Every finding on record at Roselawn Manor

Based on record review, observation, staff interview, and policy review the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed. This affected one (#48) of four residents reviewed for EBP. The facility failed to ensure glucometers were sanitized following accuchecks. This had the potential to affect seven (#8, #9, #11, #20, #28, #32, and #41) who the facility identified as receiving accuchecks testing on the E and D-halls. The facility also failed to ensure the measures to prevent the growth of Legionella were completed. This had the potential to affect all residents who reside in the facility. The facility census was 40. Findings include: 1) Review of medical record for Resident #48 revealed an admission date of 01/02/26 with diagnoses including but not limited to acute on chronic respiratory failure with hypoxia, malignant neoplasm of tonsil, tracheostomy status, and gastrostomy status. Review of care plan dated 01/06/26, revealed Resident #48 had an indwelling medical device and may be in EBP while residing at the facility. Interventions included educating resident/family/staff on EBP and answering questions they may have, monitoring for psychosocial effects regarding the EBP and staff would report to appropriate person, encourage to participate in activities, go to the dining room for meals as able and willing, and report any concerns to the appropriate person. Observation of medication administration on 05/26/26 at 10:15 A.M., with Licensed Practical Nurse (LPN #270) revealed medications were being administered through the Percutaneous Endoscopic Gastrostomy (PEG) tube (a medical feeding tube surgically inserted directly through the abdomen into the stomach). LPN #270 did not have a gown on related to the resident being in EBP. Observation of the signage located on the resident's bathroom door indicated the resident was in EBP and indicated the staff must wear gown and gloves when providing high contact resident care. LPN #270 exited the resident's room to get additional supplies. LPN #270 retrieved supplies to unclog the resident's PEG tube and returned to the resident's room. LPN #270 was observed to have a mask and gloves on and continued to work with the resident's PEG tube without donning a gown. LPN #270 was attempting to get the peg tube unclogged without success. LPN #270 removed the tube feed dressing and cleaned around the stoma moving from inner to outer. During an interview on 05/26/26 at 10:35 A.M., LPN #270 verified Resident #48 was in EPB and verified she did not have a gown on when providing care/medications to Resident #48's via his PEG tube. LPN #270 stated that she did not wear one due to not having access to one in the resident's room. LPN #270 stated she did not know where to locate the gowns to stock them. LPN #270 verified there were no gowns in the resident's room. Review of policy titled Enhanced Barrier Precautions dated 08/2022, revealed all personnel must wear gloves when high-contact resident care activities are being performed. An impervious gown should be worn when high-contact resident care activities are being performed. High-contact resident care activities: dressing, bathing, transferring, providing hygiene, changing linens, changing attends or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and wound care any skin opening requiring a dressing. 2) Observation of medication administration on 05/26/2026 at 8:10 A.M. with LPN #203 revealed nurse did not sanitize the glucometer after checking Resident #20's blood sugar. LPN #203 completed the accucheck and put the glucometer back in the medication cart without any type of sanitization. Observation of an accucheck for Resident #8 on 05/26/2026 8:35 A.M. with LPN #270 revealed the nurse did not sanitize the glucometer after checking the resident's blood sugar. LPN #270 completed the accucheck and put the glucometer back in the medication cart without any type of sanitization. Interview at the same time, LPN #270 verified the glucometer was not sanitized after using it on Resident #8 and before putting it back in the medication cart. LPN #270 stated they used one glucometer for all residents on D-Hall. LPN #270 stated she sanitized the glucometer once at the start of the shift. During an interview on 05/26/2026 8:51 A.M., LPN #203 verified the glucometer was not sanitized after using it for Resident #20. LPN #203 stated they used one glucometer for all residents on the E-Hall. LPN #203 stated that she only sanitized the glucometer at the end of her shift when she stocked the cart and cleaned everything. 3) Record review of facility's legionella records revealed no monitoring and routine pipe flushing were conducted in portions of the building that were inactive or not in regular use, as required by the facility's Water Management Program. During an interview on 5/27/26 at 2:53 P.M., Project Manager #288 confirmed that required water flushes had not been completed in accordance with the facility's Water Management Plan policy. Review of the facility policy titled Legionella Policy-Environmental, undated, revealed the facility should monitor and flush pipes in rooms and/or areas of the building that are not in use.

Based on facility document review and staff interview, the facility failed to ensure the Facility Assessment included the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet the residents' needs. This had the potential to affect all the residents. The facility census was 40.Findings include:Review of the Facility assessment dated [DATE], which was reviewed on 03/12/26 revealed no documentation to support the facility determined the number of qualified staff needed to provide care for the residents. During an interview on 05/27/26 at 2:43 P.M., the Administrator confirmed the Facility Assessment did not contain documentation to support the facility determining the number of staff that would be needed to provide care for the residents.

Based on facility staffing review and staff interview, the facility failed to ensure at least eight hours of consecutive Registered Nurse (RN) coverage per day for seven days. This had the potential to affect all residents who reside in the facility. The facility census was 40.Findings include:Review of the nursing staff schedule from 05/19/26 to 05/25/26 revealed no documentation to support the facility had eight hours of consecutive RN coverage on 05/23/26 and 05/24/26.Interview on 05/28/26 at 11:00 A.M., the Administrator verified the facility did not have eight hours of consecutive RN coverage on 05/23/26 and 05/24/26.

Based on observation, staff interview and facility policy, the facility failed to ensure the kitchen stored, prepared, distributed and served food in accordance with professional standards for food service safety. This had the potential to affect 36 out of 40 residents who received food from the kitchen. Four Residents (#23, 26,37, and 48) do not receive food from the kitchen. The facility census was 40.Findings include:Observation of the kitchen on 05/26/26 at 7:47 A.M., with [NAME] #265, revealed one six pound eleven ounce can of crushed pineapple, approximately half full, and one seven pound empty chocolate pudding can being stored under the three compartment sink with the lids left open and positioned upright. Both cans contained black residue on the interior and exterior surfaces. The findings were verified at the time of observation with [NAME] #265.Continued observation of the kitchen on 05/26/26 at 8:00 A.M., with [NAME] #265, revealed black, loose residue around the gas burners of the stove, along with crumbled food debris. Multiple dried streaks of an unidentified substance were present on the right side of the stove. The findings were verified at the time of observation with [NAME] #265.Continued observation of the kitchen on 05/26/26 at 8:10 A.M. with [NAME] #265, revealed in the back corner of the dishwasher an area approximately eleven inches by eleven inches containing a thick black substance. A spoon was present with its spoon head protruding from the substance. [NAME] #265 removed the spoon, which had approximately one half inch of the black substance adhered to the entire handle. [NAME] #265 reported the dishwasher had been leaking for two months and the maintenance staff tried to fix it but now a company was coming to fix it. The findings were verified at the time of observation with [NAME] #265.During an interview on 05/26/26 at 9:03 A.M., Maintenance #243 stated he thought dishwasher leak was fixed earlier with a clamp that he put on earlier. Maintenance #243 stated a plumbing contractor would be replacing the high-pressure line on the dishwasher later in the week.Review of facility, undated How to clean the kitchen and dietary center revealed the floors should be wet mopped after each meal service to clean and disinfected. Stove top is to be cleaned daily with a diluted cleaner disinfectant.

Based on record review, observation, staff interview, and policy review the facility failed to ensure medications were not left at the bedside. This affected one (#33) of four residents observed during med pass. The facility identified 10 residents (#9, #14, #16, #22, #27, #31, #32, #33, #38 and #41) who were independently mobile whether ambulatory or wheelchair on D-hall. The facility census was 40. Findings include: Review of medical record for Resident #33 revealed an admission date of 11/15/24 with diagnoses including but not limited to epilepsy, nonrheumatic aortic (valve) stenosis, hypertension, and cognitive communication deficit.Review of Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #33 had moderate cognitive impairment. The resident was dependent on staff for medication administration. Review of Active physician orders for Resident #33 revealed the following medications to be given upon rising: bee pollen (dietary supplement) 500 milligrams (mg) daily, docusate (stool softener) sodium 100 mg daily, Theragran-M multivitamin with minerals daily, calcium (supplement) 600 mg twice daily, metoprolol (beta blocker/blood pressure) tartrate 50 mg twice daily, sodium chloride (hypertonic) ophthalmic solution five percent (%) one drop in both eyes two times daily, and artificial tears ophthalmic solution 1% one drop in both eyes twice daily.Observation of Resident #33's room on 05/26/26 at 10:47 A.M. revealed a clear plastic medication cup on the resident's over the bed table containing five medications. There were no staff observed in the room. Resident #33 stated the nurse was usually here and she was thirsty. Resident #33 stated she should probably take her medications.During an interview on 05/26/26 at 10:49 A.M., Licensed Practical Nurse (LPN) #270 verified Resident #33's medications were left at the bedside. LPN #270 stated the resident would normally just take her meds without difficulty. LPN #270 verified the following medications in the cup: Theragran-M vitamin, calcium 600 mg, bee pollen 500 mg, metoprolol 50 mg, and Colace 100 mg. Review of policy titled Medication Administration-General Guidelines dated 01/13/2026 revealed that the resident is always observed after administration to ensure the dose was completely ingested, this is noted on the MAR, and action is taken as appropriate.

Based on medical record review, observation, interview, and policy review, the facility failed to ensure splints were applied per physician order. This affected one (Resident #37) of one resident reviewed for splints. The facility census was 40.Findings include:Review of the medical record for Resident #37 revealed an admission date of 10/12/23. Diagnoses included contracture of muscle right hand, contracture of left hand, contracture of right elbow, and contracture of left elbow.Review of the physician orders revealed a left blue palm protector and a right hand small tan hand roll if able (or washcloth) on in the morning at breakfast time and remove at lunch time approximately for four hours and monitor skin.Review of the care plan dated 09/05/24 revealed assist with bilateral hand splints apply after morning care or hand hygiene and remove at end of first shift or as tolerated. Small tan hand roll to right, blue soft hand splint to left. Provide skin checks before applying and after removal. Interventions included assess skin for redness, irritation, open areas and report to nurse if noted, cleanse and dry affected areas before and after application, monitor for any signs and symptoms of pain/discomfort and notify nurse, and reassess every 90 days and as needed.Further review of the care plan dated 05/22/26 revealed Resident #37 had an alteration in musculoskeletal status related to contractures of upper extremities due to immobility and stroke effects. Interventions included resident's hands are very tight, tell him that skin needs looked at in each hand and to attempt to relax his hand and fingers, gently pull fingers away from hand, cleanse hands as needed, check skin condition of both hands, fingers are contracted into the palm of his hand, wears a separator in day and use of washcloth when separator not in place, keep nails trimmed and hand cleansed, and dry completely. Review of the Point of Care (POC) aide documentation for the past 30 days revealed assistance with left blue palm protector and right hand small tan hand roll (or washcloth). Place on at breakfast time and remove at lunch time, approximately four hours was documented as response not required on 04/28, 04/29, 05/02, 05/03, 05/04, 05/06, 05/07, 05/09, 05/10, 05/11, 05/18, 05/21, and 05/26.Observation on 05/27/26 at 8:30 A.M. of Resident #37 resting in bed revealed no hand splits were currently applied. Resident #37 was lying with his arm over his eyes. Bilateral hands were contracted. Interview on 05/27/26 at 8:47 A.M., the Certified Nursing Assistant (CNA) #244 stated they had not been in his room yet. CNA #244 stated they put the hand splints on when they get him ready in the morning and the resident wears them for four hours.Follow up observation and interview on 05/27/26 at 11:00 A.M. of Resident #37 lying in bed revealed no hand splints were currently applied. The CNA #244 verified they had not put the splints on yet today.Observation on 05/28/26 at 8:26 A.M. of Resident #37 revealed the resident resting in bed with no hand splints.Follow up observation on 05/28/26 at 9:21 A.M. of Resident #37 revealed the resident resting in bed with no hand splints.Follow up observation on 05/28/26 at 10:55 A.M. of Resident #37 revealed the resident resting in bed with no hand splints. Diathermy (generates heat) machine observed over the left hand.Follow up observation 05/28/26 at 1:08 P.M. of Resident #37 revealed the resident resting in bed with no hand splints.Interview on 05/28/26 at 9:55 A.M. with Director of Nursing (DON) revealed the resident had order for a washcloth or calcium alginate as the resident's hand gets moist at times. The DON verified the POC should not be documented as response not required or not applicable. The DON verified the resident did not have a noncompliant care plan to indicate the resident would refuse to wear the hand splints nor documentation in electronic record to indicate the resident refused to wear hand splints. Review of policy titled Specialized Rehabilitative/Restorative Services, dated 03/2017 revealed the restorative nursing care program is designed to assist each resident to achieve and maintain the highest practicable physical, mental and psychosocial well-being. The program includes but not limited to maintaining good body alignment and proper positioning, assisting residents to adjust to their disabilities, to use their prosthetic devices, and to redirect their interests if necessary, and assisting residents with routine range of motion exercises.

Based on medical record review, staff interview, and policy review, the facility failed to provide activities to meet residents' physical, mental, and psychosocial needs. In addition, the facility failed to document individual participation in activities as per policy. This affected one (Resident #26) out of one resident reviewed for activities. The facility census was 40.Findings include:Review of the medical record for Resident #26 revealed an admission date of 11/16/18 with medical diagnoses of Parkinson's disease, dementia, chronic kidney stage III, gastrostomy tube, essential tremor, and moderate Intellectual Disabilities.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had severe cognitive impairment and was dependent upon staff for all activities of daily living.Review of the Resident Preference Evaluation dated 06/25/25 revealed it was important to Resident #26 to listen to music, do things with groups of people, and participate with religious activities.Review of the activity care plan dated 11/28/18 revealed Resident #26 enjoyed being active in care community daily including attending activities and sitting in the lounge with others. Resident #26 was dependent upon staff for activities, cognitive stimulation, and social interactions related to cognitive deficits and physical limitations. The interventions included invite Resident #26 to scheduled exercise classes, any music programs, Bingo, parties, socials, and religious programs.Review of Resident #26's medical record revealed no activity participation documentation.Observation on 05/26/26 at 10:03 A.M. revealed Resident #26 sitting in a specialty chair in the common area on the unit in front of the television. Observation on 05/26/26 at 11:17 A.M. revealed Resident #26 continued to sit in the common area in front of the television.Observation on 05/27/26 at 9:51 A.M. revealed Resident #26 sitting in a specialty chair in the common area in front of the television. No other residents observed sitting in the common area.Interview on 05/28/26 at 7:28 A.M., the Activity Director (AD) #259 stated the activity department staff provide one-on-one activities with Resident #26 two times per week which include listening to music, hand massages, or grooming. The AD #259 stated Resident #26 did attend group activities at times. The AD #259 stated the activity department did not document Resident #26's participation in group or individual activities.Review of the facility policy titled, Activities, revised March 2017 revealed based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities designed to [NAME] the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independent and interaction in the community. The policy stated the following records are maintained by the Activity Coordinator including activity assessment, individual participation documentation, calendar of events, activity progress notes, and overall plan of care-activities.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) was provided to a resident timely. This affected one (Resident #17) out of three residents reviewed for beneficiary notices. The facility census was 40.Findings include:Review of the medical record for Resident #17 revealed an admission date of 10/16/25 with medical diagnoses of traumatic subdural hemorrhage, cerebrovascular accident (CVA), hypertension and epilepsy. Resident #17 discharged to the hospital on [DATE] and readmitted to the facility on [DATE].Review of the end of Prospective Payment System (PPS) Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact and required partial/moderate staff assistance with bathing, bed mobility, and transfers and supervision with eating and toilet hygiene. Review of the MDS revealed Resident #17's last day of Medicare A coverage was 12/23/25.Review of Resident #17's NOMNC revealed Medicare last covered day was 12/23/25 and the form was signed on 12/24/25 by Resident #17's power of attorney. Interview on 05/27/26 at 11:42 A.M., the Administrator verified Resident #17 received skilled services under his Medicare part A from 11/09/25 until 12/23/25. The Administrator verified the NOMNC indicated Resident #17's last covered day under Medicare A was 12/23/25 and the NOMNC was signed by Resident #17's power of attorney on 12/24/25. The Administrator said the NOMNC was to be provided to the resident or power of attorney at least two days prior to Medicare A services ending.Review of the facility policy titled, Beneficiary Notice Requirements, revised November 2022, revealed Medicare-participating long term care facilities are obligated to information Medicare Part A and B beneficiaries about specific rights related to billing, and to submit bills to the Fiscal Intermediary (FI) or Medicare Administrative Contractor (MAC) when requested by the beneficiary. The financial liability and appeal rights are communicated to beneficiaries through notices given by the providers. The policy the revealed the facility would issue the Notice of Medicare Provider Non-Coverage (form CMS-10123) when there was a termination of all Medicare Part A and part B therapy services for coverage reasons. The Notice of Medicare Provider Non-Coverage (NOMNC) informs the beneficiary of his/her right to an expedited review of a service termination by the Quality Improvement Organization (QIO). The facility must issue the notice, no later than two days before the services are terminated, but far enough in advance that the beneficiary/representative can make an informed choice. If the NOMNC was delivered via telephone, the skilled nursing facility must note the name of the person initiating the contact, name of the representative, contacted by phone, the date and time of telephone contact and telephone number called along and annotates that all required information was communicated on the second page of the NOMNC under the additional information.

Based on medical record review, observation, interview, and skills demonstration/evaluation review, the facility failed to ensure enteral nutrition (tube feed) was labeled, dated, and timed. This affected one (Resident #48) out of three residents reviewed for tube feed. The facility census was 40.Findings include:Review of medical record for Resident #48 revealed an admission date of 01/02/26. Diagnoses included acute/chronic respiratory failure with hypoxia, malignant neoplasm of tonsil, tracheostomy status, and gastrostomy status.Review of physician orders revealed Nutren 2.0 at 45 milliliters (ml) per hour every shift, change syringe daily, and document total intake of enteral feed and water flushes three times daily.Observation on 05/27/26 at 8:26 A.M. of Resident #48 revealed the resident resting in bed. Nutren tube feeding hanging on pole running at 45 ml per hour. The Nutren bag was not labeled, dated, or timed as to when it was hung.Interview on 05/27/26 at 8:38 A.M. with the Minimum Data Set (MDS) Staff #237 verified the Nutren tube feed hanging for Resident #48 was not labeled, dated, or timed.Review of Skills Demonstration/Evaluation Record Feeding Tube-Closed System dated 04/2013 revealed competency performance criteria revealed the nurse labels container and spike set with resident name, date, and time hung.

Based on medical record review, resident and staff interviews, and policy review, the facility failed to address a resident's significant loss. This affected one (Resident #05) out of two residents reviewed for nutrition. The facility census was 40.Findings include:Review of the medical record for Resident #05 revealed an admission date of 03/04/25 with medical diagnoses of anemia, anxiety, arthritis, and depressive disorder.Review of Resident #05's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #05 was cognitively intact and was dependent upon staff for toilet hygiene, required substantial/maximum staff assistance for bathing and bed mobility, and partial/moderate assist with transfers. The MDS revealed Resident #05 had a significant weight gain, was edentulous, and received a mechanically altered diet.Review of Resident #05's physician order dated 03/04/25 for bumetanide (a diuretic) 2 milligram one tablet by mouth daily and an order 12/02/25 for a regular mechanical soft diet with thin liquids. Review of Resident #05's physician orders revealed no orders for meal supplements or changes in diuretics.Review of Resident #05's weight log revealed a weight of 275.2 pounds on 02/04/26, a weight of 293.0 pounds on 03/06/26, a weight of 270.8 pounds on 04/07/26, and a weight of 263.0 pounds on 04/13/26.Review of Resident #05's nutrition note dated 12/02/25 documented a quarterly review with current weight of 273.8 pounds. The diet recently changed to regular, mechanical soft diet due to conversation with Speech Therapy related to food avoiding and modifying on regular diet. The note continued to document Resident #05 continued with high intakes of meals which was typical for the resident. Continue to monitor. Review of a nutritional note dated 04/10/26 revealed Resident #05 was reviewed on this date. Current body weight of 270.8 pounds and weight was just 293.0 pounds 30 days ago. The note revealed Resident #05 had been on a new diuretic which led to significant positive weight loss. The note stated Resident #05 continued with good intakes of diet and the physician was aware of all of the above.Interview on 05/26/26 at 1:38 P.M. with Resident #05 stated he has lost a lot of weight because he doesn't eat the food. Resident #05 stated his diet was changed to mechanical soft after all of his teeth were pulled. Resident #05 stated he was going to get dentures soon.Interview on 05/27/26 at 3:40 P.M. with Corporate Dietician #290 stated the diet technician visits the facility one day per week to review residents with weight loss. Corporate Dietician #290 stated she was not familiar with Resident #05's nutritional status but stated all residents who had a significant change in weight, whether loss or gain, needed to be reweighed within a reasonable amount of time. Corporate Dietician #290 stated she would expect the reweight to be done within a day or two of the weight showing the loss or gain. Corporate Dietician #290 also stated that any residents who had significant weight changes would be discussed at the weekly Nutrition Risk Meeting.Interview on 05/28/26 at 10:15 A.M. with Director of Nursing (DON) stated the facility did not have any documentation to support Resident #05's significant weight loss was discussed at the weekly Nutrition Risk meeting to determine possible cause of weight loss and if any interventions were needed. The DON verified Resident #05 had not had any changes in diuretics in March or April 2026 which would contribute to the significant weight loss.Review of the facility policy titled Weight, revised April 2024 revealed weight is an indicator and method of monitoring resident nutritional status and resident's weight would be monitored monthly, or more frequently when indicated. The policy stated residents would be re-weighted in reasonable time frame if their weight change meets the following criteria: resident shows a significant weight change of 5% from previous weight. The electronic documentation system should be utilized to assess whether alerts are of significance and worthy of further assessment by the team. The Nutrition at Risk committee would assess residents with significant weight change for possible causes.

Based on medical record review, review of the pharmacy recommendations, and staff interview, the facility failed to ensure pharmacy recommendations were acted upon. This affected one (Resident #01) out of five residents reviewed for pharmacy recommendations. The facility census was 40.Findings Included:Review of the medical record revealed Resident #01 admitted to the facility on [DATE] and discharged on 05/26/26 with the following diagnoses: Hemophilus meningitis and pneumoniaReview of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #01 had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 09. Resident #01 was taking an antipsychotic medications.Review of the care plan dated 04/12/26 revealed Resident #01 had an alteration in neurological status related to Hemophilus meningitis. Risk for high falls related to psychoactive drug use.Review of a pharmacy recommendation dated 03/30/26 revealed an Abnormal Involuntary Movement Scale (AIMS) evaluation (a test to detect and monitor tardive dyskinesia (TD) and other involuntary movements) was recommended due to Resident #01 was receiving the antipsychotic medication quetiapine. Further review of the medical record revealed no AIMS evaluation was completed.Interview on 05/27/26 at 11:38 A.M., the Director of Nursing verified no AIMS evaluations were completed for Resident #01.

Based on record review, staff interview and facility policy, the facility failed to ensure staff followed physician orders for medication administration. This affected one (#21) out of five residents reviewed for medication errors. The facility census was 40.Findings include: Review of the medical record for Resident #21 revealed an admission date on 11/14/23. Diagnosis included displaced simple supracondylar fracture without intercondylar fracture of right humerus, hypertension, subsequent encounter for fracture with routine healing and Parkinson's disease.Review of the physician orders dated 03/19/24 for Resident #21 revealed the resident was ordered to receive metoprolol (beta blocker/blood pressure) succinate extended release (ER) 24 hour, 25 milligrams daily for essential hypertension and hold if the resident's blood pressure was less than 110 millimeters of mercury (mmHg).Review of the Medication Administration Record (MAR) for Resident #21 revealed on 04/11/26, the resident's blood pressure was documented as 108/60 mmHg and metoprolol succinate 25 mg was administered. On 05/14/26, the resident's blood pressure was documented as 88/46 mmHg and metoprolol succinate 25 mg was administered.Review of Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #21 was cognitively impaired related a Brief Interview for Mental Status (BIMS) score of 08. During an interview on 05/27/26 at 11:39 A.M., the Director of Nursing (DON) verified Resident #21 received two doses of metoprolol succinate 25 mg outside the physician ordered parameters.Review of facility policy, dated, Medication Administration-General Guidelines revealed the physician's orders are checked for the correct dosage scheduled.

Based on medical record review, family and staff interview, and policy review, the facility failed to ensure interdisciplinary team (IDT) members attended care conferences as per facility policy. This affected one (Resident #26) out of one resident reviewed for care conferences. The facility census was 40.Findings include:Review of the medical record for Resident #26 revealed an admission date of 11/16/18 with medical diagnoses of Parkinson's disease, dementia, chronic kidney stage III, gastrostomy tube, essential tremor, and moderate Intellectual Disabilities.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had severe cognitive impairment and was dependent upon staff for all activities of daily living.Review of Resident #26's care conference documentation revealed care conferences were held on 10/10/25 and 01/02/26 and the staff attendees included nursing and Social Service designee only. Review of the care conference note on 04/04/26 revealed staff attendees included Resident #26' family and a Social Service designee only.Interview on 05/26/26 at 10:29 A.M. with Resident #26's representative stated she attended one care conference in the past year and only the Social Service designee was in attendance.Interview on 05/28/26 at 7:19 A.M., the Resident Service Coordinator (RSC) #276 verified she was the facility Social Service designee. RSC #276 verified the facility staff members who attended Resident #26's care conferences on 10/10/25 and 01/02/26 included herself and a nursing staff member and on 04/04/26 only herself.Review of the facility policy titled, Care Plan, revised May 2025 revealed The Manor would develop a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan is prepared by an interdisciplinary team (IDT) that includes the attending physician, a registered nurse, an state tested nursing assistant with responsibility for the resident, a member of food and nutrition staff and other appropriate staff and disciplines as determined by the resident's needs and to the extent practicable, the participation of the resident, the resident's family, or resident representative. The care plans are reviewed and revised by a team of qualified personas after each assessment.

Based on observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure staff performed proper hand hygiene when preparing meals. This specifically affected one (Resident #16) and had the potential to affect all residents in the facility except seven residents (#22, #31, #32, #33, #34, #36, and #193) identified to receive no meals from the kitchen. The facility census was 35. Findings include: Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses of anemia and diabetes. Review of the physician order dated 06/21/23 revealed Resident #16 received a Consistent Carbohydrate Diet (CCD) with mechanical soft textures and thin liquids. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #16 had moderate cognitive impaired and required supervision with setup assistance for eating. No swallowing or weight loss concerns were identified. Observations on 07/26/23 beginning at 11:02 A.M. revealed Cook #100 wearing plastic gloves and touching serving utensils for the regular texture chicken and noodles, mechanically altered chicken and noodles, mashed potatoes, green beans, touching plates, and repeatedly opening lids on the steam table. Observation on 07/26/23 at 11:09 A.M. revealed Cook #100, wearing the same gloves, opening a bag of hot dog buns, removing a bun from the bag with her gloved hands, opening the bun, and touching the steam table lid to uncover the mechanically altered bratwurst, using a utensil to scoop the bratwurst into the bun, while holding the bun steady with her gloved hand, scooping mashed potatoes onto the plate and handing the plate to the dietary aide to place on the tray cart. Continued observation revealed dietary staff took the cart from the kitchen and delivered it to the hall. Interview on 07/26/23 at 11:11 A.M. with Cook #100 confirmed she touched the bun for Resident #16 with the same gloves she had worn while touching serving utensils, plates, and steam table lids. Cook #100 further confirmed she should have performed hand hygiene prior to touching Resident #16's ready-to-eat hotdog bun. Further observation revealed Cook #100 did not recall Resident #16's meal tray from the tray cart. Observation on 07/26/23 at 11:27 A.M. revealed Resident #16 in his room with a meal tray on his overbed table. Resident #16's plate was empty and spillage from his ground bratwurst was on his gown. Interview at that time with Resident #16 revealed he ate, and enjoyed, the ground bratwurst served in the hotdog bun. Review of the facility policy, Handwashing, revised March 2017, revealed food handlers must wash their hands after touching anything that may contaminate hands, such as dirty equipment, work surfaces, or towels.

Based on medical record review, staff interview, and policy review, the facility failed to ensure treatments for a pressure ulcer were provided as ordered. This affected one (Resident #8) of one resident reviewed for pressure ulcers. The facility census was 35. Findings include: Review of the medical record for Resident #8 revealed an admitted [DATE], with medical diagnoses of chronic respiratory failure, chronic obstructive pulmonary disease, congestive heart failure, hypertension, and atherosclerotic heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact and required extensive staff assistance with bed mobility, transfers, incontinence cares, and bathing. Resident #8 was frequently incontinent of bowel, and had an indwelling catheter. Further review of the medical record revealed Resident #8 had a Stage IV pressure ulcer to the sacrum. Review of the Resident #8's physician's orders revealed an order dated 03/15/23 to cleanse sacrum, apply solution soaked kerlix, cover with ABD pad and secure with tape every day and every evening shift. Further review revealed the wound care order was changed on 06/28/23. Review of the March 2023 TAR revealed Resident #8 did not receive treatment to the sacrum pressure ulcer as ordered on 03/05/23, 03/09/23, 03/17/23, 03/26/23, and 03/31/23. Review of the April 2023 TAR revealed Resident #8 did not receive treatments to the sacrum pressure ulcer as ordered on 04/10/23, 04/11/23, 04/14/23, and 04/23/23. Review of the May 2023 TAR revealed Resident #8 did not receive treatments to the sacrum pressure ulcer as ordered on 05/16/23 and 05/20/23. Review of the June TAR revealed Resident #8 did not receive treatments to the sacrum pressure ulcer as ordered on 06/03/23 and 06/27/23. Further review of the medical record for Resident #8 revealed the sacrum wound was evaluated weekly by the wound physician, who documented multiple episodes of debridement of the sacral pressure ulcer from February 2023 to July 2023. Review of the wound physician note dated 07/18/23 revealed Resident #8 had a Stage IV pressure ulcer to sacrum which measured 3.5 cm by 2.7 cm x 3.5 cm and the ulcer had improved. Interview on 07/26/23 at 9:09 A.M. with the Director of Nursing (DON) confirmed Resident #8 did not receive the treatment to his sacral pressure as ordered on the dates stated above in March, April, May, and June 2023. Review of the facility policy, Pressure ulcer, revised April 2016, stated all residents with a pressure ulcer would receive interventions and monitoring to promote healing, prevent infection, and prevent new ulcers from developing.

Based on record review and staff interview, the facility failed to ensure enteral nutrition (tube feeding) was provided as ordered by the physician. This affected one (Resident #193) of two residents reviewed for enteral nutrition. The facility census was 35. Findings include: Review of the medical record for Resident #193 revealed an admitted [DATE] with diagnoses of seizures, gastrostomy (an opening in the stomach for a feeding tube) status, and anoxic brain damage. Review of the comprehensive Minimum Data Set assessment dated [DATE] revealed Resident #193 was in a comatose state and was totally dependent on staff for receiving nutrition. Review of the physician order dated 06/27/23 revealed Resident #193 received tube feeding formula Impact Peptide 1.5, 225 milliliters (ml) every four hours via bolus feeding, scheduled at 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. daily. Review of the administration times of the tube feeding formula from 07/12/23 to 07/25/23 revealed thirteen instances when the tube feeding was administered late: 07/12/23 scheduled at 12:00 A.M., given at 1:17 A.M. 07/13/23 scheduled at 8:00 A.M., given at 11:53 A.M. 07/13/23 scheduled at 4:00 P.M., given at 5:19 P.M. 07/13/23 scheduled at 12:00 A.M., given at 1:47 A.M. 07/14/23 scheduled at 4:00 A.M., given at 6:18 A.M. 07/14/23 scheduled at 8:00 A.M., given at 10:03 A.M. 07/14/23 scheduled at 12:00 P.M., given at 1:25 P.M. 07/15/23 scheduled at 12:00 P.M., given at 1:19 P.M. 07/15/23 scheduled at 4:00 P.M., given at 5:35 P.M. 07/16/23 scheduled at 4:00 P.M., given at 5:19 P.M. 07/19/23 scheduled at 4:00 A.M., given at 6:10 A.M. 07/19/23 scheduled at 12:00 P.M., given at 2:09 P.M. 07/20/23 scheduled at 12:00 P.M., given at 1:28 P.M. Review of Resident #193's weight history revealed no concerns regarding weight changes. Interview on 07/27/23 at 12:15 P.M. with the Director of Nursing (DON) confirmed 13 instances when tube feeding for Resident #193 was given late. Further interview confirmed tube feeding administration times would follow the standard of practice of the medication must be administered within one hour before or after the scheduled time. Review of the facility policy, Specific Procedures for All Medications, revised 10/17/07, revealed no guidance regarding administration times for medications.

Based on record review and staff interview, the facility failed to ensure a Gradual Dose Reduction (GDR) was attempted on a psychotropic medication in the past year. This affected one (Resident #2) of five residents reviewed for GDRs. The facility census was 35. Findings include: Review of the medical record for Resident #2 revealed an admitted [DATE] with a diagnosis of depression. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #2 had severely impaired cognition and received an antidepressant. Review of a physician order dated 01/19/21 revealed Resident #2 received Celexa (an anti-depressant) 20 milligrams (mg) by mouth once daily for depression. Review of a Note to Attending Physician/Prescriber form dated 12/30/21 revealed the pharmacist recommended the physician review Resident #2's order for citalopram (generic Celexa) 20 mg. Further review revealed the physician reviewed and signed the form on 01/06/22 and determined Resident #2 was stable on the current dose and was not appropriate for a GDR at that time. Interview on 07/27/23 at 2:29 P.M. with the Director of Nursing confirmed no recommendation for or attempt of a GDR for Resident #2's Celexa was completed since 01/06/22.

Based on record review, staff interview, and review of the facility policy, the facility failed to administer anti-convulsant medications per physician order. This affected one (Resident #193) of ten residents reviewed for medication administration. The facility census was 35. Findings include: Review of the medical record for Resident #193 revealed an admitted [DATE] with diagnoses of seizures, gastrostomy (an opening in the stomach for a feeding tube) status, and anoxic brain damage. Review of the comprehensive Minimum Data Set assessment dated [DATE] revealed Resident #193 was in a comatose state and was totally dependent on staff for all activities of daily life. Review of a physician order dated 06/27/23 revealed Resident #193 received phenytoin (an anti-convulsant medication) 125 milligrams (mg) per 5 milliliters (ml) oral suspension, give 10 ml via percutaneous gastrostomy (PEG) tube three times daily for seizures. The doses were scheduled for morning (4:00 A.M. to 6:00 A.M.), lunch (11:00 A.M. to 1:00 P.M.) and evening (8:00 P.M. to 10:00 P.M.). Special instructions were to hold the tube feeding (TF) one hour before and one hour after the dose of phenytoin. Review of a physician order dated 06/27/23 revealed Resident #193 received TF formula Impact Peptide 1.5, 225 ml every four hours via bolus feeding, scheduled at 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. daily. Further review of the physician orders for Resident #193 revealed an order for Dilantin (phenytoin) laboratory level to be drawn at one month after admission, ordered for 07/28/23. Review of the phenytoin and tube feeding administration times from 07/12/23 through 07/24/23 revealed 21 instances (of 41 opportunities) when phenytoin was given within one hour of the TF: Tube feed given on 07/12/23 at 7:58 P.M. Phenytoin given on 07/12/23 at 8:03 P.M. Tube feed given on 07/13/23 at 11:53 A.M. Phenytoin given on 07/13/23 at 12:03 P.M. Tube feed given on 07/13/23 at 7:50 P.M. Phenytoin given on 07/13/23 at 7:54 P.M. Tube feed given on 07/14/23 at 8:24 P.M. Phenytoin given on 07/14/23 at 8:26 P.M. Tube feed given on 07/15/23 at 1:19 P.M. Phenytoin given on 07/15/23 at 1:21 P.M. Tube feed given on 07/16/23 at 3:52 A.M. Phenytoin given on 07/16/23 at 4:33 A.M. Tube feed given on 07/16/23 at 12:54 P.M. Phenytoin given on 07/16/23 at 12:56 P.M. Tube feed given on 07/16/23 at 7:38 P.M. Phenytoin given on 07/16/23 at 7:41 P.M. Tube feed given on 07/17/23 at 11:28 A.M. Phenytoin given on 07/17/23 at 11:29 A.M. Tube feed given on 07/17/23 at 9:02 P.M. Phenytoin given on 07/17/23 at 9:05 P.M. Tube feed given on 07/18/23 at 3:59 A.M. Phenytoin given on 07/18/23 at 3:59 A.M. Tube feed given on 07/18/23 at 11:48 A.M. Phenytoin given on 07/18/23 at 11:49 A.M. Tube feed given on 07/19/23 at 7:50 P.M. Phenytoin given on 07/19/23 at 7:53 P.M. Tube feed given on 07/20/23 at 1:28 P.M. Phenytoin given on 07/20/23 at 1:30 P.M. Tube feed given on 07/21/23 at 4:16 A.M. Phenytoin given on 07/21/23 at 4:17 A.M. Tube feed given on 07/21/23 at 11:58 A.M. Phenytoin given on 07/21/23 at 11:59 A.M. Tube feed given on 07/22/23 at 12:38 P.M. Phenytoin given on 07/22/23 at 12:38 P.M. Tube feed given on 07/22/23 at 7:23 P.M. Phenytoin given on 07/22/23 at 7:27 P.M. Tube feed given on 07/23/23 at 12:37 P.M. Phenytoin given on 07/23/23 at 12:37 P.M. Tube feed given on 07/23/23 at 8:16 P.M. Phenytoin given on 07/23/23 at 8:20 P.M. Tube feed given on 07/24/23 at 4:02 A.M. Phenytoin given on 07/24/23 at 4:42 A.M. Tube feed given on 07/24/23 at 8:11 P.M. Phenytoin given on 07/24/23 at 8:13 P.M. Review of the progress notes for Resident #193 from admission to current revealed no seizure incidents. Interview on 07/27/23 at 10:34 A.M. with the Director of Nursing confirmed the phenytoin doses and TF administration occurred without holding the TF for one hour before and after phenytoin administration as ordered on 21 occurrences for the above dates and times between 07/12/23 and 07/24/23. Review of the facility policy, Specific Procedures for All Medications, dated 10/17/07, revealed staff should read the medication label instructions three times prior to administration, and follow administration instructions.

Based on resident record review and staff interview, the facility failed to administer insulin as ordered by the physician. This affected three Residents (#1, #2, and #3) of three residents reviewed for blood sugar monitoring. The census was 39. Findings Include: 1. Review of the medical record for Resident #1 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #1 on 11/17/21, 11/18/21, or 11/19/21. Interview on 04/01/22 at 12:30 P.M. with the Director of Quality (DOQ) verified Resident #1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DOQ further verified the medical record contained no evidence of Resident #1 being administered the [MEDICATION(S)] as ordered. 2. Review of the medical record for Resident #2 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if glucose is less than 120. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if glucose is less than 120. Review of the MAR for March 2022 for Resident #2 revealed the resident's glucose level on 03/05/22 at rising was 80, eight units of [MEDICATION(S)] insulin was administered. Further review revealed on 03/25/22 at rising the residents glucose level was 117, eight units of [MEDICATION(S)] insulin was administered. Continued review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 04/01/22 at 12:30 P.M. with the DOQ verified the seven units of [MEDICATION(S)] insulin administered to Resident #2 on 03/02/22 at supper, 03/07/22 at supper, and on 03/10/22 at lunch was administered in error. The DOQ further verified the eight units of [MEDICATION(S)] insulin administered to Resident #2 on 03/05/22 and 03/25/22 at rising was administered in error. 3. Review of the medical record for Resident #3 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for March 2022 revealed on 03/14/22 at bedtime there was no evidence of insulin [MEDICATION(S)] being administered to Resident #3. Interview on 04/01/22 at 12:30 P.M. with the DOQ verified the medical record for Resident #3 contained no evidence of [MEDICATION(S)] insulin being administered to Resident #3 on 03/14/22 at bedtime. This deficiency substantiates Complaint Number OH 361.

Based on record review and interview, the facility failed to have a registered nurse (RN) on duty for eight hours. This had the potential to affect all residents. The facility census was 41. Findings include: Review of the nursing schedules for January 2021 revealed there was no RN scheduled on 01/01/21. Review of the time punch detail revealed no RN worked on 01/01/21. RN #110 worked 12/31/20 from 10:25 P.M. until 01/01/21 at 7:00 A.M. The facility did not have RN coverage again until 01/02/21 at 6.50 A.M. when RN #120 clocked in and worked until 3:30 P.M. During interview on 02/03/21 at 12:09 P.M., the Administrator confirmed there was no RN scheduled to work on 01/01/21. This deficiency substantiates Complaint Number OH 204.

Based on medical record review, observations, review of the National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer staging guide, review of in-service records, interviews with facility staff and the physician, and review of facility policy, the facility failed to prevent the development of an avoidable Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) for a resident using a splint device for contractures. This resulted in Immediate Jeopardy when Resident #2 suffered actual harm, caused by a hand splint which was incorrectly applied by facility staff, and subsequently developed an avoidable Stage IV pressure ulcer to the left thumb, developing pain and infection at the wound site requiring treatment with antibiotics. This affected one (#2) of four sampled residents reviewed for skin integrity. The facility census was 48. On 08/10/16 at 4:31 P.M., the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Regional Director of Operations (RDO) were notified Immediate Jeopardy began on 07/04/16 when Resident #2 was observed by State tested Nurse Aide (STNA) #12 to have drainage coming from the dry disposable wipes in her left hand. STNA #12 reported the drainage to Licensed Practical Nurse (LPN) #106 who assessed the resident to have a Stage IV pressure ulcer of the left palmar-medial interphalangeal joint (left thumb joint) from the inappropriate use of a staff applied splint device to the left hand. LPN #106 described the tissue surrounding the wound as macerated due to excess moisture related to contractures, with the wound bed being dark red in areas with a hard white area exposed. Consequently, Resident #2 developed an infection in the pressure ulcer and had associated pain during treatment evidenced by the resident's grimacing and becoming red-faced. The Immediate Jeopardy was removed on 07/08/16 when the DON provided education to the restorative nursing staff and floor nursing staff regarding splints, the reason for use and care of splints, patient specific management program per therapy, assessing for signs and symptoms of potential skin impairments. In addition, all residents were assessed and no other residents were identified as having contractures, utilizing splints or braces or having potential skin impairments. The deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 08/12/16 when the facility implemented the following corrective actions: · On 07/04/16 at 10:00 P.M., Resident #2's physician was immediately notified of a change in condition involving a 2 centimeter (cm) x 1 cm x 0.2 cm wound to the pad of the resident's left thumb and a treatment was obtained. · On 07/04/16 at 11:30 P.M., a new physician order was obtained for hand hygiene and assessment for skin issues every shift. · On 07/05/16, the Occupational Therapist (OT), DON and Wound Nurse provided hands-on education concerning Resident #2's treatment plan including appropriate assessment, application of the bladder splint, hygienic care and treatment to her hands. The hands-on training was provided to all restorative and floor nursing staff. Started on 07/06/16 completed by 07/08/16, all staff members assigned to care for Resident #2 had received the training specific to the resident's individualized care plan. · On 07/06/16, the certified wound physician evaluated Resident #2 and provided a treatment plan. · On 07/07/16, new physician's orders were obtained to change the left thumb dressing daily. Orders were also obtained to assess skin on both hands daily, provide hand hygiene using two staff members, and apply a rolled wash cloth to both hand. · On 07/07/16, all residents were assessed by the DON and appointed nursing staff, no other residents were identified as having contractures or utilizing splints or braces. · On 07/14/16, the Quality Assurance (QA) Committee met and reviewed all wounds in the facility. · On 07/20/16, the OT completed all staff in-service training to employees regarding care of residents with splints or hand devices, care of contractures, and skin hygiene. All staff either attended the in-service or were given training verbally via telephone. · On 07/20/16, all new residents identified as having contractures or potentially requiring the use of a splinting device or brace will be assessed by the OT. All staff will be trained on resident specific requirements when utilizing splints or braces and assessing for potential skin impairments. · On 07/20/16, the DON formalized weekly QA audits to visualize Resident #2's skin care and at least two other residents at random. The DON will complete skin audits no less than once weekly for four weeks with findings reported to the QA committee for on-going recommendations. The audit dates have included the following: 07/21/16, 07/28/16, 08/05/16 and 08/12/16 with no deficient practices identified. The QA committee will meet no less than once per month until any deficient practice is corrected, and will review quarterly thereafter. · On 08/10/16, medical records were reviewed for three additional residents who were identified currently with pressure ulcers or at risk for the development of pressure ulcers. Resident #23 was identified with possible hand contractures of both hands and at risk for skin impairments. Resident #28 and Resident #46's medical records were reviewed for care and treatment of [REDACTED]. · On 08/10/16, interviews with Restorative Aides #108 and #110, Registered Nurse (RN) #104, and LPN #103 revealed the staff were able to verbalize the training and in-serving received on the correct application of splint devices. Findings include: Review of Resident #2's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively impaired (resident is rarely/never understood). In addition, the resident was assessed to need extensive assistance for all activities of daily living (ADLs). Resident #2 required the physical assistance of two persons for ADLs. The skin assessment identified the resident free of any pressure sores or related skin problems but at risk to develop skin impairments. Review of the OT screening assessment dated [DATE] for bilateral hand contractures revealed the resident's hands were fully closed with ability to passively open minimally with 8/10 pain (pain scale of eight with ten being the highest) and facial grimacing (nonverbal indication of pain). During the evaluation, OT #100 documented the resident was at risk for skin integrity issues due to hand contractures and poor hand hygiene . OT #100 documented Resident #2's hands were odorous and the skin integrity was intact at that time. The assessment documented the bilateral hand contractures had been present for several years without developing skin impairment. Review of the OT treatment service notes from initial evaluation (03/18/16) through discharge from therapy, summary dated 06/16/16, revealed progress had been made during the therapy period. The notes documented the use of a special splinting device called a bladder splint was being utilized by therapy to improve passive range of motion (PROM) for adequate hygiene and reduce pain caused by muscle tightening and joint deformity. Review of the OT sessions revealed gradual improvement in Resident #2's PROM, but also included training of the restorative nursing staff in the proper use of the device and demonstration of effective techniques to provide efficient hand hygiene and monitoring the skin for breakdown. Prognosis (projected outcome) to maintain current level of function per licensed therapy staff was good with consistent staff follow-through. Review of the in-service education record dated 05/17/16 revealed OT #100 provided training for Bladder Splint Management and Wear for Resident #2 . Review of the sign-in sheet revealed all designated restorative nursing aides as well as five other nursing aides were present for the education. Review of the OT discharge documentation dated 06/16/16 revealed PROM to the left hand had improved enough to open the resident's fist slightly to provide care and assess the skin. Decreased [DIAGNOSES REDACTED] of the joints/muscles was also noted. A restorative splint and brace program was established at that time and documentation revealed the restorative nursing staff had been trained. Continued daily use of the bladder splint was integrated as part of the recommended plan of care by OT #100. Review of the restorative nursing care plan revealed the plan was to follow therapy's recommendations to continue with PROM to the upper and lower extremities using splints to decrease risk for skin breakdown and further contractures. Interventions included the use of bladder splints on the upper extremities (hands) after gentle PROM. The splints were to be worn seven to eight hours per day and deflate splints before taking off and at the end of the day. Check skin for any signs and symptoms of skin breakdown while the splints are in use. Clean the splints each week with mouthwash or shave cream and let air dry overnight. Review of the nurse's notes dated 07/04/16 at 10:00 P.M. revealed an open area on the pad of Resident #2's left thumb measuring 2 cm in length x 1.5 cm wide and 0.2 cm deep. The nurse described the tissue surrounding the wound as macerated due to excess moisture related to contractures. Additionally, the wound bed was dark red in areas with a hard white area exposed. The nurse thoroughly cleansed and dried both hands and cut the fingernails. A large non-adhering padded dressing was folded in half and placed on the area and separating other fingers from the palm of the hand. The physician was notified and orders were received. Review of the physician order dated 07/04/16 revealed wound care and application of the non-adherent dressing was to be changed every three days and as needed. The order continued for the floor nurses to provide hand hygiene to Resident #2 and access the hands for any skin issues every shift. Review of in-service education records dated 07/05/16 revealed training for how to apply and remove the bladder splint device was conducted by Restorative Nurse #104. Review of the sign-in sheet revealed all designated restorative nursing aides, as well as five other nursing aides were present for the education. Included in the information provided was the explicit directive to apply the orthotic splint stem side down (towards the little finger) and then pump to inflate. Review of Wound Care Physician #5's consultation dated 07/06/16 revealed documentation indicated the resident presented with a Stage IV pressure wound of the left, first palmar-medial interphalangeal joint finger of at least 14 days duration. Initial wound measurements by the wound physician were 2 cm x 1.5 cm x 0.3 cm. Wound Care Physician #5 identified the etiology of the wound to be pressure. Review of the care plan for the potential of skin breakdown revealed on 07/06/16 the plan was updated to address the development of a pressure ulcer on the left thumb of the contracted hand. Interventions on that date included educate caregivers as to causes of skin breakdown including: positioning requirements, ROM technique and cleansing of the hand, good nutrition and frequent skin checks and if unable to do the cleansing of the hands due to resistance, her stiffening up, state tested nursing assistant (STNA) needs to let nurse know. The restorative nursing care plan was updated on 07/06/16 to exclude use of the bladder splints. The new interventions included the use of gentle static stretches to the contracted hands/wrists/fingers and hold stretches for 30-45 seconds. Review of the in-service sheets dated 07/06/16 revealed all nursing staff were educated by OT #100 to incorporate the recommendations by Wound Care Physician #5. The education included detailed instructions to be provided for hand care for Resident #2 to be completed DAILY; the skin check needs to continue to be done as ordered. The wound physician is suggesting that staff have two people when providing her care. Apply a warm cloth and begin to provide passive stretching. Cleanse both hands with wound cleanser using a toothette. Dry completely and place a washcloth in the right hand and complete the treatment to the left hand as ordered by the wound physician. Closely observe for any signs of new pressure or compromised areas. Review of the nurse's notes dated 07/11/16 revealed while providing treatment on the resident's hand, the nurse observed the left thumb to be warm to touch and an elevated body temperature measuring 99.4 degrees Fahrenheit. The primary physician was notified and an order for [REDACTED]. Review of the care plan for the potential for skin breakdown revealed on 07/11/16, the care plan was updated to include the infection of the thumb wound, noting increased drainage and odor. Review of the physician order dated 07/18/16 revealed the staff was to apply wash cloths or disposable wipes (two folded) in both hands daily in place of the bladder splints. Review of the Interdisciplinary Team Meeting (IDT) notes dated 07/20/16 revealed documentation by the nursing staff to include restorative PROM for contractures. Resident #2 was being seen by the wound doctor for thumb wound and an antibiotic due to infection of the wound on the thumb. Review of in-service education records dated 07/20/16 revealed all nursing staff education by the DON regarding splints, the reason for use of and care of splints, patient specific management program per therapy, assessing for signs and symptoms of skin impairments to report to nursing and OT immediately. Review of Wound Care Physician #5's progress notes dated 07/20/16 revealed the physician documented the resident appears to have associated pain evidenced by: grimacing, red-faced. Measurements of the left thumb revealed the area was slightly larger (2.4 cm x 1.8 cm x 0.3 cm). Wound Care Physician #5's progress notes dated 07/27/16 revealed the wound has some improvement as the exposed bone spicule (a sharp piece) is nearly covered by the granulation tissue. The physician referenced the indications of pain experienced at the wound site as evidenced by Resident #2's grimacing and red-faced. Review of Wound Care Physician #5's progress notes dated 08/02/16 revealed the physician documented improvement in the wound as evidenced by increased granulation and decreased exposed bone. Interview with OT #100 on 08/10/16 at 8:30 A.M., verified Resident #2 was evaluated and treated by OT for the contractures of bilateral hands. OT #100 stated when Resident #2 was first seen she had an obvious odor from her hands not being cleaned thoroughly and pain upon staff trying to open the hands to clean. The resident was fitted for the bladder splints to provide PROM, comfort from contractures and assistance with hygienic care. OT #100 stated upon discharge and referral to the restorative nursing program, Resident #2 had intact skin and showed no signs of odor or areas of skin irritation from the use of the bladder splints. Resident #2 was wearing the bladder splints for periods of up to four hours without discomfort or skin irritations. Observation on 08/10/16 at 8:35 A.M. revealed OT #100 demonstrating the application, removal and use of the bladder splint. She explained the bladder air splint is especially useful for the severely contracted hand. An adjustable and removable air bladder with a soft, antimicrobial cloth covering allows gradual extension of the joints. The adjustable, soft cloth band secured over the top of the hand for customized fit. OT #100 demonstrated on the surveyor's tightly squeezed hand, by gently sliding the un-inflated splint with the bladder inside, under the fingers and through the tight fist, pointing out how it fit into a tightly clenched hand. A bulb shaped hand pump was easily attached to the stem of the orthotic next to the fifth digit and slowly inflated with gentle puffs of air. The orthotic device was slowly inflated for low pressure stretch to the muscles, tendons and joints. The only hard piece on the appliance was noted to be the metal inflation stem that protruded from the fifth digit side of the fist. Properly positioned, the hard stem was not in contact with any portion of the hand/skin. OT #100 also demonstrated by gesture the baseline finger extension on Resident #2 and showed the improved extension following the therapy sessions. When questioned if the splint was placed in the opposite direction, OT #100 stated the inflation stem would cause pressure to the pad of the thumb. Interview on 08/10/16 at 9:30 A.M. with Wound Care Physician #5 revealed the physician determined the etiology of the wound to be from pressure. Wound Care Physician #5 stated the wound could have developed from the thumb joint resting on the valve stem of the bladder splint. The physician stated with proper use of the device, pressure would have been relieved and no wound would have resulted. The wound specialist agreed the splinting device was either not consistently used or was improperly applied. Observation on 08/10/16 at 9:35 A.M. with Wound Care Physician #5 revealed the physician was completing the dressing change for Resident #2. The physician changed the dressing with the assistance of LPN #106 to pull the contracted fingers/thumb from the fist position for visibility. The wound bed was observed covered with pink, granulated tissue (healthy tissue growth). Measurements at the time of the dressing change were 1.2 cm x 1.2 cm with no depth remaining. The resident did not demonstrate facial grimacing or redness with the dressing change that day. The physician stated the area was improving and he was satisfied with the wound progress. Wound Care Physician #5 stated Last week you could still see the bone. Interview with Restorative Aide #110 on 08/10/16 at 10:20 A.M. revealed she was provided education on use of the bladder splint and techniques to provide hand hygiene to Resident #2 prior to Resident #2 being discharged to the restorative nursing program. Restorative Aide #110 stated she had great difficulty getting the resident's left hand open enough to apply the bladder splint device on 07/04/16. Restorative Aide #110 stated she was unable to visualize the skin on Resident #2's hands during care and she just applied the dry disposable wipes instead of the bladder splint. Interview with Restorative Aide #108 on 08/10/16 at 10:25 A.M. revealed she was provided education on use of the bladder splint and techniques to provide hand hygiene to Resident #2 prior to Resident #2 being discharged to the restorative nursing program. Restorative Aide #108 stated she had great difficulty applying the bladder splint device due to the tight fisted contracture of the left hand. Restorative Aide #108 stated with patience, gentle words and a soft touch, the resident would relax slightly and the tension would lessen. However, Restorative Aide #108 admitted there were times she was unable to insert the bladder splint fully, only half-way at times. She described the inflation port on the end of the device to be hard and if the splint was put in the hand the wrong way, pressure by the port could cause skin damage. Interview with the DON and Regional Clinical Director (RCD) #10 on 08/10/16 at 11:00 A.M. revealed at the time the wound was found to the left thumb of Resident #2 it was not reported to the State Agency and investigated as an Injury of Unknown Origin because the cause was not known. RDC#10 stated the pressure wound developed from use of the bladder splint. Interview with LPN #106 on 08/10/16 at 11:10 A.M. revealed she was the nurse who was notified by STNA #12 that Resident #2 had drainage coming from the dry disposable wipes in her hands. LPN #106 verified she assessed the resident and found the documented area on the left thumb on 07/04/16. LPN #106 stated she was the wound nurse for the facility and called the doctor to obtain a treatment to the open area. Interview with Restorative Nurse #104 on 08/10/16 at 2:00 P.M. revealed the restorative aides do not document the removal or the placement of the bladder splint for Resident #2. Review of the NPUAP pressure ulcer staging guide dated 2007 described a Stage IV pressure ulcer as full thickness tissue loss with exposed bone, tendon or muscle. Review of the facility policy titled, Pressure Ulcer-Prevention dated 06/05 revealed the objective of the policy was to prevent and treat pressure ulcers. Included in the procedure key points was the need to maintain skin cleanliness and protect bony prominences with cushions and pads. Reduce pressure from external sources such as clothing, casts, braces or adaptive devices was also a key point outlined in the policy. This was an incidental finding discovered during the investigation of Complaint Number OH 850