Every finding on record at Rockland Ridge Nursing & Rehabilitation Center

Based on medical record review, staff interview, physician assistant interview, review of the National Pressure Injury Advisory Panel (NPIAP) guidelines, and facility policy review, the facility failed to identify potential risks for skin breakdown and implement preventative measures and failed to timely identify the resident's pressure injury until it reached an advanced stage. This resulted in Actual Harm on 03/11/26 when the facility found an unstageable pressure ulcer (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar) on Resident #32's mid back caused by mechanical lift pad straps bunched up behind the resident's back while seated in the wheelchair. This affected one (Resident #32) of four residents reviewed for wound care. The facility census was 59. Findings include:Review of the medical record for Resident #32 revealed a re-entry date of 11/20/25 and a discharge date of 03/30/26. Diagnoses included dementia, displaced fracture of the left femur, moderate protein calorie malnutrition and adult failure to thrive. Review of the plan of care (POC) dated 07/28/25 revealed Resident #32 was at risk for alteration in skin integrity related to impaired independence in mobility, stage two chronic kidney disease, vision impairment, incontinence, impaired cognition, malnutrition, pain, and fragile skin. Interventions include applying Aquaphor to bilateral upper and lower extremities, complete skin assessments per facility policy, turn and reposition, and provide skin care as needed. Review of the Braden Scale for Predicting Pressure Ulcers/Injuries dated 01/16/26 revealed Resident #32 was at risk for skin breakdown.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had severe cognitive impairment, required substantial to maximum assistance from staff with upper body dressing and was dependent on staff with bathing.Review of a shower/bath skin sheet dated 02/28/26 revealed Resident #32 was free of any pressure wounds or injuries. Review of the wound assessment dated [DATE] revealed Resident #32 had a new unstageable pressure injury on mid-back measuring 8.4 centimeter (cm) in length by 7.8 cm in width and unable to determine depth. The wound had a small amount of serous exudate, and there was no odor or pain. The wound had 70 percent slough (moist, dead tissue that is pale yellow, cream, or tan and appears stringy or sticky) and 30 percent eschar (a layer of dead, necrotic tissue that forms over severe wounds, such as burns, pressure injuries, or diabetic ulcers which appear as dry, firm, and black or brown leathery crust).The progress note dated 03/02/26 at 5:30 P.M. and written by the Director of Nursing (DON) revealed she was called into Resident #32's room by Certified Nursing Assistant (CNA) #110 to look at an area on the resident's back. While transferring Resident #32 back to bed via mechanical lift, CNA #110 noticed that the mechanical lift pad handles were bunched up behind Resident #32. The new intervention was to place a pillow between Resident #20 and the lift pad when up in a wheelchair.Review of the interdisciplinary team (IDT) note dated 03/03/26 at 8:15 A.M. revealed the IDT met to discuss the area found to Resident #32's back on 03/02/26 at 5:30 P.M. The area was caused by the mechanical lift pad handles rubbing against the resident's back while she was up in her wheelchair. The doctor and family were notified. New orders were received and implemented. The IDT agrees with the intervention to place a pillow between Resident #20 and the lift pad when up in a wheelchair and there were no further recommendations at the time. The POC dated 03/03/26 revealed Resident #32 had an alteration in skin integrity as evidenced by a pressure ulcer to the mid back. Interventions included body check weekly and as needed, notify the physician and family of changes as needed, provide resident and family education on skin impairment and potential complications as needed, provide skin care as needed, treatments per physician orders, and request therapy screening and evaluations as needed. This new focus area did not include the new intervention to place a pillow between the resident and lift pad when up in wheelchair. The wound physician note dated 03/11/26 revealed Wound Nurse #320 documented that Resident #32 had a new pressure injury to midline back caused from a medical device (lift pad) that was initially staged as unstageable pressure injury. The physician classified the pressure injury to the midline line as a stage IV pressure injury (Full thickness tissue lost with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed.) The wound has undermining and exposed tendon and measured 3.1 cm in length by 6.5 cm. in width and 0.7 cm in depth.During an interview on 06/02/26 at 1:10 A.M., Physician Assistant (PA) #350 revealed Resident #32 was suspectable to developing pressure injuries due to multiple issues including her age, weight, lack of or poor nutritional intake, and a diagnosis of Kyphosis (an excessive, forward rounding of the upper back). During an interview on 06/02/26 at 1:20 P.M., the DON revealed she was the one who completed the initial wound assessment on Resident #32 for the midline back wound observed on 03/02/26. The DON stated the area to Resident #32's back was dark in color like to have a bruise appearance and the skin appeared like a yellowish color where the mechanical lift pad straps appeared to rub. The DON verified the unstageable pressure injury was caused by the mechanical lift pad straps. The DON revealed after the pressure injury was noted on Resident #32's mid back, the new intervention was to complete wound care and treatments as ordered along with ensuring a pillow was placed between the resident and the mechanical lift pad when up. During an interview on 06/02/26 at 1:54 P.M., Registered Nurse (RN) #250 revealed she has worked with Resident #32, and her daily routine was to get up after breakfast and lay back down when she wanted to or at least after lunch. Most of the time when the CNAs would provide incontinent care for her between breakfast and lunch, Resident #32 would choose to stay in bed. When Resident #32 would be up in her wheelchair, she could very easily and would often move around in the chair and fidget. She liked to be placed in front of the windows and would lean forward and side to side often to see things or follow objects. There were a few times she was found swinging her legs over the side of the arm rest and had to be repositions. Resident #32 was able to tell them when she was having pain or discomfort and when she wanted to go back to bed. RN #250 confirmed Resident #32 had an abnormal outer curvature of the back and verified there was no protection in this area to prevent skin injuries or issues when the resident was noted to be moving and fidgeting in her chair.Review of the NPIAP Current 2026 PI (Pressure Injury) Guideline dated 09/16/25 revealed it is good practice to consider the following factors when selecting a chair or wheelchair that meets the individual's needs for pressure redistribution and shear reduction: the individual's overall risk of pressure injuries, independence, mobility, and activity needs, body size, shape and weight distribution, posture deformity and asymmetry and its affect on pressure distribution, need for enhanced features, and the individual's preferences and care goals.Review of the facility policy titled Skin Assessment dated 03/15/24 revealed it is the intent of the facility to provide necessary care to prevent the development of pressure injuries unless the resident's clinical condition demonstrates that the development is unavoidable. Licensed nurses should ensure skin assessments are completed timely by evaluating residents as scheduled and per the resident's need. Risk factors impacting the development, treatment and/or healing of pressure injuries, including underlying medical conditions, intrinsic/extrinsic risk factors and casual factors are evaluated and provide the basis for defining approaches for the prevention and management of pressure injuries in accordance with the resident's needs, goals and professional standards or practice.This deficiency represents non-compliance investigated under Complaint Number 2999890.

Based on record review, observation, and interview, the facility failed to ensure call lights were maintained in a resident's reach. This affected one resident (#78) of 24 residents reviewed for observations during the initial pool. The facility's census was 66. Findings Include:Review of the medical record revealed Resident #78 was admitted to the facility on [DATE]. Diagnoses included left knee replacement, osteoarthritis of the left knee, diabetes, left foot drop, lumbar sacral plexus disorder, hypertension, anxiety disorder, varicose veins of the lower extremities, radiculopathy, sacrococcygeal disorders, hip trochanteric bursitis, low back pain, thoracic spine pain, sciatica, Raynaud's syndrome, spinal stenosis, pacemaker, and anemia. Review of the admission note dated 09/21/25 at 12:10 P.M. revealed Resident #78 had a surgical incision to the left knee with 43 staples. She was transferred to bed with three staff assistance. Observation and interview on 09/22/25 at 10:15 A.M. revealed Resident #78 was sitting up in her recliner with her feet elevated. She stated her call light was over on the bed. The call light cord was lying across her bed, out of reach. On 09/22/5 at 10:19 A.M. an interview with Registered Nurse #111 confirmed the call light for Resident #78 was lying across her bed, out of her reach.

Based on medical record review, observation, interview, and policy review the facility failed to ensure a pressure ulcer was accurately assessed and treatment implemented timely. This affected one (Resident #5) of two reviewed for pressure ulcers.Medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including stage III pressure ulcer (full-thickness loss of skin), diabetes, venous insufficiency, and heart failure. Review of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed the resident was at risk for pressure ulcer and had one stage III pressure ulcer. Review of Resident #5's current plan of care for alteration in skin integrity as evidence by pressure ulcers to coccyx and left buttocks revealed assess areas for size, color, drainage, pain weekly and as needed and to administer treatments as ordered. Review of Resident #5's progress notes and assessment dated [DATE] to 09/24/25 revealed no evidence of a comprehensive assessment of the pressure ulcer on left buttocks or coccyx. Review of Resident #5's miscellaneous documentation tab dated 07/02/25 to 09/24/25 revealed Resident #5 had been seen weekly by a visiting wound company nurse practitioner (NP). On 09/10/25 the visiting wound team had seen Resident #5 for a follow-up for a stage III pressure injury to the coccyx and left buttocks and skin tear to the left shin. The left shin skin tear measured 5.5 centimeters (cm) by 2.3 cm by unable to determine due to scabbed/crusted. The in-house acquired stage III pressure ulcer on the coccyx measured 0.3 cm by 0.3 cm by 0.1 cm. No new orders. Continue with Xeroform gauze (petrolatum-impregnated gauze) daily with large, bordered foam dressing. The in-house acquired stage III pressure ulcer on the left buttocks measured 0.5 cm by 0.4 cm by 0.1 cm. No new orders. Continue with Xeroform gauze daily with a silicone bordered foam dressing. The care plan was discussed with nursing staff and residents. Please have the resident follow up with the visiting wound team in one week. On 09/17/25 at 7:41 A.M., the visiting wound team saw Resident 5 for a follow-up on the stage III pressure ulcer on the coccyx and left buttocks and skin tear to left shin. The coccyx wound was larger and declined, and treatment plan was changed. The left buttocks and left shin area was healed but will continue to follow for another week. The coccyx wound measured 2.1 cm by 1.9 cm by 0.1 cm. New orders collagen gauze daily with a large foam dressing. The left buttocks had healed however orders to continue the Xeroform gauze with a silicone bordered foam dressing. The plan of care was discussed with nursing staff and resident. Please have the resident follow up with the visiting wound team in one week. Review of Resident #5's progress note dated 09/17/25 at 4:37 P.M., revealed the resident was seen by wound care. A skin tear to left shin measured 5.5 cm by 2.3 cm by unable to determine, clustered wound. Order to continue to cleanse skin tear to left shin with soap and water and pat dry. Apply silicone contact dressing every Wednesday and as needed. The coccyx measured (0.3 cm by 0.3 cm by 0.1 cm) stage II. Continue to cleanse coccyx with soap and water or normal saline and apply Xeroform then cover with foam dressing. The left buttocks measured (0.5 cm x 0.4 cm x0.1 cm) continue to cleanse left buttocks with soap and water or normal saline then apply xeroform cover with daily dressing daily. The physician and family are aware. Review of Resident #5's orders and treatment administration records dated 09/17/25 to 09/22/25 revealed no evidence of resident was ordered or received collagen gauze daily to the coccyx. Review of the visiting wound nurse amendment note dated 09/22/25 at 6:37 P.M. for 09/17/25 revealed the NP changed the order to the coccyx from Collagen to Collagen with silver and added a note that she was notified by the wound nurse that supply of collagen with silver was not available and will have to be ordered. Will continue previous order for dressing of Xeroform daily to wound until collagen with silver was made available. At that time, dressing would be changed to collagen with silver daily. Review of invoice dated 09/23/25 revealed the facility had ordered Collagen and Collagen with silver dressing on 09/23/25. Observation on 09/24/25 at 9:35 A.M., of Resident #5 with visiting wound nurse practitioner (NP) #300 and Registered Nurse (RN) (facility wound nurse) #101 revealed the coccyx pressure ulcer measured 0.9 cm by 0.3 cm by 0.1 cm. The left buttocks had three open areas measuring 4.1 cm by 1.5 cm by 0.1 cm. The visiting wound NP #300 reported she was just covering today due to the wound NP that usually comes weekly was on vacation. The NP reported the areas on the left buttocks appeared to be moisture associated dermatitis. The facility's wound nurse RN #101 reported she had been on vacation last week and the areas on the left buttocks were new. RN #101 reported she usually measures wounds with the NP oversite, however several months ago (not sure the exact date, however after the last annual) the facility stopped documenting comprehensive assessment and just use the visiting wound nurse assessment, unless the wound NP doesn't arrive she would complete a paper assessment and scan it into the electronic medical record under the miscellaneous tab. The wound NP #300 confirmed the facility receives her progress note the same day as the assessment for the facility's records. The NP reported she usually types her reports prior to leaving the facility. Interview on 09/24/25 at 1:21 P.M., 2:26 P.M. and 3:21 P.M. with the Director of Nursing (DON) revealed Licensed Practical Nurse (LPN) #103 was covering for RN #101 last week and entered inaccurate measurement and treatment plan in the progress note on 09/17/25 for Resident #5. The DON reported LPN #103 was on vacation this week, however it was her understanding the Collagen was not available last week and the visiting wound NP, which was on vacation this week as well, have orders to continue the Xeroform until the Collagen was available, however neither the LPN or visiting wound NP had documented or wrote orders. The DON confirmed she had contacted the visiting wound NP on 09/22/25 (after the survey was entered and concerns identified) and had the visiting wound NP add an addendum to her progress note on 09/17/25. The DON also confirmed on 09/22/25 she clarified the Collagan with the visiting wound NP and new orders were received for Collagen with silver daily to the coccyx, discontinued the order to the left shin, and continue the Xeroform to the left buttocks. The DON reported the Corporate Nurse had stopped and picked up Collagan with silver from a sister facility on 09/22/25 due to the facility places orders on Thursday and they usually don't arrive until Monday, and the Collagen never arrived due to it being not ordered. The DON confirmed the physician and family were updated on new orders on 09/22/25. Interview on 09/24/25 at 1:34 P.M., with RN #101 confirmed the measurement and treatments LPN #103 had documented on 09/17/25 were the same measurement and treatments that were done on 09/10/25. The RN confirmed LPN #103's documentation on 09/17/25 did not match the comprehensive assessment or orders the visiting wound NP had documented on 09/17/25. Interview on 09/24/25 at 1:36 P.M., with the Administrator revealed the Collagen was never ordered until 09/23/25. The Administrator reported that the facility realized the Collagen was never ordered the Corporate Nurse had stopped at the facility's sister facility and picked up Collagen with silver on Monday so the nurse could start the treatment and the Collagen with silver was also ordered on 09/23/25. Review of the facility policy titled Skin assessment dated [DATE] and revised 03/15/24 revealed skin assessments include a collection of objective and subjective data by the licensed nurses that contributes to the nursing process, including observation, measurements, and comparative analysis of a wound. Data collected for the completion of skin assessments would be documented by the licensed nurses in the resident's medical record. The licensed nurse collaborates with other members of the healthcare team to ensure necessary treatments and services are provided related to data collected for completion of skin assessments and documented per facility policy.

Based on record review, observation, interview, and policy review, the facility failed to ensure appropriate infection control practices were followed during urinary incontinence care and wound care. The facility also failed to ensure a resident's indwelling urinary catheter's collection bag was maintained off the floor to prevent possible contamination/ infection. This affected one (Resident #23) of three residents reviewed for pressure ulcers and two (Resident #3 and #5) of four residents reviewed for catheters and/ or urinary tract infections. Findings include: 1. Review of Resident #23's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included an encounter for other orthopedic aftercare, staphylococcal arthritis of the right hip, infection and inflammatory reaction due to internal right hip prosthesis, presence of right artificial hip joint, osteoarthritis, need for assistance with personal care, muscle weakness, and abnormalities of gait and mobility. Review of Resident #23's admission skin record dated 08/16/25 revealed the resident had an unstageable pressure ulcer (full thickness skin and tissue losses in which the extent of the tissue damage could not be determined because it was obscured by slough and/ or eschar) to her sacrum, left proximal buttock, and left distal buttock upon admission. The sacral wound measured 2.3 centimeters (cm) by 1.7 cm, the left proximal buttock wound measured 0.8 cm by 0.7 cm, and the left distal buttock wound measured 2 cm by 2.6 cm. Review of Resident #23's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was known to be frequently incontinent of her bowel and bladder and was considered to be at risk for pressure ulcers. She was known to have three unstageable pressure ulcers that were present upon admission. Review of Resident #23's weekly wound assessments completed through 09/24/25 revealed the unstageable pressure ulcer to the sacrum had resolved on 09/10/25 and the unstageable pressure ulcer to the left proximal buttock resolved on 09/17/25. The unstageable pressure ulcer to the left distal buttock was the only pressure ulcer that remained as of 09/24/25 and was classified as a stage III pressure ulcer (full thickness skin loss that extended into the subcutaneous tissue but did not expose muscle, tendon, or bone). Review of Resident #23's active physician's orders revealed the resident had orders in place to treat the left proximal buttock and the left distal buttock. The treatment was the same for both and included the need to cleanse the areas with normal saline or soap and water and apply Triad paste every shift and as needed (prn). They were to leave both areas open to air (OTA). On 09/25/25 at 9:00 A.M., an observation of Resident #23's treatment of the stage III pressure ulcer to her left distal buttock revealed the treatment was performed by Registered Nurse (RN) #112. She was assisted by RN #101. The nurses donned personal protective equipment (PPE) to include a gown and gloves upon entering the room, due to the resident being on enhanced barrier precautions due to her wounds. Hand hygiene was performed prior to starting the treatment and supplies were set up on the bedside table. RN #101 assisted the resident with turning over on her left side. Resident #23 was noted to have had a small bowel movement that was found in her incontinence brief when RN #112 was getting ready to do the treatment. She proceeded to provide incontinence care to the resident with the disposable gloves that she already had on. Several disposable wipes were used to clean the stool from around her rectal area. The resident had dried Triad paste coating her buttocks that had been applied during a previous treatment. Once the nurse finished wiping the stool from around the resident's rectal area, she proceeded to use another disposable wipe to clean off the dried Triad paste that was already on her buttocks. She wiped the Triad paste from over top of the area (where the resident had her stage III pressure ulcer on the left distal buttocks) exposing the area of the resident's wound. She did not remove her contaminated gloves and perform hand hygiene, after cleaning the resident's rectal area to remove the stool, before she proceeded with wiping the area on the left distal buttock where the wound was. It was not until she had wiped the wound area to where it was clear of any Triad paste that she removed her gloves and performed hand hygiene. She donned new gloves, after washing her hands, and then proceeded to wash the pressure ulcer with soap and water. She completed the treatment as ordered and then finished changing the resident before gathering her used supplies and left the room. On 09/25/25 at 9:20 A.M., an interview with RN #112 confirmed she did not change her gloves or perform hand hygiene between wiping Resident #23's rectal area following an unexpected bowel movement and wiping the dried Triad paste off her left buttock where her stage III pressure ulcer was. She acknowledged she should have removed her gloves, performed hand hygiene, and then donned new gloves before wiping the Triad paste off her left buttock directly over the area where her pressure ulcer was. She acknowledged by doing so, she risked the contamination of the resident's pressure ulcer cite with Escherichia coli (E.Coli) commonly found in the intestines and stool. Review of the facility's policy on Dressing Changes dated 09/29/17 revealed dressing changes were to be changed following the manufacturer's recommendations and as needed. The procedure included the need to use proper hand hygiene techniques and glove changes when performing dressing changes. 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included right side hemiplegia, aphasia, apraxia, diabetes, dysarthria, cerebral infarction, hypothyroidism, major depressive disorder, interstitial cystitis, paroxysmal vertigo, carpel tunnel osteoporosis, osteoarthritis, cataracts, atherosclerotic heart disease, dysfunction of the bladder, anxiety disorder and hypertension. Observation of incontinence care on 09/23/25 at 1:05 P.M. revealed Certified Nursing Assistant (CNA) #301 and CNA #168 provided care to Resident #3. CNA #301 provided perineal care to the labial area of Resident #3 with no concerns with infection control. However, when she rolled Resident #3 over to provide perineal care to her rectum and buttocks area she washed and rinsed Resident #3 from the rectum to the vaginal area, potentially contaminating the vagina with feces. On 09/23/25 at 1:18 P.M. an interview with CNA #301 confirmed she washed and rinsed Resident #3 from the rectum to the vagina. Review of the facility policy titled, Perineal Care, revealed the purpose was to provide care to the genitalia and rectal areas, to prevent broken skin and infection to provide comfort and cleanliness and to prevent body odors. The policy indicated for females to always wipe front to back, using a different part of the washcloth for each wipe. 3. Review of Resident #5's medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, obstructive and reflux uropathy, urinary retention, and obstructive reflux uropathy. Review of Resident #5 Minimum Data Set (MDS) dated [DATE] revealed the resident had an indwelling catheter. Review of Resident #5's orders dated 09/2025 revealed catheter care every shift and to change suprapubic catheter monthly and as needed per urologist recommendations. Review of Resident #5's alteration in elimination plan of care dated 07/08/25 and revised 02/11/25 revealed the resident had a suprapubic catheter for obstructive uropathy. Review of Resident #5's urine culture dated 08/18/25 revealed the resident had Enterobacter Cloacae Complex (ECC), Methicillin Resistant Staphylococcus Aureus (MRSA) and Enterococcus Faecalis (VRE). Observation on 09/22/25 at 1:13 P.M., of Resident #5 revealed the resident was sitting in a wheelchair with his urinary catheter bag under the seat of the wheelchair directly touching the floor without a barrier or covering over the urinary catheter bag. The surveyor activated the call light for the resident due to his oxygen tubing being disconnected from the portable tank. Licensed Practical Nurse (LPN) #122 assisted the resident with oxygen tubing, however, did not move the urinary catheter bag to ensure it was not touching the floor directly. Observation on 09/22/25 at 1:44 P.M. revealed Resident #5 was still up in the wheelchair, and the urinary catheter bag was directly touching the floor. Observation on 09/24/25 at 11:16 A.M. revealed Resident #5 was being pushed down the hall in a wheelchair by Certified Nursing Assistant (CNA) #302. The Resident's urinary catheter bag was dragging on the floor as the CNA was pushing the resident down the hall. The urinary catheter bag was in direct contact with the floor without a barrier/covering. Interview on 09/24/25 at 11:16 A.M. with CNA #302 confirmed Resident #5's urinary catheter bag was directly dragging onto the floor. The CNA confirmed the urinary catheter bag should not be touching the floor. The CNA then removed the urinary catheter bag from the bottom of the wheelchair and moved it to the side of the wheelchair and took the resident to the dining room. Interview on 09/24/25 at 12:03 P.M., with the Director of Nursing (DON) confirmed urinary catheter bags should not be directly touching the floor. The DON reported she had recently educated staff on the catheter care policy; However, the facility's policy didn't include placement of the catheter bag. The DON confirmed last month the resident was treated for a urinary tract infection that contained VRE, MRSA, and Enterobacter Cloacae.

Based on observation, interview, and facility record review the facility failed to ensure refrigerators had thermometers in them to confirm the internal temperature, failed to ensure refrigerator and freezer temperatures were monitored, failed to ensure all food was temperature checked prior to being served, and failed to ensure food preparation equipment was air dried. This had the potential to affect all 68 residents receiving meals from the kitchen. Findings included: 1. Observations on 06/05/23 between 8:10 A.M. and 8:25 A.M. of facility refrigerators revealed no thermometers in the walk-in refrigerator, cook's reach in refrigerator or service refrigerator. An interview at the time with Dietary Cook (DC) #101 verified the three refrigerators did not have thermometers in them and should have to monitor the internal temperature of the units. Review of facility refrigerator and freezer temperature check logs dated May 2023 to June 2023 revealed no documentation to support the kitchen reach in refrigerator temperature was monitored on 05/19/23, 06/02/23, 06/03/23, or 06/04/23, the kitchen walk-in freezer temperature was monitored on 05/19/23, 06/02/23, 06/03/23, or 06/04/23, and the kitchen walk-in refrigerator temperature was monitored on 05/19/23, 05/26/23, 06/02/23, 06/03/23, or 06/04/23. Interview on 06/07/23 at 9:10 A.M. with the Dietary Manager #114 verified refrigerator and freezer temperature checks were missing for the above-mentioned days and should be assessed at least daily. 2. Review of the food temperature logs dated January 2023 to June 2023 revealed food temperatures were not always being monitored to confirm safe food temperatures prior to being served. Review of the facility form titled, Foundations Health Solutions Food Temperature Log, dated January 2023, revealed lunch and dinner meals were not temperature checked on 01/10/23. Review of the facility form titled, Foundations Health Solutions Food Temperature Log, dated May 2023, revealed lunch and dinner meals were not temperature checked on 05/29/23 or 05/31/23 and breakfast, lunch and dinner meals were not temperature checked on 05/30/23. Review of the facility form titled, Foundations Health Solutions Food Temperature Log, dated June 2023, revealed lunch and dinner meals were not temperature checked on 06/01/23 or 06/02/23 and breakfast, lunch and dinner meals were not temperature checked on 06/03/23. Interview on 06/05/23 at 8:30 A.M. with DC #101 verified there was no documentation to confirm meals were temperature checked on the above dates. He also verified the importance of temperature checking all food temperature prior to serving to confirm it was a safe temperature for consumption. Interview on 06/07/23 at 9:10 A.M. with the Dietary Manager #114 verified food temperature checks were missing for some meals and all food should be temperature checked prior to serving. 3. After pureeing the carrots, DC #101 ran the Robot Coupe bowl, chopper, and lid through the dishwasher and proceeded to dry the three pieces of the Robot Coupe with a towel. DC #101 then used the towel dried Robot Coupe bowl, chopper, and lid to puree noodles. Interview on 06/06/23 at 12:35 P.M. with DC #101 verified he did dry the parts of the Robot Coupe with a towel and should not have. He reported he wanted to get the purees done and didn't have time for the three parts to air dry. He verified all cooking utensils should air dry to prevent contamination.

Based on observation, interview and facility form review, the facility failed to ensure puree was at an appropriate texture for consumption. This had the potential to affect all five residents (Resident #1, #10, #24, #35, and #209) who received a pureed diet. The facility census was 68. Findings included: Observation of the puree process on 06/06/23 at 10:50 A.M. of Dietary Cook (DC) #101 preparing the puree. DC #101 placed the glazed rainbow carrots in the Robot Coupe food processor. The carrots were purred, and he believed the mixture was too thin and therefore, added one tablespoon of thickener. After pureeing for a couple of minutes, DC #101 tasted the carrot puree and reported it was the correct consistency and ready to be served. This surveyor then tasted the carrot puree and after pushing the puree to the roof of her mouth, noted there were pieces of carrot which needed to be chewed. The consistency was not smooth. After informing DC #101 of her findings, DC #101 verified the carrot puree was not ready to be served and there were chunks of carrot in it. DC #101 processed the carrots for an additional three minutes and then an additional four minutes prior to tasting them again and reporting they were at the proper texture to be served. The puree was noted to be smooth after the additional time in the Robot Coupe. Review of the Diet Master form provided by the facility, dated 06/05/23, revealed five Residents (#1, #10, #24, #35, and #209) received pureed diets. Review of the facility form titled, Provider Services Puree Production Competency, date May 2014, revealed puree until smooth (pudding-like to mash potato consistency). Follow recipe using proper thinning agent and thickening agent as directed in recipe. Further review revealed to taste the completed product. Push food from tongue to roof of mouth. Ensure it is smooth like pudding or mash potato-like consistency.

Based on record review, observation, resident interview, and staff interview, the facility failed to ensure a resident with recurrent urinary tract infections (UTI's) received indwelling urinary catheter care consistently as per her physician's orders and plan of care. This affected one resident (Resident #4) of two residents reviewed for urinary catheter or UTI's. The census was 68. Findings include: A review of Resident #4's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included neuromuscular dysfunction of the bladder, Alzheimer's disease, and dementia. A review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not known to display any behaviors nor was she known to reject care. She required an extensive assist of two for toilet use and an extensive assist of one for personal hygiene. She was identified as having the use of an indwelling urinary catheter. A review of Resident #4's care plans revealed she had a care plan in place for an alteration in elimination with the use of an indwelling urinary catheter due to her diagnosis of a neurogenic bladder. The care plan indicated the resident had a history of recurrent UTI's. The care plan originated on 11/08/21. The goal was for the resident to be free of complications related to the use of the indwelling urinary catheter. The interventions to achieve that goal included providing urinary catheter care every shift and as needed (prn). She also had a care plan for being at risk for recurring UTI's related to the use of the indwelling urinary catheter. The care plan indicated she required assistance with urinary catheter care. The interventions included the need to provide urinary catheter care if applicable. A review of Resident #4's physician's orders revealed the use of a 16 french indwelling urinary catheter to a collection bag related to neurogenic bladder. Catheter care was to be provided every shift. The order for catheter care had been in place since 12/02/21. The orders also included the need to monitor the indwelling urinary catheter stabilization device daily and to replace the indwelling urinary catheter securement device every seven days and as needed (prn). That order had also been in place since 12/02/21. She was receiving Macrobid 100 milligrams (mg) by mouth two times a day x 10 days for the treatment of a UTI. That order originated on 05/30/23 and was due to end on 06/09/23. A review of Resident #4's treatment administration record (TAR's) for June 2023 revealed the nurses were initialing to show they were performing catheter care every shift as ordered and per the plan of care. They were also initialing the TAR to show they were monitoring the urinary catheter stabilization device daily on the night shift. A nurse had initialed to show the urinary catheter securement device had been changed on the night shift the night of 06/01/23, as was ordered to be done that shift every seven days. On 06/05/23 at 10:39 A.M., an interview with Resident #4 revealed she did not receive catheter care every shift as she should. An additional interview with the resident on 06/06/23 at 11:23 A.M. revealed she continued to claim catheter care was not being provided to her and denied she had received it that morning. She denied catheter care was provided as part of her morning or evening care she received, if she received that at all. If she wanted catheter care done, she would have to ask the staff to do it and would be told they would be back, but would not return to do it. She stated she would like to have it done then as it was not done yet that day. She denied the facility staff were using any type of securing device to stabilize her urinary catheter and to prevent movement or possible dislodgement. A Velcro strap used to secure indwelling urinary catheter tubing to a resident's leg was noted rolled up on the resident's dresser and had a date of 04/08/23. She reported the indwelling urinary catheter pulled when it was not properly secured. She stated they used a securing device when she had first come, but had not used one in a while. She had worked as a nursing assistant for years and knew what the staff were supposed to be doing and they were not doing it. On 06/06/23 at 12:30 P.M., an interview with State tested Nursing Assistant (STNA) #300 revealed the aides were responsible for doing catheter care on the residents with an indwelling urinary catheter. They documented the completion of catheter care in the kiosk. She thought Resident #4 had catheter care already provided to her that shift and was done earlier in the morning. She reported it was done by one of the younger aides she was working with that day. She was not sure of the younger aide's name but stated the aide had blonde hair. She did not observe catheter care being done for the resident, but had been told it was. She indicated the catheter's collection bag was secured to the bed using a hook. She denied knowledge of the resident having a leg strap or any other securing device to secure the tubing to the resident's leg to help prevent dislodgement. She indicated the catheter's tubing was left to dangle instead. On 06/06/23 at 12:32 P.M., an interview with LPN #160 revealed the aides were responsible for doing catheter care for the residents with an indwelling urinary catheter. She was not sure how it was documented when it had been completed. She then checked on the computer and indicated the nurses documented the completion of catheter care on the TAR's. She claimed, after the resident was up, she would verify that catheter care had been done by the aides. She alleged the resident's catheter care had been done by the aides, after the resident had a bowel movement. She was not sure who it was that did the catheter care, but was told by STNA #204 it had been done. She confirmed STNA #204 was a younger aide with blonde hair, as was described by STNA #300. LPN #160 confirmed she had signed off the TAR to reflect catheter care had already been provided to Resident #4 by the aides as was allegedly reported to her. She stated they were securing the catheter tubing to the resident's leg using a leg strap. She denied the nurses were signing that off on the TAR's. She was not sure how often the securing device (strap) was being changed and had to look at the orders to verify. She indicated it was to be replaced every seven days and as needed (prn). The TAR indicated it was last changed on 06/01/23. She reported the night shift nurse was signing the TAR to reflect they were monitoring for the securing device to be in place. She was asked to accompany the surveyor back to the resident's room to verify if the securing device was in place. She entered the resident's room and pulled down her blanket exposing the resident's catheter tubing. She confirmed the resident was not wearing a leg strap as a securing device or had any other type of securing device to help stabilize her urinary catheter tubing to her leg and prevent possible dislodgement. The resident informed the nurse she had not had a leg strap in place or any other type of securing device on her leg in a long time despite the facility nurses signing it off on the TAR. The nurse acknowledged there was a Velcro strap on her dresser at the resident's bedside that had the date of 04/08/23 on it. She stated she would get the resident a leg strap on so her indwelling catheter tubing could be properly secured as ordered. Further review of Resident #4's electronic health record (EHR) revealed the aides were documenting the completion of catheter care on a bowel and bladder elimination documentation under the task tab of the EHR. A review of the last 30 days (05/08/23 to 06/05/23) revealed the aides were not consistently documenting the completion of catheter care for the resident during that 30 day period. There was no documented evidence to support catheter care had been provided at all on 05/10/23 or on 05/24/23. The aides only documented catheter care being provided only once on 05/13, 05/17, 05/19, 05/20, 05/21, 05/25, 05/29, 05/30/23 or on 06/05/23. There was no documentation to support catheter care had been completed twice a day on those days as was ordered every shift (facility staff worked 12 hour shifts). There had not been any documentation to support catheter care had been provided the morning of 06/06/23, as was signed off on the TAR by LPN #160 as having been completed. On 06/06/23 at 12:42 P.M., an interview with STNA #204 revealed she was one of two aides assigned to work the 300 hall that day. She denied that she had performed catheter care to Resident #4, as was reported by STNA #300 and LPN #160, after the resident allegedly had a bowel movement according to LPN #160. She indicated she was new and had just recently come off her orientation period. She was not sure how often catheter care was to be completed or who was to do it. On 06/06/23 at 3:30 P.M., the Director of Nursing (DON) was made aware Resident #4 was reporting she was not receiving catheter care twice a day as ordered and per her plan of care. She was identified as having had three UTI's in the past 12 months as indicated by the facility's infection control logs. She was also made aware the LPN #160 signed off the TAR to indicated catheter care had been provided the morning of 06/06/23, when it had not been provided. She acknowledged the aides were not consistently documenting catheter care on the bowel and bladder elimination form under the task tab of the EHR. She also acknowledged the nurses were signing the TAR to reflect they were monitoring the resident's securing device and were changing it every week as ordered, when the resident reported a securing device had not been used for some time now. She was informed a securing device was not noted to be on the resident's leg when LPN #160 checked her on 06/06/23 and there was a leg strap on her dresser that was rolled up and dated 04/08/23. She denied the facility had any policies specific to the use of indwelling urinary catheters or the provision of catheter care. She stated the facility followed standards of practice.

Based on observation, staff interview and policy and procedure review, the facility failed to ensure all medications were properly stored to prevent unauthorized access. This had the potential to affect four (Resident #2 , #18, #21 and #50) of 22 residents on the 100 hallway identified as independently mobile and cognitively impaired. The census was 68. Findings include: On 06/07/23 from 7:55 A.M. to 8:06 A.M. the medication cart was sitting in the 100 hallway, unlocked and out of the nurse's view. The nurse was in a resident's room. This was verified during interview at 8:07 A.M. with Licensed Practical Nurse (LPN) #113, who revealed she had went into a resident's room to check on him and forgot to lock the medication cart that was not in her sight while she was in the resident's room. Review of the facility policy and procedure General Guidelines for Medication Administration dated 06/21/17 revealed the (medication) cart should remain unlocked only when the nurse or authorized individual is physically present at the cart.

Based on record review, observation, staff interview, review of CDC guidelines, and policy review, the facility failed to ensure staff properly donned and doffed appropriate personal protective equipment (PPE) when entering a resident's room in transmission based precautions (TBP's) as part of a 14 day quarantine following a recent admission. The facility also failed to ensure staff properly disinfected their eye protection when leaving the isolation room. This affected one resident (Resident #41) of 59 residents residing in the facility. Findings include: A review of Resident #41's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #41's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was initiated on 03/26/22. On 03/28/22 at 12:50 P.M., an observation noted Licensed Practical Nurse (LPN) #96 to enter the room of Resident #41. Resident #41 was noted to have a PPE cart outside her room and also was noted to have signs on her door that identified her as being in droplet and contact precautions. Her door was partially opened. LPN #96 was in the room talking to the resident and her husband. LPN #96 was noted to be wearing a surgical mask while in the room. She had other PPE on to include a gown, gloves and eye goggles that was required to be worn when in a resident's room on droplet and contact precautions. She did not remove her surgical mask and don a N95 mask as part of her PPE before entering the room. She was noted to doff her gown and gloves before leaving the room. She came back out into the hallway wearing the same surgical mask she had on when she entered the room. She was not noted to remove that mask and don a new one upon leaving the room nor was she noted to disinfect her eye goggles. On 03/28/22 at 12:53 P.M., an interview with LPN #96 revealed Resident #41 was in droplet and contact precautions due to her not being fully vaccinated for Covid-19 and a recent admission. She stated the resident was not considered to be fully vaccinated as she did not have her booster vaccine. The resident was to be in droplet and contact precautions for seven days. She denied the need for her to wear a N95 mask in that room despite the resident being in droplet and contact precautions for a quarantine period following a recent admission. She stated she was not required to wear a N95 mask since her quarantine was only for seven days. She indicated if the resident was in droplet and contact precautions for 14 day then she would have to wear a N95 mask. She was then asked about the doffing procedures and confirmed she did not discard that mask and get a new one when leaving Resident #41's room. She also confirmed she did not disinfect her eye goggles after leaving her room and before she started to head to other areas of the facility. There were no alcohol wipes or other disinfectant wipes available in the PPE cart outside the resident's room to be used to disinfect her eye goggles. She denied she was educated on the need to wear N95 masks for those residents in isolation precautions as part of a quarantine period following a recent admission. On 03/28/22 at 1:10 P.M., an interview with the Director of Nursing revealed the staff were to don a N95 mask when entering the rooms of those residents in isolation precautions as part of a quarantine period following a new admission. She stated it did not matter whether they were in quarantine for seven days or 14 days when it came to wearing a N95 mask. She stated the nurse (LPN #96) should have also doffed that mask and got a new surgical mask when leaving that room. They should have also disinfected their eye protection when leaving the room as part of the doffing process. A review of the facility's Covid-19 Prevention and Response policy revised 03/19/21 revealed they were to assess residents for symptoms of Covid-19 infections upon admission, implementing infection prevention practices and TBP's per the Centers for Disease Control (CDC) guidelines. Interventions to prevent the spread of Covid-19 within the facility included keeping employees informed by explaining what they could do to protect themselves and the other residents. They were to educate staff on proper use of PPE and application of standard, contact and droplet transmission precautions. Under considerations for admitting residents with suspected or confirmed Covid-19, residents admitted or readmitted would be quarantined per CDC guidance. A review of CDC guidelines for Interim Infection Prevention and Control Recommendations to Prevent Covid-19 Spread in Nursing Homes updated 02/02/22 revealed due to concerns about increased transmissibility of the Covid-19 Omicron variant, the guidance was being updated to enhance protection for healthcare personnel, residents and visitors and to address concerns about potential impacts on the healthcare system given a surge in Covid-19 infections. Empiric use of TBP's (quarantine) was recommended for residents who were newly admitted to the facility and for residents who had close contact with someone with Covid-19 infection if they were not up to date with all the recommended Covid-19 vaccine doses. Older adults living in congregate settings were at risk of being affected by respiratory and other pathogens, such as Covid-19. A strong infection prevention and control program was critical to protect both residents and healthcare personnel (HCP). HCP caring for residents with suspected or confirmed Covid-19 infections should use full PPE to include gowns, gloves, eye protection and N95 masks. Residents who were up to date with all the recommended Covid-19 vaccine doses do not need to be placed in quarantine. A review of the facility's policy on Donning and Doffing PPE for Covid-19 revised 02/04/22 revealed PPE would be donned before entering the isolation area under TBP's. They were to identify and gather PPE to be donned which may include an isolation gown, respirator (N95 mask), surgical mask, eye protection and disposable gloves. Doffing procedures included the need to remove, sanitize and replace the eye protection. They were also to remove, discard and replace the respirator/ facemask. This deficiency substantiated Complaint Number OH 231.