and terminated on completion of the investigation. Review of the facility investigation dated 07/20/14 revealed a statement from STNA #10 indicating she was joking with Resident #8 when she taped the sign to her. Review of a witness statement dated 07/20/14 from STNA #11 indicated she observed STNA #10 and STNA #12 teasing Resident #8 while she was seated in her wheelchair in the hallway outside the dining room. STNA #10 then taped the sign to Resident #8's wheelchair. The witness statement indicated STNA #11 removed the sign from Resident #8's wheelchair and put it on her dresser. STNA #11 indicated she was not going to argue with STNA #10 since she had been employed at the facility for [AGE] years. STNA #11 indicated she thought it (the sign) was "ridiculous". STNA #11 reported STNA #10 told Resident #8 she was "spoiled" and "ornery". Review of a witness statement dated 07/20/14 from STNA #13 indicated Resident #8 was having behaviors so STNA #10 made a sign and put it in front of Resident #8. Resident #8 then kicked the sign to the floor. STNA #13 indicated STNA #10 then told Resident #8 she was going to tape the sign where Resident #8 could see it. STNA #13 stated STNA #10 stuck tape on Resident #8's head and connected it to the wheelchair. STNA #13 indicated she did not see any harm as Resident #8 was laughing. Review of witness statements from STNAs #14 and #15 dated 07/20/14 indicated they found the sign in Resident #8's room and brought it to the director of nursing. On 08/18/14 at 11:00 A.M. observation of Resident #8 revealed the resident was sitting in a high back wheelchair with both a head rest and a foot rest. The resident was noted to be sliding down in the wheelchair and leaning to the right side. The resident's head was hanging down. When an attempt to interview Resident #8 was made the resident would lift her head up and laugh and smile inappropriately. On 08/18/14 at 12:10 P.M. interview with the administrator revealed Resident #8's parents were upset at first until they found out which STNA it was and then they were okay with the incident. The administrator verified the facility substantiated the incident as abuse and the STNA was terminated on completion of the investigation. All staff were educated on the abuse protocol. On 08/19/14 at 3:55 P.M. interview with Resident #8's mother revealed she knew the resident liked attention from the staff and she thought the incident was funny. The mother indicated even with the tape she knew the STNA was joking with Resident #8. Review of the undated facility policy titled 'Abuse, Neglect and Misappropriation of Funds' revealed it is the policy of the facility to maintain a zero tolerance in regard to abuse. Abuse includes verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. This deficiency substantiates Complaint Number OH 868

Based on record review, and staff interview the facility failed to implement their abuse policy when one resident (Resident #8) was physically abused by a staff member. Resident #8 sustained actual harm when a State-tested Nurse Aide (STNA) taped her head to a wheelchair headrest and had her wear a "sign of shame" claiming she was "bad". This affected one of three residents reviewed for abuse. The facility census was 23. Findings include: Review of the medical record revealed Resident #8's latest admission was 06/23/14 with [DIAGNOSES REDACTED]. Review of Resident #8's quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] revealed the resident sometimes made self understood and usually understands others. The MDS indicated Resident #8 had modified independence for cognitive decision making skills, required extensive assistance to being dependent on staff for activities of daily living (ADL) and was always incontinent of bowel and bladder. Review of a facility self-reported incident (SRI) dated 07/20/14 revealed a State tested Nurse Aide (STNA) #10 taped a sign on the back of Resident #8's wheelchair which read "I am so bad that I have to have my own sign of shame. (Resident #8's) sign of shame." In addition the SRI indicated STNA #10 applied scotch tape to Resident #8's head and attached the scotch tape to the resident's wheelchair headrest because Resident #8's head kept sliding off the headrest. STNA #10 was suspended immediately and terminated on completion of the investigation. On 08/18/14 at 12:10 P.M. interview with the Administrator verified the facility substantiated the incident as abuse and the STNA was terminated on completion of the investigation. Review of the undated facility policy titled 'Abuse, Neglect and Misappropriation of Funds' revealed it is the policy of the facility to maintain a zero tolerance in regard to abuse. Abuse includes verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property.

Based on observation, clinical record review and staff interview, the facility failed to ensure provision of care and services in regard to treatment of [REDACTED]. This affected three of three sampled residents of four residents identified with pressure sores (Residents #16, #20 and #23). According to facility documentation, four residents were identified with pressure sores; two were identified as in house development. The census was 23. Harm occurred when Resident #16's Stage II pressure sore worsened to a Stage III and after the resident's pressure sore wound was cultured, there was a delay in treatment. The wound was identified with three bacterial organisms and needed treatment with intravenous medication. Findings include: 1. Review of the clinical record for Resident #16 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive assistance of one person for bed mobility and personal hygiene. The resident was assessed as incontinent of bowel and bladder. The resident was identified at risk for pressure sores and had one Stage II pressure sore present (Stage II - Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater). Interventions noted on the assessment included pressure reducing devices in the chair and bed with turning and repositioning program in place. The resident had nutrition interventions in place and was receiving dressings changes to the pressure area. Review of the skin assessment dated [DATE] for Resident #16 revealed the area to the resident's left buttock had worsened from a Stage II to a Stage III, (Stage III - Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue). The area measured 3.5 centimeter (cm) length (l) by 3.5 cm width (w). An open area to the coccyx was described as 2.5 cm w by 2 cm l with yellow center. The pressure area to the resident's right heel was described as Stage II, 6 cm l by 5 cm w with red/pink center and maceration to the surrounding tissue. A new area was identified to the left buttocks measuring 2.5 cm (l) by 1 cm (w) with a pink/red center, no stage was identified. Review of the skin assessment dated [DATE] for Resident #16 revealed the Stage III pressure area to the left buttock measured 3.5 cm (l) by 5 cm (w) with yellow brown slough, foul odor and red surrounding tissue. The area to the coccyx was described as 2 cm (l) by 1.5 cm (w) with yellow center and no stage was identified. The second area to the left buttock was described as 2 cm (l) by 1 cm (w) with yellow center and red surrounding tissue. The right heel was described as 6 cm (l) by 5 cm (w) with red/brown center with macerated surrounding tissue. Review of wound consult documentation for Resident #16 dated 10/12/11, described the area to the coccyx/ left buttocks as measuring 5 cm (l) by 9.8 cm (w) and was unstageable. The recommendation was for the use of an enzymatic debridement agent with calcium alginate and non-bordered foam. The right heel was described as 6 cm (l) by 5 cm (w) unstageable area. The recommendation for treatment was for calcium alginate and non-bordered foam dressing. The skin assessment completed by the facility on 10/19/11 for Resident #16 revealed the area to the left buttocks measured 7 cm (l) by 7 cm (w) by 3 cm deep (d) and had 4 cm tunneling and was identified as a Stage III. An area to the left upper buttocks was identified as 2 cm (l) by 1 cm (w) by .25 cm (d), Stage II. The right heel was measured as 8 cm (l) by 8 cm (w). The area was unstageable with eschar (dead tissue that is cast off from the surface of the skin) and yellow slough present. On 10/22/11 at 3:15 P.M., observation of the treatment to the pressure sore to the left buttock, coccyx and left outer buttock revealed the area to the left buttock presented as a Stage IV pressure sore (Stage IV - Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Undermining and sinus tracts also may be associated with Stage IV pressure ulcers). Interview of Registered Nurse (RN) #28 confirmed the staging of the pressure area. The opening of the pressure area measured 5 cm (l) by 5 cm (w) with a tunnel at 12:00 o'clock measuring 7 cm. The center of the pressure area measured 4 cm deep. The pressure area was dark red with a large amount of serosanguinous (bloody serum) drainage. The coccyx pressure sore measured 2 cm (l) by 1 cm (w) with hard yellow slough covering the area. The pressure sore to the left outer buttock measured 2 cm (l) by 1 cm (w) with hard yellow slough tissue covering the area. The right heel was unable to be observed. The dressing was intact and not due to be changed. Further review of the clinical record for Resident #16 revealed a would culture was ordered on [DATE]. The laboratory results with sensitivity was returned on 10/21/11 in a two page report at 11:03 A.M. This finding was verified by RN #50. The surveyor requested to review the report on 10/22/11 at 2:25 P.M. RN #50 found the report in a folder at the nursing desk. There was no documentation the physician was notified of the wound culture results on 10/21/11 upon receipt of the report. The report revealed the pressure sore had three organisms present, E-Coli, light growth (Escherichia coli is a Gram-negative, rod-shaped bacterium that is commonly found in the lower intestine of warm-blooded organisms), [MEDICATION NAME] spp moderate growth ([MEDICATION NAME] are part of the normal intestinal flora of humans and animals but are also important pathogens responsible for serious infections. The genus [MEDICATION NAME] includes more than 17 species, but only a few cause clinical infections in humans. With increasing antibiotic resistance, [MEDICATION NAME] are recognized as feared nosocomial pathogens that can be challenging to treat), and Peptostreptococcus heavy growth (Peptostreptococcus species are organisms in humans, living predominantly in the mouth, skin, gastrointestinal, vagina and urinary tracts and compose a portion of the bacterial gut flora). On 10/22/11 at 2:30 P.M., RN #50 called the physician. The physician returned the call and instructed the nurse to fax the sensitivity results to the pharmacy for direction. The sensitivity report was faxed to the pharmacy on 10/22/11 at 2:34 P.M. The physician returned a call at 3:35 P.M. on 10/22/11 with a physician order [REDACTED]. 2. Review of the clinical record for Resident #20 on 10/22/11 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed the resident required extensive assistance of two for bed mobility and personal care. The assessment revealed the resident had two unstageable pressure areas that were covered by slough or eschar. Review of a weekly skin assessment for Resident #20 dated 10/19/11 revealed an area to the coccyx measured 1 cm (l) by 1 cm (w) by .25 cm deep. A second area measured .25 cm (l) by .25 cm (w) by .25 cm deep was present to the buttock. Review of the physician's orders [REDACTED]. Review of the treatment administration record (TAR) for October 2011 revealed the order for a gel cushion was not on the TAR. On 10/22/11 at 8:20 A.M., observation of Resident #20 revealed the resident was seated in a geri-chair in the room. There was no cushion in the geri-chair. A second observation of Resident #20 on 10/22/11 at 11:15 A.M. in the dining room in a geri-chair revealed the resident did not have a gel cushion in place. On 10/22/11 at 11:40 A.M., interview with RN #50 verified the gel cushion to Resident #20's geri-chair was not in place. A search was conducted of the resident's room and staff were unable to locate the gel cushion. On 10/22/11 at 3:50 P.M., observation of the treatment to the two coccyx areas completed by RN #28 revealed the areas were 4 cm (l) by 4 cm (w) with .25 cm (d). Yellow slough was present in the center of the area. The wound was described as unstageable due to the slough tissue. On 10/22/11 at 4:00 P.M., review of the pressure areas to the coccyx/buttocks for Resident #20 with the Director of Nursing (DON) confirmed the pressure areas were acquired in house. The DON stated they found the gel cushion for Resident #20 in another geri-chair. 3. Review of the clinical record for Resident #23 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed the resident required extensive assist of one person for bed mobility and was totally dependent for personal care. The resident was incontinent of bowel and had a urinary catheter. Review of the nurse's note for 10/22/11 at 12:25 A.M., revealed the nurse documented the urinary catheter was changed and draining clear yellow urine. Review of the TAR for the Stage IV pressure area to the coccyx of Resident #23 for October 2011 revealed the treatment was to be completed every other day. According to documentation on the TAR, the treatment had not been completed since 10/15/11. On 10/22/11 at 8:25 A.M., observation of Resident #23 revealed the resident was complaining of being dirty. There was no urine in the urinary catheter tubing or drainage bag. State-tested Nurse Aide (STNA) #40 was called to the room by the surveyor. Observation of incontinence care revealed the resident was incontinent of bowel and the urinary catheter was lying on the bed with the balloon intact and still expanded with fluid. The resident's bed was wet including the incontinence pad and sheets. Interview of STNA #40 at the time of the observation confirmed Resident #23's buttocks were red and wet with urine and dirty with feces and a dark red area was present to the resident's right hip. Review of Resident #23's admission pressure area assessment revealed the Stage IV pressure area measured 5 cm (l) by 3 cm (w) with tunneling. The last skin assessment completed by the facility on 10/19/11 revealed the Stage IV area measured 4 cm (l) by 0.7 cm (w) by 0.25 cm (d). On 10/22/11 at 3:30 P.M., observation of the dressing change for Resident #23 completed by RN #28 revealed the coccyx area measured 7 cm (l) by 4 cm (w) and was covered with eschar. The area to the right hip at the bony prominence remained dark red and measured 3.0 cm (l) by 3 cm (w). Interview of RN #28 at the time of the dressing change verified Resident #23 had the red area to the right hip and it was not previously identified by the facility. A foam dressing was applied to the red area. This certification deficiency substantiated allegations contained in Complaint Number OH 860 and is an example of continued non-compliance from the annual survey completed on 08/19/11.

Based on medical record review, observation, facility policy review, and staff interview, the facility failed to ensure residents without pressure sores did not develop pressure sores and failed to ensure residents received the necessary treatment and services to promote healing and prevent new sores from developing by applying the required pressure-relieving devices and turning the residents as per their plans of care. This affected two of three residents reviewed for pressure sores (Residents #4 and #6). The facility identified three residents as having pressure sores on the Resident Census and Conditions of Residents document. Further review of the document revealed the facility identified only one resident had pressure sores upon admission. The census was 25. Harm occurred when Resident #6 was assessed at high risk for pressure sore development and the resident did not receive care and services to prevent multiple pressure sores. Findings include: 1. On 08/16/11 at 12:49 P.M., observation revealed Resident #4 was lying on her left side, sleeping. Her heels were directly touching the bed. On 08/16/11 at 2:10 P.M., observation revealed Resident #4 was lying in bed on her left side, sleeping. Her heels were directly touching the bed. On 08/16/11 at 3:50 P.M., observation of Licensed Practical Nurse (LPN) #80 completing a dressing change revealed Resident #4 was lying in bed. No pressure-relieving mattress was noted. The resident's feet were directly on the mattress. When the resident rolled to her back, dark, reddened areas were noted to her right outer toe joint and right heel. Redness and a dark purple area were observed to the right ankle. Resident #4 was observed with a reddened area noted to her left fifth toe outer joint and left outer heel. The open area to Resident #4's outer left foot measured 0.3 centimeters (cm) length (l) by 0.3 cm width (w). A piece of metal was visible in the open area. A small area of white tissue was surrounding the open area, and redness surrounded the white tissue. On 08/17/11 at 9:02 A.M., observation revealed Resident #4 was lying on her left side. Her heels were not elevated. They were directly lying on the bed. On 08/17/11 at 9:58 A.M., observation revealed Resident #4 was lying on her left side. Her heels were not elevated. They were directly lying on the bed. On 08/17/11 at 1:45 P.M., observation revealed Resident #4 was lying in bed on left side, sleeping. Her heels were lying directly on the bed and were not elevated. On 08/17/11 at 2:35 P.M., observation revealed staff had just provided care to Resident #4. Resident #4 was positioned on her left side. A rolled-up blanket was placed under her heels. Review of the facility's policy regarding Staging of Pressure Ulcers (not dated) revealed a Stage I pressure sore was intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding tissue. A Stage II pressure sore was a partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed without slough. May also present as an intact or open/ruptured blister. Review of Resident #4's annual Minimum Data Set (MDS) assessment dated [DATE] revealed short and long-term memory loss. The resident required extensive assistance with bed mobility, dressing, and personal hygiene. Review of the unhealed pressure sore section of the MDS revealed the resident had no unhealed pressure sores at Stage I or higher. Review of Resident #4's weekly skin assessment dated [DATE] revealed the resident had a small callus on the side of her left foot. Documentation on the weekly skin assessments between 02/14/11 and 05/09/11 revealed the area was a callus with pink surrounding the area. No measurements were noted. Review of Resident #4's weekly skin assessment dated [DATE] revealed a callus area had opened on Resident #4's left outer foot and was 0.4 centimeters (cm) in diameter. Review of Resident #4's pressure ulcer risk assessment dated [DATE] revealed a score of 13. A total score of 8 or above represented high risk. Review of Resident #4's physician's orders [REDACTED]. Keep on her back or left side only when in bed and to turn the resident every one hour when in bed. Position when out of bed in a high-back wheelchair with footrests and separator. The resident was also to have a pressure-reduction mattress to her bed. Review of Resident #4's quarterly MDS assessment dated [DATE] revealed the resident was at risk for developing pressure ulcers and the number or current amount of unhealed pressure ulcers was identified as none. Review of Resident #4's At Risk for Skin Breakdown Due to Immobility and Dependent on Staff for Activities of Daily Living (ADL) care plan dated 07/10/11 revealed interventions included monitor skin every day for signs/symptoms of potential skin breakdown, apply lotion to dry skin, and turn and reposition every one hour when in bed. Turn back to left side, keep off right side when in bed, keep skin clean/dry and bed linens clean, dry and wrinkle free every shift, nutritional supplement (ProCel), one scoop with each meal, provide a minimum of 12 to 16 ounces of fluids per tray, minimize environmental factors leading to dry skin, keep heels off of the bed as needed, and use positional devices to keep bony prominence's from direct contact with one another. Review of Resident #4's Potential for Pain Related to Wound Right Hip and Dressing Changes Every Day care plan dated 07/10/11 revealed interventions included to plan activities and caregiving to allow adequate rest, medicate, treatment as ordered, turn and reposition every 1 to 2 hours when in bed, turn back to left side, keep off right, alternate relief measures, and use a pillow to support in a position of comfort. Review of Resident #4's weekly skin assessment dated [DATE] revealed an open area 0.3 cm in length by 0.3 cm in width with a small amount of yellow drainage. On 08/16/11 at 4:00 P.M., interview with LPN #81 revealed she stated the open area was from a pin that was placed in her foot after a surgery many years ago and they think it was pressure "from the inside out." On 08/17/11 at 3:30 P.M., interview with the director of nursing (DON) verified Resident #4 was to have her heels off of the bed at all times. She stated the mattress she had was a pressure-reducing mattress. The DON verified the resident had multiple dark red areas to her outer left foot, one on the outer fifth toe joint, one on the ankle, and one on the heel. The resident also had one on the right great toe joint and on the right heel. The DON stated she was unable to say what these areas were until she further investigated them. The DON verified there was no documentation on the weekly skin assessment of the reddened areas. The DON also verified she was unaware of the reddened areas until viewing them with the surveyor. The DON stated she was unable to determine the stage, if any, for the open area to the resident's left outer foot. The DON stated they think it was from "pressure from the inside out." She stated there was metal from a pin that was placed years ago. 2. Review of Resident #6's medical record revealed the resident had [DIAGNOSES REDACTED]. The resident had a feeding tube that infused only at night. The resident had a Stage IV pressure sores (Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling), on her right and left hips, and a Stage III pressure sore on her right calf (Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling). Review of the pressure ulcer risk assessment dated [DATE] revealed the resident was assessed at high risk for the development of a pressure sore. Review of the quarterly MDS with an assessment reference date of 07/02/11 revealed the resident did not have any pressure sores. Further review of the medical record revealed a weekly skin assessment dated [DATE] identified the resident's right hip had a reddened area to the bony prominence. The area was assessed as reddened and soft. There were no measurements of the area. On 03/14/11, the area to the right hip was described as slightly reddened and blanchable. No measurements were documented. On 03/20/11, the right hip was identified on the weekly skin assessment as "reddish area, blanchable skin protectant applied." No measurements were obtained. On 03/27/11, the area to the right hip was described as "reddened area to bony prominence, skin intact, skin protectant applied." There was no documentation that evidenced any measurements had been obtained. On 04/04/11, the area to the right hip continued with redness and skin protectant was documented as applied. No measurements were documented of the area. On 04/10/11, the area to the right hip was documented as reddened area, blanchable. No measurements were obtained. On 04/18/11, the right hip remained reddened. A Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) area was identified to the left hip as a shallow ulcer, center pink, 0.5 centimeters (cm) in diameter with red surrounding tissue. On 04/26/11, the right hip was identified with a 1.0 cm in width (w) open area with a pink center and red surrounding tissue. Treatment started, (the specific treatment was not identified on the weekly skin assessment). The left hip was identified with an 0.5 cm open area with a pink center and the surrounding skin was assessed as pink. On 05/02/11, the right hip was assessed as 0.5 cm in diameter with a pink center and pink surrounding tissue. The left hip was assessed as pink in color and spongy. No measurements were obtained. On 05/08/11, the right hip was assessed as having a 0.5 cm in diameter open area with a pink center. Dark pink tissue was surrounding the wound bed. The left hip was identified as pink, soft and spongy. No measurements were obtained. On 05/15/11, a weekly skin assessment was not completed. On 05/23/11, Resident #6's right hip was assessed as a Stage II open area that measured 3.0 cm length (l) by 2.5 cm (w). Red center with dark edges and small amount of serosanquinous (composed of serum and blood) drainage. The left hip was assessed with [REDACTED]. The area was soft and spongy. On 05/30/11, the right hip was identified as a Stage II area that measured 2.2 cm l, by 2.2cm w. Red/brown/black center. A yellow ring was surrounding the wound bed and reddened tissue was surrounding the yellow ring. The left hip was assessed as having a 0.5 cm in diameter spongy area. On 06/05/11, Resident #6 was assessed with [REDACTED]. The center was described as yellow, brown, and slimy with a red ring surrounding the wound bed. The right hip was described as 0.5 cm in diameter reddened, spongy area. On 06/12/11, the weekly skin assessment identified the resident's left hip wound measured 2.0 cm l by 3.0 cm w and had a brown center. The right hip wound was 3.0 cm l by 3.5 cm w with a yellow, slimy center and brown-yellowish drainage. On 06/19/11, Resident #6's right hip was assessed to have a 3.5 cm l by 4.0 cm w open area with a brown/yellow slimy center with dark red tissue surrounding. A foul odor was noted. The left hip was identified with a 4.0 cm l by 5.0 cm w open area with a brown slimy center with red tissue surrounding the wound bed. A foul odor was detected. On 06/26/11, Resident #6 was assessed to have an open area to the right hip that measured 6.2 cm l by 8 cm w with eschar and a boggy center. A large amount of brown/red drainage as well as foul odor was noted. Red tissue surrounded the wound bed. The left hip was assessed as having a 4.0 cm l by 4.0 cm w open area that was black/brown in color with a boggy center. Red tissue surrounded the wound bed and a foul odor was noted. In addition, a 2.5 cm l by 0.5 cm w open area was identified to the resident's right lower extremity. An intervention of placing blankets between the resident's legs was implemented. Review of the wound healing center's initial evaluation documentation dated 06/27/11 revealed Resident #6 had a right hip wound that measured 6.5 cm l by 8.7 cm w by 0.4 cm depth (d). The area was non-stageable. There was a large amount of purulent drainage. There was some odor. There was a large amount of black necrotic tissue present. The left hip ulceration measured 3.0 cm l by 4.2 cm w by 0.4 cm d. There was no tunneling. A large amount of purulent drainage was present. There was odor. It was unstageable. There was a large amount of white and yellow necrotic tissue present. No exposed tendon or bone were identified. The right leg ulceration measured 1.6 l by 0.5 w by 0.1 cm d. It was a Stage III. There was a small amount of serosanquinous drainage present. Review of the [MEDICAL CONDITION] risk assessment dated [DATE] identified Resident #6's score at 22. A total score above 10 represented the resident was at high risk. On 07/03/11, Resident #6's right hip was assessed with [REDACTED]. There was a large amount of serosanquinous drainage. The left hip was measured at 4.0 cm (l) by 5.0 cm (w) with four areas of tunneling noted. The wound bed was described as yellow/brown, slimy slough center with a moderate amount of serous drainage. The open area to the resident's right leg measured 2.0 cm (l) by 1 cm (w) with a red/pink center. Review of a nutritional progress note dated 07/05/11 revealed Resident #6's current laboratory values dated 06/30/11 revealed the [MEDICATION NAME] (test often performed to check or monitor nutritional status) was low at 1.6 gram per deciliter (g/dl) (normal values 3.5-5.0 g/dl). Her [MEDICATION NAME] (test for nutritional status) was low at 7.4 milligram per deciliter (mg/dl) (normal values 17-40 mg/dl), her blood urea nitrogen (BUN) (test to detect renal disorder or dehydration) was elevated at 27 (normals 5-25 mg/dl). According to the August 2011 physician orders [REDACTED]. On 07/10/11, the right hip was assessed as 9.2 cm l by 8.3 cm w with areas of tunneling. The left hip was 5.0 l by 5.5 (w) with tunneling present. The open area to the resident's right leg measured 1.0 cm l by 0.5 cm (w) with reddened tissue surrounding the wound bed. On 07/17/11, Resident #6's right hip was a Stage IV and measured 8.0 cm (l) by 9.0 cm (w) with tunneling present. A large amount of serosanquinous drainage was noted. The wound bed was described as yellow/brown slimy center with red tissue surrounding. The left hip was a Stage IV and measured 5.0cm l by 5.cm (w). Tunneling was present. the wound bed was described as yellow/brown and slimy. The resident's open area to the right leg measured 1.0 cm (l) by 0.5 cm (w). On 07/25/11, the resident's right hip was 8.0 cm (l) by 9.0 cm (w) with tunneling identified. The left hip was 5 cm (l) by 5 cm (w) with tunneling. The right leg was 1.0 cm (l) by 0.5 cm (w). On 08/01/11, the area to the right hip measured 10.0 cm (l) by 10.0 cm (w) with tunneling. The left hip measured 5.0 cm (l) by 6.0 cm (w) with tunneling. The right leg measured 1.2 cm (l) by 0.8 cm (w). The wound clinic notes dated 08/03/11 revealed the right hip measured 8.8 cm (l) by 10.8 cm (w) by 0.1 cm (d) described as bone and muscle exposed and undermining. The left hip measured 4.8 cm (l) by 5.8 cm (w) by 0.8 cm (d) with bone and muscle exposed and undermining. The right leg wound measured 1.2 cm (l) by 0.6 cm (w) by 0.1 cm (d). On 08/07/11, the resident's right hip measured 10.0 cm (l) by 10.0 cm (w) with tunneling present. The left hip measured 5.0 cm (l) by 6.0 cm (w) with tunneling and a foul odor present. The right leg measured 1.2 cm (l) by 0.8 cm (w). On 08/14/11, review of the weekly skin assessment indicated Resident #6's right hip had a Stage IV decubitis measuring 9.5 cm by 10.0 cm with tunneling noted. The left hip was described as a Stage IV decubitis measuring 6.0 cm (l) by 5.5 cm (w) with tunneling present. The right leg had an open area measuring 1.8 cm (l) by 1.0 cm (w) red-brown with dark red surrounding tissue. The resident was assessed as having a 102.2 degree Fahrenheit temperature. Review of the treatment administration records (TAR) for August 2011 revealed the dressing to the resident's leg was changed on 08/02/11 and according to the TAR was not changed again until 08/05/11. Further review revealed the right leg dressing was changed 08/08/11, 08/11/11, and 08/14/11, which was greater than two days as ordered. Resident #6 also had a physician's orders [REDACTED]. Review of the plan of care for pressure ulcers to bilateral hips dated 07/20/11 revealed the following interventions were to be implemented: Do not position onto trochanter when side-lying position used, maintain head of bed at lowest possible degree of elevation, and use positional devices (e.g., pillows, foam wedges) to keep bony prominence's from direct contact with one another. On 08/16/11 at 11:20 A.M., Resident #6 was observed in bed on the right side with no pillow between her knees, and both heels were on the bed. At 1:35 P.M., the resident was in bed on her left side with no pillow between her legs, and no heel elevators were applied. On 08/17/11 at 7:30 A.M., the resident was positioned on her right side with a pillow between her knees, but no heel elevators were applied. At 9:30 A.M., the resident was positioned on her left side; no heel elevators were applied. At 10:30 A.M., Resident #6 was positioned on her left side with no heel elevators applied and no pillow between her legs. At 2:43 P.M., the resident had no heel elevators applied. No pillow was between her legs, and her heels were on the bed. On 08/17/11 at 8:48 A.M., interview of the DON revealed the first time the nurse identified the pressure sore on Resident #6's left hip was 04/18/11, and it was a Stage II pressure sore. On 04/26/11 was the first time the right hip area was described as an open area. The DON stated the area on the left hip developed after the area on the right hip, and they were trying to keep her off the right hip. On 08/17/11 at 9:49 A.M., continued interview of the DON confirmed the treatment to the right leg was ordered changed every two days and the nurses at the facility were changing the dressing every three days. On 08/17/11 at 2:54 P.M., interview of LPN #80 confirmed Resident #6 did not have heel elevators applied and no pillow had been placed between her legs. LPN #80 confirmed the resident was supposed to have the pillow between her legs and heel elevators applied. On 08/17/11 at 2:10 P.M., interview of State-tested Nurse Aide (STNA) #87 revealed Resident #6 was repositioned every two hours and she was a side-to-side turn. On 08/17/11 at 2:40 P.M., interview of STNA #88 revealed this resident was turned side-to-side every 2 hours and should have a pillow between her legs and heel elevators applied when in bed. On 08/18/11 at 8:54 A.M., interview of the ADON revealed there was no current reason to turn Resident #6 side-to-side only. Review of the facility's Wound Care Policy (not dated) revealed weekly assessment of the wound with measurements of the area were to be documented by the treatment nurse.