Every finding on record at Royal Oak Nursing & Rehab CTR

Based on observation, record review, interview, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented during Resident #22's incontinence and wound care care and Resident #43's wound care. This affected two residents (#22 and #43) of three residents reviewed for EBP. The facility identified 16 residents who required EBP. The facility census was 77.Findings include: 1. A review of Resident #22's clinical record revealed an admission date of 02/11/25 with diagnoses including fracture of the right patella and upper end of humerus, atherosclerotic heart disease, pulmonary hypertension, morbid obesity, anxiety, gastroesophageal reflux disease, high blood pressure, diverticulosis, cardiomegaly, kidney stones with hypertensive kidney failure, benign prostatic hyperplasia, encephalopathy, and obstructive reflex uropathy.A review of Resident #22's physician's orders revealed an order dated 03/11/25 for gloves and gown to be worn when providing dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. Resident #22 had an additional order dated 07/24/25 which stated to cleanse the right buttock with normal saline, apply hydrogel and calcium alginate to the wound and cover the wound with a foam dressing once a day on the night shift.A review of Resident #22's wound assessment dated [DATE] revealed a left buttock wound measured 1 centimeter (cm) long by 2 cm wide by 0.1 cm deep. The wound was draining a moderate amount of serosanguinous fluid with dry red skin surrounding the wound edges. There were no changes in the wound treatment, and the wound was improving.An observation on 08/06/25 at 10:30 A.M. of Licensed Practical Nurse (LPN) #808 perform Resident #22's wound care revealed a failure to implement the enhanced barrier precautions (EBP) to prevent cross contamination of germs during the task. LPN #808 entered Resident #22's room and donned a pair of disposable gloves, but did not don a gown. LPN #808 proceeded to assist with turning Resident #22 to perform his wound care. When Resident #22 was turned on to his side he was incontinent with a large soft bowel movement and LPN #808 performed the incontinence care. LPN #808 then proceeded to apply the physician ordered wound treatment to Resident #22's right buttock cheek. After cleaning Resident #22's perineal area and performing the wound care Resident #22's draw sheet was soiled with blood and feces. Resident #22 was turned side to side and the draw sheet was removed and LPN #808 placed the soiled draw sheet directly on the floor.An interview with LPN #808 on 08/06/25 at 12:31 P.M. verified the above findings and was unsure what the facility's policy was for handling soiled linens to prevent cross contamination of germs. LPN #808 agreed there was no signage on Resident #22's door to indicate EBP should be implemented and there was no personal protective equipment placed outside Resident #22's door. LPN #808 agreed he should have worn a gown during Resident #22's incontinence and wound care.2. A review of Resident #43's clinical record revealed an admission date of 07/14/25 with diagnoses including high blood pressure, heart arrhythmias, heart failure with a cardiac pacemaker, hypothyroidism, osteoarthritis, atherosclerotic heart disease, and high cholesterol.A review of Resident #43's physician orders revealed an order dated 08/02/25 to perform the left shin wound treatment every Tuesday, Thursday and Saturday. Cleanse the left shin with normal saline, apply xeroform and cover with border gauze every night shift every Tuesday, Thursday, and Saturday.An interview with Resident #43 on 08/06/25 at 12:30 P.M. revealed the staff did not wear a gown when assisting her with wound care and other direct care needs, including her bath and personal hygiene tasks.An observation on 08/06/25 at 12:44 P.M. with LPN #808 verified there was no signage outside of Resident #43's room to indicate EBP should be implemented and there was no personal protective equipment located outside of Resident #22's room door.Review of the facility policy and procedure titled Enhanced Barrier Precautions revised on 07/13/22 revealed it was the policy of the facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms. Enhanced barrier precautions referred to the use of gowns and gloves for certain residents during specific high-contact resident care activities that have been found to increase risk for transmission of multidrug-resistant organisms. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. An order for enhanced barrier precautions will be obtained for residents with wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of multidrug-resistant organisms colonization status. High-contact resident care activities included dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of central lines, urinary catheters, feeding tubes, and tracheostomy/ventilators, and wound care for any skin opening requiring a dressing. Review of the facility's policy titled Infection Prevention and Control Program revised 01/01/25 indicated soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom.

Based on observation, interview, record review and facility policy review, the facility failed to ensure Resident #43's wound treatment was performed as ordered by the physician. This affected one resident (#43) out of three residents reviewed for wound care. The facility census was 77.Findings include:A review of Resident #43's clinical record revealed an admission date of 07/14/25 with diagnoses including high blood pressure, heart arrhythmias, heart failure with a cardiac pacemaker, hypothyroidism, osteoarthritis, atherosclerotic heart disease, and high cholesterol.A review of Resident #43's wound assessment dated [DATE] indicated the left shin wound measured 0.80 centimeters (cm) long by 2.40 cm wide by 0.1 cm deep. The wound was draining a slight amount of serosanguinous fluid with attached wound edges and intact surrounding tissue. The wound was classified as a skin tear.A review of Resident #43's physician orders revealed an order dated 08/02/25 to perform the left shin wound treatment every Tuesday, Thursday and Saturday. Cleanse the left shin with normal saline, apply xeroform and cover with border gauze every night shift every Tuesday, Thursday, and Saturday.An observation on 08/06/25 at 12:44 P.M. of Resident #43's wound treatment with Licensed Practical Nurse (LPN) #808 revealed the wound treatment located on Resident #43's shin was dated 08/03/25 with the initials of the nurse who had completed the wound treatment. LPN #808 verified the wound treatment had not been changed as ordered on 08/05/25. Review of the facility's policy and procedure titled Wound Treatment Management dated 12/01/2021 indicated the policy was to promote wound healing of various types of wounds, it was the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments would be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.This deficiency represents non-compliance investigated under Complaint Number 1289786 (OH00166311).

Based on interview, medical record review, and policy review, the facility failed to notify the resident's emergency contact regarding a change in condition. This affected one resident (Resident #100) of three residents reviewed for a change in condition. The facility census was 69. Findings Include: Medical record review revealed Resident #100 was admitted to the facility on [DATE] for skilled therapy after having a hip replacement. Resident #100 was discharged home on 10/16/24. Admitting diagnoses include diabetes, high blood pressure, heart disease, congestive heart failure, and osteoporosis. Review of the physician's orders for Resident #100 revealed the resident was taking Eliquis (an anticoagulant) 5 milligrams (mg) twice a day for blood clot prevention. Review of the admission Minimum Data Set (MDS) 3.0 comprehensive assessment for Resident #100, dated 10/14/24, revealed the resident was cognitively intact, was in need of supervision for toileting, and was receiving speech therapy, occupational therapy, and physical therapy. Review of the progress note dated 10/06/24 timed at 7:37 A.M. for Resident #100 revealed Registered Nurse (RN) #449 heard the resident yelling for help. RN #449 found the resident lying on her stomach on the floor with her walker under her legs. After assessing the resident, RN #449 assisted Resident #100 into the recliner. Resident #100 had a large hematoma on the left side of her forehead. The resident's call light was in place at the time of the fall. Resident #100 said she tripped on her oxygen tubing and fell . The nurse practitioner (NP) was notified and ordered the resident be evaluated in the emergency room (ER) and to have a Computed Tomography (CT) scan of her head. The Assistant Director of Nursing (ADON) was also notified of the fall and the transfer to the ER for an evaluation. There was no documentation regarding Resident #100's daughter being notified of the fall or of the transfer to the ER for evaluation. Review of the progress note dated 10/06/24 timed at 5:10 P.M. revealed Resident #100 returned from the ER. Her CT scan was negative, her blood sugar was high at 498, and the resident had three plus pitting edema to both of her legs. Licensed Practical Nurse (LPN) #414 educated the resident about keeping her legs elevated due to the edema, if she needed to get up to use her call light and ask for assistance, and administered Humalog (a type of insulin) 4 units subcutaneously as well as the sliding scale order for Humalog. LPN #414 placed a call to the resident's daughter at 5:39 P.M. and left a voicemail message regarding Resident #100. Interview with Human Resources Director #427 on 10/21/24 at 11:20 A.M. revealed Resident #100's daughter called the facility on 10/07/24 to report a concern that she was not notified of her mother's fall or transfer to the ER for evaluation. The daughter said the nurse she spoke with on the phone the evening of 10/06/24 was rude. The concern was investigated by the Director of Nursing (DON). Interview with the DON on 10/23/24 at 4:00 P.M. confirmed the facility should have notified Resident #100's emergency contact of the resident's fall and transfer to the ER. Review of the facility's Notification of Change policy, last reviewed on 06/01/24, revealed the responsible party/emergency contact should be notified regarding any accident that results in an injury or has the potential to require physician intervention. This deficiency represents noncompliance investigated under Complaint Number OH00158694.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, manufacturer medication information, and interview the facility failed to ensure Resident #69 was free from significant medication error. Actual harm occurred on 07/29/24 when Resident #69 required evaluation and treatment in the emergency room due to a significant medication error of the resident's Topiramate (anti-epileptic/seizure medication). The resident had been administered, per the nurse practitioner, greater than three times the recommended dose of the medication (ordered 100 mg twice a day and received 625 mg twice a day) from 07/24/24 until 07/29/24 when the error was discovered. This affected one resident (#69) of five residents reviewed for medication administration. Findings include: Review of Resident #69's admission orders provided by the family per the Director of Nursing (DON) revealed a hospital After Visit Summary report dated 09/25/23. The report indicated the resident was ordered Topiramate 25 milligrams (mg)/milliliter (ml) solution, four ml by mouth two times a day for seizures (100 mg of Topiramate twice daily). Review of Resident #69's Admission Notice form dated 07/24/24 at 5:00 P.M. revealed the resident was a respite stay from home and was admitted with spastic cerebral palsy with epilepsy. Review of Resident #69's medical record revealed the resident was admitted on [DATE] and discharged on [DATE] with diagnoses including epilepsy, gastrostomy status and scoliosis. Review of Resident #69's Discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely/never understood. Review of Resident #69's physician orders revealed an order dated 07/24/24 (discontinued 07/29/24) for Topiramate oral solution 25 mg/ml give 25 ml via percutaneous endoscopic gastrostomy (PEG) tube (tube inserted through the abdominal wall and into the stomach for nutrition, fluids and medications to be delivered directly into the stomach) two times a day to prevent seizures (625 mg of Topiramate twice daily). Review of Resident #69's Physician/Nurse Practitioner (NP) Progress Note dated 07/27/24 at 12:04 P.M. authored by NP #889 revealed Resident #69 had severe developmental delay and was not alert and oriented. The resident was nonverbal and could not make his needs known. The resident appeared comfortable. The resident's past medial history (PMH) included seizures, scoliosis, PEG tube, asthma, and unspecified lack of expected normal physiological development in childhood. Review of Resident #69's medication administration records (MARS) and treatment administration records (TARS) revealed the Topiramate 25 ml via the PEG tube twice daily due at rise and bedtime were administered at bedtime on 07/24/24, rise and bedtime on 07/25/24, rise and bedtime on 07/26/24, rise and bedtime on 07/27/24, rise and bedtime on 07/28/24 and rise on 07/29/24 for a total of 10 doses. Review of Resident #69's progress note dated 07/29/24 at 5:01 P.M. authored by the DON revealed the resident was sent to the emergency department (ED) for evaluation due to a mediation error regarding the Topiramate seizure medication. Several attempts were made to contact the resident's mother with the phone going to voicemail. Review of Resident #69's After Visit Summary form dated 07/29/24 revealed the resident's reason for visit was drug overdose and the diagnosis was poisoning by mixed antiepileptics accidental initial encounter. Review of Resident #69's physician orders revealed an order dated 07/29/24 for Topiramate oral solution 25 mg/ml give four ml via PEG tube two times a day to prevent seizures (100 mg twice daily). Review of Resident #69's physician orders revealed a new order dated 07/30/24 to hold the Topiramate for four doses then resume Topiramate 25 mg/ml four ml per PEG tube twice daily. Review of Resident #69's progress noted dated 07/30/24 at 1:50 A.M. authored by Licensed Practical Nurse (LPN) #802 revealed the resident returned from the hospital via an ambulance and on a stretcher. The aunt was notified and the pharmacy stated they would send the new order for the Topiramate seizure mediation in the night's medication tote. Review of Resident #69's progress note dated 07/30/24 at 2:16 P.M. authored by LPN #838 revealed a phone call was received from the NP inquiring on the status of the resident. A new order was received to hold the Topiramate times four doses then resume at 25 mg/ml give 4 ml per PEG tube twice daily. Review of Resident #69's progress note dated 07/30/24 at 10:30 P.M. authored by Registered Nurse (RN) #833 revealed the resident was discharged (home) and a copy of the paperwork was provided to the mother per request. Interview on 09/12/24 at 8:21 A.M. with LPN #821 revealed Resident #69 was an evening admission and she accidentally mixed up the Topiramate order. When questioned, she stated Resident #69's Topiramate seizure medication was put in the electronic health record (EHR) as the wrong dose and another nurse caught the error. Interview on 09/12/24 at 9:28 A.M. with the DON confirmed the significant medication error was identified on 07/29/24. The DON stated Resident #69's physician order for the Topiramate seizure medication was put in wrong during the admission process on 07/24/24 and the error was corrected on 07/29/24. The resident was assessed immediately following discovery of the significant medication error on 07/29/24 with no adverse outcome including increased seizure activity, convulsions and a change in the resident's vital signs. The NP was notified who sent the resident to the hospital following discovery of the significant medication error and the resident's family members were notified of the significant medication error. The DON stated all other residents were then assessed for significant medication errors. LPN #821 was immediately provided education on significant medication errors and putting in orders for new admissions during the admission process. All other nurses were educated on significant medication errors and putting in orders during the admission process. The DON stated audits for new admissions were completed daily five times a week to ensure significant medication errors did not occur again. Telephone interview on 09/12/24 at 12:39 P.M. with NP #889 indicated she was made aware of Resident #69's accidental overdose of Topiramate seizure medication. She confirmed the maximum dosage of the medication was 400 mg per day and the resident received greater than three times the recommended dosage on the dates noted above. NP #889 stated she had assessed Resident #69 in person on 07/27/24 and denied the resident had a change in condition because of the overdose of the seizure medication including changes in the resident's vital signs, changes in mentation and increased seizure activity but the resident was sent to the hospital for monitoring because he had received such a high dose. The NP confirmed she ordered Topiramate 25 mg/ml four ml twice per day and the facility put in 25 mg/4 ml 25 ml twice per day in error. NP #889 stated she believed the resident tolerated the overdose because he had been on the medication for an extended length of time, but the outcome could have been different with a far more severe outcome including death. NP #889 confirmed she did not catch the inaccurate dose of Topiramate in the resident's EHR during her visit on 07/27/24 but immediately addressed the overdose on 07/29/24 when she was called by the facility staff. Review of the manufacturer directions for Topiramate dated 10/2012 revealed the medication was used for epilepsy with the recommended dose of 400 mg/day in two divided doses. Further review revealed overdoses of Topiramate had been reported. Signs and symptoms included convulsions, drowsiness, speech disturbance, blurred vision,, mentation impaired, lethargy, abnormal coordination, stupor, hypotension, abdominal pain, agitation, dizziness and depression. The clinical consequences were not severe in most cases, but deaths had been reported after poly/drug overdoses involving Topiramate. In acute Topiramate overdose, if the ingestion was recent, the stomach should be emptied immediately by lavage or by induction of emesis. Treatment should be appropriately supportive. Hemodialysis was an effective means of removing Topiramate from the body. The deficient practice was corrected on 07/30/24 when the facility implemented the following corrective actions: On 07/29/24 at approximately 3:00 P.M., Resident #69 was immediately assessed following discovery of the significant medication error and subsequent overdose of the Topiramate anti-seizure medication. On 07/29/24 at approximately 3:08 P.M., the DON notified NP #889 of Resident #69's Topiramate significant medication error. On 07/29/24 at 3:45 P.M., NP #889 and LPN #822 sent Resident #69 to the hospital for further evaluation. On 07/29/24 at approximately 5:01 P.M., the DON notified Resident #69's family members of the Topiramate significant medication error. On 07/29/24 at approximately 5:00 P.M., the DON provided education to LPN #821 regarding the Admission Order Procedure policy (revised 11/2016), Admission/Readmission Chart Review Process policy (revised 03/01/22) and Medication Errors inservice. On 07/29/24 at approximately 6:00 P.M., the DON completed a whole house audit on resident medications to determine if any other residents had medication errors. No outcomes were identified. On 07/29/24 at 6:00 P.M., the DON implemented a new 24-Hour Admission/Re-Admit Chart Review form to be completed by all nurses which states once the follow-up had been completed, the audit form would be maintained in a binder for review by the regional nurse. From 07/29/24 at 4:20 P.M. to 07/30/24 at 8:25 A.M., the DON provided inservice education to LPN #822 regarding the 24-Hour Admission/Re-Admit Chart Review form to be completed by all nurses. The DON also provided inservice education to an additional 15 LPNs including LPNs #801, #804, #812, #814, #820, #838, #844, #861, #870, #872, #873, #892, #893, #894, #895 and 3 RN's including RNs #833, #841 and #875 on on the Admission Order policy, Admission/Readmission Chart Review Process policy and Medication Errors Inservice as well as the new 24-Hour Admission/Re-Admit Chart Review form. Beginning 07/30/24, the DON initiated daily audits five times per week (Monday through Friday) of the 24-Hour Admission/Re-Admit Chart Review form to ensure accuracy of medication administration orders. This deficiency represents non-compliance investigated under Complaint Number OH00156422.

Based on interview, medical record review, and facility policy review, the facility failed to document weekly weights in the medical record for Resident #9. This affected one resident (#9) of four residents reviewed for nutrition services. The facility census was 67. Findings include: Review of the medical record for Resident #9 revealed an admitted [DATE] with diagnoses including aphasia, right non-dominant side hemiplegia, hypokalemia, and diabetes mellitus. Review of the physician's orders revealed an order dated 02/28/24 Resident #9 was to have weekly weights on Wednesdays. Review the Weight Summary revealed on 02/28/24 Resident #9 weighed 162.4 pounds and on 03/06/24 Resident #9 weighed 147.3 pounds. There were no additional weights recorded for 03/13/24 and 03/20/24. Review of the Treatment Administration Record (TAR) for March 2024 revealed missing weight documentation for 03/13/24 and 03/20/24. Review of the Medical Nutrition and Hydration assessment dated [DATE] revealed Resident #9 had significant weight loss over one month and six months. The dietitian noted Resident #9 needed a re-weight to confirm weight loss and was on weekly weights for monitoring. Interview on 03/27/24 at 2:43 P.M. with Registered Dietitian (RD) #340 confirmed there were no weekly weights completed for Resident #9 on 03/13/24 and 03/20/24 as ordered. RD #340 indicated he was unsure why the weights were not completed. Interview on 03/28/24 at 1:20 P.M. with Regional Director of Clinical Services #331 revealed the staff reported they had completed the weights but were unable to locate the actual documentation. Interview on 03/28/24 at 2:22 P.M. with Licensed Practical Nurse (LPN) #287 revealed she was the unit manager for Resident #9's unit. LPN #287 indicated on 03/20/24 Resident #9 refused to be weighed; however, indicated the refusal was not documented in the medical record. Follow up interview on 03/28/24 at 2:35 P.M. with LPN #287 revealed she had contacted the nurse's aide who obtained Resident #9's weight on 03/13/24. LPN #9 indicated the aide reported Resident #9 weighed between 148 and 149 pounds. The aide was unable to remember the exact weight. LPN #287 confirmed the weight was documented in the medical record. LPN #287 indicated she was responsible for ensuring weights were completed and documented as ordered. Review of the facility policy Weight Policy, dated 03/01/22, revealed weights would be obtained in a timely and accurate manner, documented and responded to appropriately.

Based on interview, record review, and facility policy review the facility failed to honor Resident #72's preferences for showers. This affected one resident (#72) of two residents reviewed for showers. The facility census was 67. Findings include: Review of the medical record for Resident #72 revealed she was admitted on [DATE] with diagnoses including hypertension (high blood pressure), diabetes mellitus, and muscle weakness. Review of the undated shower schedule revealed Resident #72 received her showers on Wednesdays and Saturdays from 3:00 P.M. to 11:00 P.M. Review of the shower sheet dated 03/09/24 revealed Resident #72 refused her shower on afternoons and wanted her showers in the mornings. Review of the nursing progress note dated 03/12/24 revealed Resident #72 wanted to change her shower times from the evenings to the mornings. Interview on 03/25/24 at 9:44 A.M. with Resident #72 revealed she wanted her showers earlier in the day. She stated she had asked the facility staff, and they told her she had to take them later in the day. Interview on 03/26/24 at 3:30 P.M. with Registered Nurse (RN) #331 verified Resident #72's showers were scheduled on Wednesdays and Saturdays on the evening shift. Review of the shower sheet dated 03/09/24 and nursing progress note dated 03/12/24 with RN #331 verified Resident #72 wanted her showers in the mornings. Review of the facility policy titled, Resident Care, revised June 2018, revealed the facility staff would provide general care as necessary for each resident per their preferences when able and per physician orders. The policy stated residents would be bathed or assisted to shower or bathe routinely and as needed per their preference.

Based on observation, record review, interview, and policy review the facility failed to ensure equipment was maintained and in good working condition to prevent a fall with injury for Resident #13. This affected one resident, Resident #13, of two residents reviewed for falls. The facility census was 78. Actual harm occurred on 01/28/21 when Resident #13 sustained a fall resulting in a neck fracture while being assisted by one State tested Nurse Assistant (STNA) during a shower in a shower bed. Findings include: Review of Resident #13's medical record revealed an admitted [DATE] with diagnoses including dementia without behavioral disturbance, major depressive disorder, hypertension, contracture, cerebral infarction, and [CONDITION(S)] and [CONDITION(S)] following unspecified [CONDITION(S)] disease affecting left non-dominant side. Review of the plan of care dated 10/08/19 revealed Resident #13 required assistance for activities of daily living (ADL) related to cognitive impairment, [CONDITION(S)] immobility and [CONDITION(S)]. Resident #13 was also at risk for impaired communication related to dementia, and at risk for falls and injury related to cognitive function and decreased physician function. Interventions included keep call light within reach while in bed, total dependence for bathing, staff assist as needed with daily hygiene and with showering per facility policy, anticipate resident needs, and assist with transfers as needed. Review of the Fall Risk Evaluation dated 12/24/21, revealed Resident #13 had a fall risk score of nine indicating the resident was a fall risk and interventions should be initiated. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of five indicating severe cognitive impairment. Further review of the MDS assessment revealed Resident #13 was a two-person physical extensive assist for bed mobility, two-person physical total dependence for transfers, one-person physical total dependence for locomotion on and off the unit, dressing, toileting, personal hygiene, and one-person physical total dependence for bathing. Review of the progress note dated 01/28/22 at 9:05 A.M. revealed Licensed Practical Nurse (LPN) #762 was called into the shower room located on the 200 unit by nursing staff. LPN #762 observed blood and Resident #13 on the floor. Resident #13 was assessed and appeared to have a head injury with a laceration on the left side of his head. LPN #762 informed STNA #904 to call 911 (emergency medical services) and to get the other nurse. LPN #762 held pressure to Resident #13's head and applied a bandage to the head while awaiting the ambulance. Resident #13 was covered and dried off while LPN #762 kept him talking. Nurse Practitioner (NP) #915 and Power of Attorney (POA) #920 were notified that Resident #13 was alert and aware of going to the hospital with an immediate intervention of staff education of two State tested Nurse Aides (STNAs) while showering resident in the shower bed. Review of the progress note dated 01/28/22 at 9:07 A.M. revealed Resident #13 was admitted to the local hospital with a subdural hematoma and a fractured neck. Review of the fall investigation for the fall that occurred on 01/28/22 at 6:46 A.M. revealed STNA #904 was assigned to Resident #13 and witnessed the fall. STNA #904 was bathing Resident #13 in the chair/table and turned him on his right side to wash his bottom and back. STNA #904 washed his backside for about 15 minutes, walked around to wash his left side and to rinse with water, and as he was turned, she heard a snap. The right side bar broke or came loose and Resident #13 fell . STNA #904 attempted to reach for Resident #13 but was unable to prevent the fall. Resident #13 fell straight down with his knees and his head hitting the ground with a loud thump. STNA #904 yelled for the nurse. Review of the progress note dated 01/29/22 at 11:00 P.M. revealed Resident #13 returned from the local hospital via ambulance on stretcher with a cervical collar. Review of the hospital discharge instructions dated 01/29/22 revealed Resident #13 had a diagnosis of acute subdural hematoma and closed C3 fracture (fracture of an upper cervical vertebra). Review of the physician orders dated 01/30/22 revealed Resident #13 had an order to have left resting hand splint on after morning ADLs and remove at night for range of motion and hygiene, mat to the floor next to bed while occupied, may be up in tilt-in-space wheelchair with customized seating system when out of bed, and bilateral grab bars to bed for positioning and mobility. Review of the physician orders dated 02/01/22 revealed an order for shower every Tuesday and Friday 11:00 A.M. to 7:00 P.M. and to document any refusals. Review of the physician orders dated 02/02/22 revealed an order to have two STNAs when using shower bed. Review of the physician orders dated 02/03/22 revealed an order for Hoyer (mechanical) lift with two-person assistance to transfer, cleanse scabbed area scalp injury with [MEDICATION(S)] every shift as needed and leave open to air, may remove hard neck brace for small periods of time while eating only with supervision, and staff to assess neck under brace every shift. Review of the physician orders dated 02/05/22 revealed an order for follow-up computerized tomography (CT) scan on 02/21/22. Review of the incident log dated 02/07/21 to 02/07/22, revealed Resident #13 had a history of falls with one fall sustained on 12/24/21. During initial tour of the facility on 02/07/22 from 8:30 A.M. to 10:30 A.M. Resident #13 was observed at 9:29 A.M. lying in bed with his head facing the wall. Resident #13 was observed to have a neck brace around his neck and grimaced in pain when making slight movements. STNA #884 was observed assisting Resident #13 with repositioning. Interview on 02/07/22 at 9:29 A.M. with STNA #884 revealed Resident #13 sustained a fall and broke his neck. STNA #884 revealed Resident #13 was using the shower bed in the shower room when it broke and he fell . Interview on 02/09/22 at 8:46 A.M. with the Director of Nursing (DON) revealed Resident #13 was getting a shower at approximately 6:00 A.M. The STNA had Resident #13 on the shower bed, washing him up, rolled him over to one side, washed his back, when he rolled out of the shower bed. The DON revealed the shower bed snapped near the prongs, leaving the top side moveable. The STNA was giving Resident #13 a shower alone and because she was an agency aide the facility could not provide disciplinary action. Staff were in-serviced on providing showers using the shower bed with two-person assist. The DON was unaware if there was a policy related to maintaining shower and bath equipment. Interview on 02/09/22 at 9:38 A.M. with Maintenance Director (MD) #595 revealed he was made aware of Resident #13's fall related to the broken shower bed. MD #595 revealed the shower bed had four corners that were held together using pins. One of the pins was not properly seated in the hole which resulted in one of the corners coming off and breaking. MD #595 removed the shower bed immediately and a new shower bed was ordered. MD #595 revealed he was a recent hire and was responsible for making sure the facility equipment was in working order. MD #595 used paper forms and lists to keep track of maintenance upkeep in the facility and was trying to become acclimated to the facility and systems. MD #595 revealed he had not provided any maintenance to the shower bed. Review of the facility document titled Facility/Non-Facility Equipment/Appliances Guidelines revised September 2018, revealed the facility was responsible for equipment, appliances, or other items used by residents whether they were provided by the facility, vendors, hospice, or families. Review of the policy revealed staff should be alert for equipment such as wheelchairs, Geri-chairs, walkers, etc. with loose parts, torn or cracked materials, squeaky items, or other issues and if found, should be brought to the attention of the maintenance department or the vendor, resident, representative for repair and/or replacement. Review of the facility document titled Preventative Maintenance Program undated, revealed the purpose of the policy was to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The policy indicated MD #595 was responsible for developing and maintaining a schedule of maintenance services to ensure the buildings, grounds, and equipment was maintained in a safe and operable manner.

Based on review of the meal sheets, staff interview, resident interview, and review of the facility policy, the facility failed to ensure there were alternative menu choices with variety to meet resident preferences. This affected three residents (#16, #49, and #83) of four residents (#16, #49, #71, and #83) reviewed for food and had the potential to affect all residents. The facility census was 78. Findings include: Review of the medical record for Resident #83 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included [CONDITION(S)], hypertension ([CONDITION(S)]), mild protein-calorie malnutrition, and gastro-[CONDITION(S)] reflux disease (GERD). Review of physician orders for June 2021 identified orders for regular diet, regular texture, and regular consistency. Review of the medical record for Resident #16 revealed an admitted [DATE]. Diagnoses included [CONDITION(S)], diabetes mellitus (DM), and GERD. Review of physician orders for February 2022 identified orders for regular, no added salt diet, regular texture, and regular consistency. Review of the medical record for Resident #49 revealed an admitted [DATE]. Diagnoses included recurrent depressive disorder, anxiety disorder, and mild cognitive impairment. Review of physician's orders for February 2022 identified orders for regular diet, regular texture, and regular consistency. Interviews on 02/07/22 at 1:22 P.M. and 2:19 P.M. with Residents #16 and #49 revealed they felt the menu was repetitive and lacked choices or alternatives. Resident #49 stated they had a meal one day and the next day it would be some combination of yesterday's meal. Interview on 02/08/22 at 5:15 P.M. with Dietary Manager (DM) #610 revealed there were three items listed on the always available menu but stated if residents wanted a side salad or soup those were also available. DM #610 stated the dietary staff went around to the residents every morning to obtain their choice for lunch and dinner and they chose between the main meal or the alternative. The dietary staff marked the menu sheet with the resident's choice. Review of the dinner meal sheet dated 02/08/22 revealed the resident name and room number. At the top was the main meal which included barbeque chicken, fries, coleslaw and listed as the alternative was hot dog, fries, coleslaw. DM #610 stated the staff would mark a H which indicated the resident chose the main meal and an A to indicate the alternate. Review of the meal sheets dated 02/01/22 through 02/08/22 revealed the following. * Sloppy joes were offered as the main meal on 02/01/22 and as an alternative on 02/05/22. * Meatballs in some form (meatballs, sweet and sour meatballs, meatball sub, spaghetti and meatballs) were offered on 02/01/22, 02/02/22, 02/03/22 as the alternative for dinner and on 02/06/21 as the alternative for lunch, and on 02/07/22 as the main meal. * Ham was offered on 02/01/22 as the main meal at lunch, on 02/03/22 the main meal for dinner, and on 02/08/22 as the main meal for lunch. * Chicken patty was offered on 02/04/22 as the alternate meal for dinner, on 02/05/22 as the main meal for lunch, and 02/07/22 as the alternate for lunch meal. * Pork patty was offered on 02/04/22 as the alternate on lunch and on 02/06/22 as the main meal for dinner. Interview on 02/09/22 at 9:32 A.M. with DM #610 verified the repetitiveness of the menu options and alternatives. DM #610 stated the cooks decided the alternate meal. The cooks utilized the leftovers and food orders were based on the menu. The always available menu had been that way for a while and she rarely heard complaints regarding the repetitiveness of the menu. Interview on 02/09/22 at 9:43 A.M. with Registered Dietitian (RD) #950 stated he and DM #610 worked together and RD #950's duties included monthly kitchen inspections, relaying resident preferences or dislikes to DM #610, and tray ticket audits. RD #950 stated the menu recently switched to the new food supplier's menu but was not sure how the alternates were created. During review of the menu sheets with RD #950 he verified the receptiveness of the offered options. RD #950 stated he had heard resident complaints regarding the receptiveness of the options. Interview on 02/09/22 at 12:04 P.M. with Resident #70 revealed he was the resident council president. Resident #70 stated he felt the menu was repetitive. Resident #70 said one week they had stuffed peppers multiple times and he thought the facility must have gotten a good deal on them. Review of facility policy titled Resident Selective Menus, dated 02/09/22, revealed a planned four week menu plan was used along with always available menu items for selecting and providing alternates. the policy indicated the facility could choose the always available options or could use the following standards. For breakfast - hard-boiled egg, scrambled egg, cold cereal variety, yogurt, and peanut butter. For lunch and dinner- chef salad, cottage cheese and fruit plate, hamburger, cheeseburger, hot dog, grilled cheese, deli sandwich with or without cheese, soup of the day, alternative hot vegetable, canned or fresh fruit (seasonal), peanut butter and jelly sandwich, and yogurt. This deficiency substantiates Complaint numbers OH 9862 and OH 655.

Based on observation and interview, the facility failed to maintain a clean and uncluttered area surrounding the outside dumpster. This had the potential to affect all residents. The facility census was 78. Findings include: Observation on 02/07/22 at 8:56 A.M. with Dietary Aide (DA) #796 of the outside dumpsters revealed garbage bags piled high and a moderate amount of debris and empty cardboard boxes in the snow surrounding the dumpsters. Interview at the time of the observation with DA #796 verified the observations. DA #796 stated the dumpsters always looked like this and the nursing aides threw trash around the dumpsters instead of putting trash inside of them. DA #796 stated the maintenance department was responsible for keeping the dumpster area clean.

Based on observation, interview, and record review, the facility failed to ensure staff wore hair nets while in the kitchen and the 100 hall nursing unit refrigerator was maintained in a clean and sanitary manner. This had the potential to affect all residents. The facility census was 78. Findings include: 1. Observation on 02/07/22 at 8:51 A.M. revealed Dietary Aide (DA) #796 scooping cooked ground beef out of a pot and into a steam table pan. DA #796 was not wearing a hairnet. Interview at the time of the observation with DA #796 verified DA #796 was not wearing a hair net. Observation on 02/08/22 at 2:02 P.M. revealed DA #904 washing her hands then retrieving serving utensils to puree food for the dinner meal. DA #904 was not wearing a hairnet. Interview at the time of the observation with DA #904 verified DA #904 was not wearing a hair net. Review of the undated facility policy titled Hair Restraints revealed hair restraints shall be worn by all employees while in the kitchen to cover all hair. 2. Observation on 02/08/22 at 2:27 P.M. with Dietary Manager #610 of the 100 hall nursing unit refrigerator revealed the freezer portion had various food stains and on the top shelf and inside of the door there was a strand of hair. The refrigerator portion had various food stains, the seal at the bottom of the inside of the refrigerator door was in disrepair, and stained with a yellowish dark brownish [NAME] as well as on the floor underneath the door of the refrigerator. Interview at the time of the observation with DM #610 verified the observations. DM #610 said the nurses on the unit were responsible for maintaining the cleanliness of the refrigerator. This deficiency substantiates Complaint number OH 336.

Based on record review and interview, the facility failed to ensure the dietary manager completed qualifications in a timely manner. This had the potential to affect all residents. The facility census was 78. Findings include: Review of the key personnel revealed Dietary Manager (DM) #610 as the kitchen director. Interview on 02/08/22 at 11:14 A.M. with DM #610 revealed she had worked for the facility for [AGE] years, seven as the dietary manager. DM #610 stated she was in the process of obtaining her certification as a dietary manager but had not started the classes. Interview on 02/08/22 at 12:24 P.M. with the Administrator verified DM #610 did not have the required qualifications and the Administrator was going to enroll DM #610 into classes to become a certified dietary manager. Review of the Dietary Director Job description under education included must possess a minimum of a high school diploma, be a graduate of an accredited course of dietetic training approved by the American Dietetic Association or have certifications as a certified dietary manager from an approved organization.

Based on observation, staff interview, and policy review the facility failed to ensure Resident #67's and #75's walls were maintained in good repair. This affected two of three residents (#67, #75 and #82) reviewed for environment. The facility census was 78. Findings include: 1. Observation on 02/07/22 at 9:06 A.M. revealed a large significant hole with scrapes, chipped paint, furniture markings, and scratches located on the wall directly behind the headboard of Resident #67's bed. Interview on 02/07/22 at 9:07 A.M. with Licensed Practical Nurse (LPN) #762 revealed the hole had been in the wall for a while and was related to the furniture being moved around in the room. Interview on 02/08/22 at 8:35 A.M. with Maintenance Director (MD) #595 confirmed the hole, scrapes, and chipped paint in Resident #67's room. MD #595 said he was aware of the hole in the wall but had just started his role a few months ago and was trying to catch up on the needs of the facility. 2. Observation on 02/07/22 at 12:13 P.M. revealed a large hole in the wall behind Resident #75's bed. Interview on 02/08/22 at 11:52 A.M. with Resident #75 revealed he wasn't sure how long the hole was there and wasn't sure if it was there when he arrived in the room. Resident #75 stated no one had been in his room to look at the hole. Observation on 02/08/22 at 11:57 A.M. with Maintenance Assistant (MA) #573 confirmed the hole behind Resident #75's bed. Interview on 02/08/22 at 12:09 P.M. with Maintenance Supervisor (MS) #595 revealed he was aware of some of the residents' rooms where the walls behind the beds needed to be repaired. MS #595 stated he had not started an audit yet to see which rooms were affected. Review of the facility document titled Preventative Maintenance Program undated, revealed the policy was to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Further review of the policy revealed MD #595 was responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment was maintained in a safe and operable manner. This deficiency substantiates Complaint Number OH 862 and is a recite to the complaint survey completed 01/19/22.

Based on record review and staff interview, the facility failed to ensure the resident record contained current and accurate information for Residents #67 and #82. This affected two residents (#67 and #82) of two reviewed for accurate medical records. The facility census was 78. Findings include: 1. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 was alert with cognitive impairment and required assistance of at least two persons for activities of daily living. Observation on 02/07/22 at 9:06 A.M. revealed no operational call light designated for Resident #67. Review of the progress note dated 02/07/22 at 12:25 A.M. revealed Resident #67's call light was within reach. Review of the progress note dated 02/07/22 at 11:41 A.M. revealed Resident #67's call light was within reach and safety maintained. Review of the progress note dated 02/08/22 at 2:23 A.M. revealed Resident #67's call light was within reach and all safety measures maintained. Interview on 02/08/22 at 8:30 A.M. with Licensed Practical Nurse (LPN) #762 revealed Resident #67 did not use a call light and would not use it, if she had one in place. Resident #67 would yell out if she needed anything. LPN #762 revealed the call light designated for Resident #67 was attached to her roommate's (Resident #57) bed. Observation and interview on 02/08/22 at 8:35 A.M. with the Director of Nursing (DON) and Maintenance Director (MD) #595 confirmed there was no call light in place for Resident #67. Interview on 02/08/22 at 2:30 P.M. with the DON revealed she was unsure why Resident #67's progress notes indicated she had a call light in place. 2. Review of the medical record for Resident #82 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurses' note dated 12/23/21 at 11:15 P.M. revealed Resident #82 arrived at facility via emergency medical services (EMS) on a stretcher. Vital signs were obtained, head to toe assessment completed, orders verified with certified nurse practitioner (CNP). Resident noted with area to right thumb, treated with [MEDICATION(S)]. Further review of the medical record revealed no further nurses' notes documenting Resident #82's fungal infection to the right thumb. Review of the skin observation sheets dated 01/01/22, 01/11/22, 01/18/22, 01/25/22, and 02/01/22 revealed no documentation of the resident's fungal infection on her right thumb. Review of the CNP's progress note dated 01/24/22 revealed, under plan and assessment, Resident #82 had thickened, yellow, flaky nails with no drainage or discharge. The progress note further indicated to ensure Resident #82 was on the podiatry list to have nail care. There was no documentation regarding the fungal infection to Resident #82's right thumb. Review of the podiatrist note dated 01/28/22 revealed the podiatrist provided care to Resident #82's toenails. There was no documentation regarding the fungal infection to Resident #82's right thumb. Review of Resident #82's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Remove with alcohol every seven days with a start date of 12/24/21. Observation on 02/07/22 at 11:44 A.M. of Resident #82 reveal a large growth on her right thumb. Interview at this time with Resident #82 revealed the growth was somewhat painful and that she was supposed to have it removed on 01/14/22 but the appointment was canceled due to insurance. Interview on 02/09/22 at 4:23 P.M. with Wound Nurse (WN) #721 revealed Resident #82 had a fungal infection that was being treated with a topical antifungal solution. WN #721 stated Resident #82 was admitted with the fungal infection and because it wasn't a wound it was not documented on the skin assessments. WN #721 stated Resident #82 was on the list for the podiatrist to look at the right thumb. Interview on 02/10/22 at 9:43 A.M. with the Director of Nursing (DON) revealed Resident #82 was seen by the CNP who wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated because the thumb nail was still intact, and the growth had not fallen off staff would only document if there were changes. The DON stated the podiatrist had seen the resident on 01/28/22 but only for her toenail. Review of the plan of care initiated on 12/24/21 for potential for alteration in skin integrity revealed a revision dated 02/10/22 which included chronic fungal area to right thumb. Interview on 02/10/22 at 9:48 A.M. with Regional MDS Nurse #657 verified the care plan was revised on 02/10/22 because the fungal infection to the right thumb was missed. Review of the facility document titled Charting and Documentation revised July 2017, revealed that all services provided to the resident, progress toward the care plan goals, or any changes in the resident medical, physical, functional, or psychosocial condition, shall be documented in the resident medical record. Further review revealed the documentation in the medical record would be objective, complete, and accurate.

Based on observation and staff interview the facility failed to ensure it had a functional and accessible call light in place. This affected two (Resident #42 and #67) of two residents reviewed for call light function. The facility census was 78. Findings Include: 1. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus with [CONDITION(S)], chronic obstructive pulmonary disease, and dysphagia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 was alert with cognitive impairment and required assistance of at least two persons for activities of daily living. Observation on 02/07/22 at 9:06 A.M. revealed no operational call light designated for Resident #67. Interview on 02/07/22 at 9:06 A.M. with Resident #67 revealed she had no call light. Interview on 02/07/22 at 9:07 A.M. with Licensed Practical Nurse (LPN) #762 confirmed Resident #67 did not have a call light. LPN #762 revealed she would inform the Director of Nursing (DON). Observation on 02/08/22 at 8:30 A.M. revealed no operational call light designated for Resident #67. Interview on 02/08/22 at 8:30 A.M. with LPN #762 revealed Resident #67 did not use a call light and would not use it, if she had one in place. LPN #762 revealed Resident #67 would yell out if she needed anything. LPN #762 revealed the call light designated for Resident #67 was attached to her roommate's (Resident #57) bed. Observation and interview on 02/08/22 at 8:35 A.M. with the DON and Maintenance Director (MD) #595 confirmed Resident #67 did not have a call light. 2. Review of the medical record for Resident #82 revealed an admitted [DATE]. Diagnoses included weakness, hypertension, and dementia without behavioral disturbances. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 had intact cognition, required extensive assistance of one staff for bed mobility, transfers, and toilet use. Interview on 02/07/22 at 11:36 A.M. with Resident #82 revealed she did not have a call light and that her roommate used her call light for her. Observation at the time of the interview revealed Resident #82's call light was on the floor behind her bed and not in reach. Interview on 02/07/22 at 12:30 P.M. with Hydration Aide (HA) #836 verified Resident #82's call light was on the floor behind her bed. HA #836 said the call light fell behind her bed because of the placement of Resident #82's phone Review of the facility document titled Call Lights revised October 2018, revealed the facility would provide an operational call light system for residents. This deficiency substantiates Complaint number OH 862.

Based on observations and interview the facility failed to maintain a safe environment ensuring all baseboard heaters were covered. This affected four (Resident #7, #9, #10 and Resident #11) of 75 residents reviewed for safety. The census was 75. Findings Include: Observations and interviews on 01/18/22 from 11:40 A.M. to 11:53 A.M., revealed baseboard heaters located in Resident #7, #9, #10, and #11's rooms had no covers exposing the heating coils/elements. Resident #7's bed was located next to the wall, with blankets hovering over the heater. Resident #7 stated that he had to keep moving his bed over, so the blankets didn't touch the heater. Residents #9, #10, and #11 stated the heater covers were off for a long period of time. Observations and interview on 01/18/22 at 2:46 P.M. with the Maintenance Director verified heater covers were not attached to the heaters, therefore exposing the heating coil in the rooms of Residents #7, #9, #10, and #11. Follow up interview on 01/19/22 at 10:08 A.M. with the Maintenance Director revealed new heater covers had been ordered for the rooms of Residents #7 #9, #10 and #11. This deficiency substantiates Complaint Number OH 860.

Based on observation, interview and record review, the facility failed to ensure [MEDICATION NAME] testing was completed upon hire for new employees. This affected five (State tested Nursing Assistants (STNA's) #410, #440 and #450, Front Desk Clerk #605 and Licensed Practical Nurse (LPN) #325)of sixteen employees reviewed. This had the potential to affect all 67 resident's residing in the facility. Findings include: Review of the facility [MEDICAL CONDITION] Risk assessment dated [DATE] revealed the facility was to perform baseline two-step [MEDICATION NAME] testing upon hire of new employees. Review of the files of STNA's #410 (hired 01/16/20), #440 (hired 12/17/19), #450 (hired 01/09/20), Front Desk Clerk #605 (hired 11/01/19) and LPN #325 (hired 12/30/19) all revealed they had not had skin testing, either one or two-step, done upon hire and did not have records of prior [MEDICATION NAME] skin testing in their record. An interview of the Director of Nursing on 01/28/20 at 1:30 P.M. confirmed the testing should be initiated, and the first-step results of the [MEDICATION NAME] testing obtained prior to the employee having resident contact. An interview with Human Resources Director (HR) #700 on 01/28/20 at 3:30 P.M. confirmed all employees should have either evidence of a two-step [MEDICATION NAME] test in the past year with a one-step test upon hire or a two-step test with the results of the [MEDICATION NAME] skin testing obtained prior to the employee having resident contact on their first day of work. This deficiency substantiates Complaint Number OH 533.

Based on review of interview, review of personal needs accounts and surety bond, the facility failed to ensure the surety bond was enough to cover the amount of money in the resident accounts. This affected all 48 residents with personal needs accounts (#3, #4, #6, #7, #8, #10, #11, #12, #14, #15, #16, #17, #19, #20, #21 (x2), #22, #23, #24, #26, #27, #28, #31, #32, #34, #35 (x2), #36, #38, #40, #41, #45, #46, #47, #48, #50, #54, #55, #56, #57 (x2), #61, #63, #64, #65, #67, #71 and #371) with a total of $30,705.20 as of 07/08/19. Findings include: Review of the trial balance report with Resident's #3, #4, #6, #7, #8, #10, #11, #12, #14, #15, #16, #17, #19, #20, #21 (x2), #22, #23, #24, #26, #27, #28, #31, #32, #34, #35 (x2), #36, #38, #40, #41, #45, #46, #47, #48, #50, #54, #55, #56, #57 (x2), #61, #63, #64, #65, #67, #71 and #371 current balances revealed the balance of the accounts was $30,705.20. Review of the surety bond dated 10/01/18 and good through 10/01/19 indicated the account was covered for $30,000.00. Interview with the Administrative Assistant, Accounts Payable and Business Office Manager #21 on 07/08/19 at at 3:29 P.M. indicated it was her first time being in this type of role. She said the surety bond was just mailed to her from corporate, and she had never seen it before. She verified the amount of the bond was less that the amount in the personal needs account. Interview with the Administrator on 07/08/19 at 3:39 P.M. also verified the surety bond was not enough to cover the amount in the personal needs account.

Based on interview and review of personal needs accounts, the facility failed to ensure the resident/responsible party was notified within $200.00 of the Medicaid resource limit in order to spend down funds in order to maintain Medicaid status. This affected three Residents (#8, #16 and #67) of 48 Residents with accounts (#3, #4, #6, #7, #10, #11, #12, #14, #15, #17, #19, #20, #21 (x2), #22, #23, #24, #26, #27, #28, #31, #32, #34, #35 (x2), #36, #38, #40, #41, #45, #46, #47, #48, #50, #54, #55, #56, #57 (x2), #61, #63, #64, #65, #71 and #371). The facility census was 66. Findings include: Review of Resident #16's personal needs account revealed she had a current balance of $6053.52 as of 07/08/19. The resident was using Medicaid funds to pay for her stay. Review of the last quarterly statement for the first quarter of 2019 revealed she was above the resource limit since 03/15/19 when she had $4026.00 in her account. Interview with the Administrative Assistant, Accounts Payable and Business Office Manager #21 on 07/08/19 at at 3:29 P.M. indicated it was her first time being in this type of role. She said the computer automatically sends a letter twice a month to residents/responsible parties when the account was $200.00 less than the resource limit. She said she had no documented evidence the letters were sent to the families. She said Resident #16 had dementia and no family involved. She informed corporate who was getting on the Licensed Social Worker (LSW) #22 to find someone or get the court involved. She also confirmed Resident's #8 and #67 should have been send spend down letters and have family to assist in spending their monies. Interview with the Administrator on 07/08/19 at 3:39 P.M. said the LSW #22 had been working to get Resident #16 a legal guardian and confirmed no attempts had been made to spend down the money on the resident to retain her Medicaid status. Interview with LSW #22 on 07/08/19 at 3:41 P.M. confirmed she worked on getting the Resident #16 a legal guardian for a while. She confirmed she made no attempts at assisting the resident in spending down her monies to retain her Medicaid status.

Based on interview and record review, the facility failed to accurately record the medical status of three residents (Resident #70, Resident #72 and Resident #32). This affected three of 28 records reviewed for accurate assessments. The facility census was 66. Findings include: 1. Review of the medical record for Resident #72 revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment with an Assessment Reference Date (ARD) of 06/25/19, section M, indicated conflicting information. The assessment indicated Resident #72 did not have a surgical wound but was receiving surgical wound care. Registered Nurse (RN) #24 was interviewed on 07/10/19 at 2:26 P.M. and was asked if Resident #72 had a surgical wound. RN #24 verified on 07/10/19 at 3:52 P.M. that Resident #72 did have a surgical wound from a biopsy site, and that the MDS data on the admission assessment was incorrect. 2. Review of the medical record for Resident #70 revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the admission MDS 3.0 assessment with an ARD of 07/02/19, section M, indicated Resident #70 had a pressure ulcer. RN #23 was interviewed on 07/09/19 at 2:43 P.M. and stated Resident #70 did not have a pressure ulcer. RN #24 was interviewed on 07/10/19 at 2:26 P.M. and was asked if Resident #70 had a pressure ulcer. RN #24 verified on 07/10/19 at 3:52 P.M. that Resident #70 did not have a pressure ulcer, and the MDS data on the admission assessment was incorrect. 3. Review of the medical record for Resident #32 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the assessments titled Skin Grid Pressure revealed the first assessment was dated 05/24/19 and documented a stage II left buttock pressure area (partial-thickness skin loss with exposed dermis) measuring 1.4 centimeters by 1.3 centimeters by 0.2 centimeters with serosanguineous drainage. Review of the Skin Pressure Grid dated 06/13/19 revealed the resident continued to have an open pressure area on the buttock. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed question M0100A had been answered no indicating the resident did hot have a pressure ulcer, injury, scar or non-removable dressing. Interview on 07/10/19 at 3:54 P.M. with MDS Nurse #24 revealed the MDS had been incorrectly coded under M0100A and should have indicated the resident had a pressure area. She modified the 06/18/19 quarterly MDS to correct the response to M0100A. Review of the MDS 3.0 Resident Assessment Instrument (RAI) manual indicated the items in Section M document the risk, presence and appearance of pressure ulcers.

Based upon interview and record review the facility failed to initiate and complete a significant change assessment as required. This affected one (Resident #32) of two resident reviewed with significant changes. Findings include: Review of the medical record for Resident #32 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the assessments titled Skin Grid Pressure revealed the first assessment was dated 05/24/19 and documented a stage II left buttock pressure area (partial-thickness skin loss with exposed dermis) measuring 1.4 centimeters by 1.3 centimeters by 0.2 centimeters with serosanguineous drainage. Review of the Skin Pressure Grid dated 06/13/19 revealed the resident continued to have an open pressure area on the buttock. Review of the weights revealed on 11/23/18 the resident weighed 157.4 pounds, and on 11/30/18 the resident weighed 154 pounds. On 05/24/19 the resident weighed 140 pounds, creating an alert in the electronic record noting the resident had a significant weight loss over the previous three months and over the previous six months. The resident continued to lose weight and created weight alerts again on 05/31/19, 06/13/19, 06/21/19 and 07/02/19. Review of the Minimum Data Set (MDS) 3.0 assessments revealed quarterly assessments were completed on 04/10/19 and 06/18/19. Review of the MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment, felt tired or had little energy two to six days during the prior two weeks, required extensive assistance for bed mobility or transfers, weighed 148 pounds, had no significant weight loss, and had no open areas. Review of the MDS 3.0 assessment dated [DATE] revealed the resident had a BIMS score of 5, indicating severe cognitive impairment, felt tired or had little energy on 12 to 14 days during the prior two weeks, was totally dependent for bed mobility and transfers, weighed 138 pounds and had significant weight loss. The MDS documented conflicting responses to questions indicating whether or not the resident had a pressure ulcer but indicated she had a stage two pressure ulcer which had not been present on the previous assessment. Interview on 07/10/19 at 3:54 P.M. with MDS Nurse #24 revealed the MDS had been incorrectly coded under M0100A and should have indicated the resident had a pressure area, she modified the 06/18/19 quarterly MDS to correct the response to M0100A. A subsequent interview on 07/11/19 at 10:46 A.M. with MDS Nurse #24 revealed she was uncertain of the the indications for completing a significant change assessment except for the addition of hospice services or a decline in activities of daily living and when asked if a significant weight loss and a new stage II pressure area were indications, she stated she did not know. Further interview with MDS Nurse #24 revealed the family of Resident #32 had been approached about considering hospice services. Interview on 07/11/19 at 1:30 P.M. with the Director of Nursing revealed the facility did not have any evidence that the facility had recognized the significant change for Resident #32, and the Interdisciplinary Team discussed the declines in cognition, mood, bed mobility, transfers, weight and the development of a pressure ulcer with relation to a significant change in the resident. Review of the MDS 3.0 Resident Assessment Instrument manual revealed a significant change occurred when declines in two or more areas of the following occurred: the emergence of unplanned weight loss of five percent in 30 days or ten percent in 180 days, decline in physical function where total dependence is coded, an increase in frequency in mood symptoms, the presence of a stage II pressure ulcer, or an overall decline in condition.

Based on record review, staff interview, and medication administration policy review, the facility failed to ensure that an ordered pain medication was delivered and administered in a timely manner to one resident to prevent and control significant pain. This resulted in Actual Harm to Resident #46 who rated her pain as a 10 of 10 on a pain scale, described her pain as not tolerable, and had to wait almost 27 hours after admission to receive pain medication. This affected one of four residents whose medications were reviewed. The facility census was 74 residents. Findings include: Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was an admitting physician order [REDACTED].M. and [MEDICATION NAME] 32 mg by mouth daily at 9:00 P.M. An admitting nursing assessment dated [DATE] at 6:31 P.M. documented the resident stated she had pain at a level of 10 of 10 on the pain scale and the pain was not at a tolerable level. There was no further description of the pain until an assessment done 11/18/15 that indicated the resident still experienced pain. There was a care plan dated 11/17/15 that addressed the resident's pain, with the goal to experience less pain. Interventions for this included to administer Exalgo ([MEDICATION NAME]) 16 mg in the morning and 32 mg in the evening, monitor pain on each shift and assess pain tolerance. Review of the Medication Administration Record [REDACTED].M. Between admission on 11/16/15 at 6:31 P.M. and 11/17/15 at 9:00 P.M. no other pain medications were administered to Resident #46. The facility medication administration policy stated that unless a medication is ordered as an emergency medication or specified as a stat medication by the physician, all orders are presumed to be administered on the first scheduled medication time following their arrival in the facility through the regularly scheduled pharmacy delivery process. In a meeting on 12/10/15 at 2:24 P.M. the facility director of nursing (DON) verified the above information and stated that in the event of a late admission, such as Resident #46 ' s, the pharmacy would normally deliver the medications in the evening medication delivery between 9:00 P.M. and 1:00 A.M. The pharmacy would also make a drop shipment (a delivery in addition to the regularly scheduled deliveries), if needed. On 12/10/15 at 3:39 P.M. the surveyor met with Registered Nurse (RN) #1 and the DON. RN #1 was the nurse who admitted Resident #46 on 11/16/15. RN #1 stated that she assisted with the admission of Resident #46 and verified the medication orders with the resident's physician. Orders for narcotic medications must be approved by the physician. The DON stated that the physician sent hard copies of this to the facility on [DATE] at 1:59 P.M. Per the pharmacy, the orders were sent to them with a time stamp of 11/17/15 at 2:27 P.M. The medications were in the pharmacy tote for delivery to the facility on [DATE] at 7:24 P.M. The DON and RN #1 verified that there was no follow-up done on 11/17/15 in regard to the ordered medications not being delivered. The DON stated that the facility medical director could have been called to obtain pain medications for the resident. Both the DON and RN #1 stated that follow-up should have been done to ensure Resident #46 received pain medication earlier than 9:00 P.M. on 11/17/15. This deficiency substantiates Complaint Number OH 723.

Based on observation, record review and interview the facility failed to implement interventions to prevent the development of unstageable pressure ulcers for residents at risk for skin breakdown. This resulted in actual harm for four residents (Resident #63, #62, #61 and #60) who developed unstageable pressure ulcers while residing in the facility. Resident #63 developed unstageable pressure ulcers to the left leg and sacrum. Resident #62 developed an unstageable pressure ulcer to the right heel. Resident #61 developed three unstageable pressure ulcers to the left heel, right buttock and sacrum. Resident #60 developed an unstageable pressure ulcer to the left ankle. This affected four residents (Residents #63, #62, #61 and #60) of six residents reviewed for pressure ulcers. The facility census was 60 residents. Findings include: 1. Review of the medical record revealed Resident #63 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of a care plan dated 01/07/14 indicated an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) was discovered on the left posterior upper leg. There was no other documentation that addressed the pressure ulcer. Review of the pressure ulcer risk assessment dated [DATE] indicated Resident #63 was low risk for the development of a pressure ulcer. Review of the medical nutrition therapy re-assessment dated [DATE] revealed Resident #63's weight was stable and had no skin integrity issues. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #63 was severely cognitively impaired. The assessment also revealed the resident required extensive assistance to total dependence for activities of daily living except for eating. The assessment indicated the resident only required supervision when eating. Review of the condition change form dated 04/28/14 revealed Resident #63 was sitting in the wheelchair and complained of discomfort to the sacral area. The resident was given Tylenol. There was no documentation to indicate the sacral area was assessed in an effort to determine the cause of the discomfort. Review of Resident #63's skin condition reports dated 05/04/14 revealed pressure ulcers were discovered on the right and left buttocks. The reports actually indicated the pressure ulcer was one sacral ulcer, not one on each buttock. The skin condition reports referred to the weekly pressure ulcer progress report dated 05/12/14. Review of the care plans dated 05/04/14 indicated Resident #63 had an abrasion to the left buttock and right buttock. There was no care plan to address the sacral wound. Review of a condition change form dated 05/09/14 indicated Resident #63 complained of increased back pain. A new order was received for [MEDICATION NAME] for pain. Review of the weekly pressure ulcer progress report revealed an unstageable pressure ulcer was discovered on 05/12/14. The report also revealed Resident #63 was to be turned every two hours and to receive a high protein supplement. Review of the condition change form dated 05/13/14 revealed Resident #63's oral intake had decreased, the resident had become lethargic and the wound on the sacral area was worsening. Review of the medical nutrition therapy re-assessment dated [DATE] revealed Resident #63 had a significant weight loss in 30 days. The resident's weight on 04/14/14 was 155 pounds and on 05/13/14 the weight was 145 pounds. The documentation indicated the weight loss was unintended and protein supplements would be added to the resident's diet. The note indicated the resident had decreased skin integrity that included the right lateral breast, the left outer forearm, the right upper arm and a sacral wound. An interview with the director of nursing (DON) on 08/08/14 from 10:30 A.M. to 11:30 A.M. verified the nurses notes dated 04/26/14 for Resident #63 revealed the resident complained of discomfort in the sacral area. There was no documentation that indicated the area was assessed. The sacral wound on Resident #63 was not discovered until it was unstageable on 05/04/14. The documentation indicated the sacral wound was worsening on 05/13/14 and Hospice was consulted. The DON verified there were no dietary progress notes or interventions that addressed the unstageable pressure ulcer until 05/13/14 when a significant weight loss was identified. An interview with the Registered Nurse (RN) #34 on 08/11/14 at 4:00 P.M. verified the pressure ulcer was located on the sacrum and was discovered unstageable. RN #34 verified an undated care plan indicated fragile skin of the right posterior upper thigh, but no further information was documented. A care plan dated 01/07/14 indicated the resident had an unstageable left posterior upper leg wound and RN #34 verified there was no further information regarding the wound in the medical record. 2. Review of the medical record revealed Resident #62 had [DIAGNOSES REDACTED]. Review of the admission nursing assessment dated [DATE] revealed the resident was admitted with a necrotic left heel and right lateral ankle pressure ulcers. Review of the skin risk assessment dated [DATE] indicated the resident was at moderate risk for the development of a pressure ulcer. Review of the Medical Nutrition Therapy assessment dated [DATE] revealed the resident was underweight at 104.6 pounds. The assessment revealed the resident had pressure ulcers to the right lateral ankle and left heel. Review of the weekly pressure ulcer progress report indicated an unstageable pressure ulcer that was necrotic and black in color on the right heel was discovered on 05/20/14. The wound measured 1.5 centimeters (cm) long and .5 cm wide. Review of a care plan dated 05/20/14 revealed Resident #62 was at risk of impaired skin integrity and a potential to develop pressure wounds due to decreased mobility and cognitive impairment. There were no care plans and no interventions specific to the care of the right lateral ankle and left heel pressure ulcers. There was no care plan and no interventions specific to the unstageable pressure ulcer on the right heel that was discovered on 05/20/14. The skin risk assessment dated [DATE] indicated the resident was at moderate risk for the development of a pressure ulcer. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #62 had short term and long term memory problems and severely impaired cognitive skills. The resident required extensive assistance to total dependence for activities of daily except for eating which required limited assistance. The assessment indicated the resident had one Stage II and one unstageable pressure ulcer. An interview with the DON on 08/08/14 at 2:00 P.M. verified Resident #62 had a right heel pressure ulcer that was discovered on 05/20/14 as unstageable. She verified the resident was admitted with a right lateral ankle pressure ulcer and a left heel pressure that were both unstageable. The DON verified the resident was at risk for the development of pressure ulcers and no interventions were initiated to prevent and detect the pressure ulcer to the right heel. 3. Review of the medical record for Resident #61 revealed [DIAGNOSES REDACTED]. Review of the minimum data set (MDS) assessment dated [DATE] indicated the resident was moderately cognitively impaired, required limited assistance to extensive assistance for activities of daily living and the resident was not at risk for the development of pressure ulcers. Review of the prevention of pressure wound care plan dated 10/25/13 indicated unstageable pressure ulcers were discovered on the left heel, right buttock and sacrum/coccyx. An interview with the DON on 08/08/14 at 2:30 P.M. verified the documentation regarding Resident #61 revealed three unstageable pressure ulcers (left heel, right buttocks and sacrum/coccyx) were discovered on 10/25/13. The DON verified the resident was at risk for developing pressure ulcers and the MDS assessment dated [DATE] was incorrect. The DON verified no pressure prevention interventions were initiated until the unstageable pressure ulcers were identified. On 08/11/14 at 4:15 P.M. the information regarding pressure ulcers was verified with RN #34. RN #34 verified the documentation indicated three pressure ulcers were not discovered until they were unstageable on 10/25/13. 4. Review of the medical record for Resident #60 revealed [DIAGNOSES REDACTED].#60 was total care, to be turned every two hours and was non-ambulatory. Review of the care plan dated 03/28/14 revealed Resident #60 had the potential for alterations in skin integrity related to impaired mobility and decreased functional ability. Review of the care plan initiated 03/28/14 revealed the resident was dependent upon staff for the completion of activities of daily living due to advanced dementia, [MEDICAL CONDITION] joint disease and arthritis. Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #60 was high risk for the development of a pressure ulcer. Review of the weekly pressure ulcer progress report revealed a Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) was discovered on Resident #60's left outer ankle on 07/25/14. The report revealed the resident crossed her feet on top of each other and put her feet on both sides of the footrests instead of on the footrests. The progress reports dated 07/28/14 revealed the wound was tan and yellow. A geriatric chair was initiated after the Stage III pressure ulcer was discovered on 07/30/14. Review of the MDS assessment dated [DATE] revealed Resident #60 was severely cognitively impaired and had one Stage III pressure ulcer. Review of the weekly pressure ulcer progress report dated 08/03/14 revealed the wound was tan and yellow. An interview with the assistant director of nursing (RN #34) on 08/05/14 at 4:20 P.M. verified the positioning of the resident's feet was identified prior to the discovery of the Stage III pressure ulcer on the left outer ankle. RN #34 revealed no interventions were initiated to assist the resident in positioning her legs and feet correctly thus, preventing the development of the pressure ulcer. On 08/06/14 at 1:45 P.M. RN #34 was observed changing Resident #60's left outer ankle dressing. There was a large amount of purulent brown drainage on the dressing. The date and time on the dressing that was removed indicated it had been changed on 08/06/14 at 3:00 A.M. There was yellow slough with a small amount of pink tissue on the wound bed. The RN #34 verified it was an unstageable ulcer due to the yellow slough on the wound bed, not a Stage 3 ulcer as was documented. An interview with the DON on 08/06/14 at 3:35 P.M. verified a form entitled Determination of Unavoidable Pressure Wound was dated 08/06/14 and indicated Resident #60 was at risk for lower extremity ulcers due to severe [MEDICAL CONDITION], immobility, severe dementia with the inability to cooperate with medical recommendations and two infections. The form also indicated the resident had a Stage III pressure wound on the left ankle. The DON verified the resident was at risk to develop pressure ulcers and would have required increased assessments due to her compromised condition. The DON verified the form was dated 08/06/14, yet the pressure ulcer was not seen by the clinician who was the author of the form on 08/06/14. During the same interview, the RN #34 verified the wound was unstageable as it presented during the dressing change. Resident #60 was observed with State-tested nursing assistant (STNA) #9 and RN #24 on 08/11/14 at 11:55 A.M. in bed with soft heel protectors in place. Stage II pressure ulcers were noted to the left upper posterior thigh and the coccyx. There was a small amount of bloody drainage from the two areas. The RN verified these were Stage II pressure ulcers and stated these open areas were not new for the resident. This deficiency substantiates Complaint Number OH 672 and Complaint Number OH 879.

Based on observation, record review, interview, and facility policy and procedure review, the facility failed to prevent the development and worsening of pressure sores for two of three sample residents (#40 and #15) reviewed for pressure sores. The facility census was 65 residents. Findings include: 1. Resident #40 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. An initial Minimum Data Set 3.0 (MDS), assessment dated [DATE], revealed the resident was severely impaired in cognition for decision making with a BIMS (brief interview for mental status) score total of 6 points (points from 1 to 6=severe impaired cognition). The MDS revealed the resident required an extensive assistance by two staff members for transferring and toileting and by one staff member for bed mobility. The MDS revealed the resident was frequently incontinent of both bowel and bladder function. The resident was admitted with no skin pressure wounds, but did have vascular wounds on her toes. The MDS triggered for resident assessment protocols in the area of pressure sores. The summary revealed the resident was at risk for the development of pressure sores. Physician orders dated 01/29/11 revealed orders for a barrier cream to be applied to the resident's buttocks following incontinent episodes. The physician orders also included placing a pressure reducing mattress on the resident's bed (a standard pressure reducing mattress was applied). There were no physician orders to turn and reposition the resident when in her bed. Review of nursing notes dated 10/07/11, and skin condition reports dated 10/07/11, revealed the finding of two open wounds on the resident's left buttock. The first wound measured 1.0 centimeters (cm) by 1.3 cm with description of "yellow/pink open area," and the second wound measured 0.3 cm by 0.3 cm with a description "pink open area." A treatment was initiated consisting of cleansing the areas with a normal saline solution, pat dry, apply (Mesalt) and a [MEDICATION NAME] dressing ([MEDICATION NAME]), and change every three days and as needed. Mesalt dressing supports the cleansing of moderately to heavily discharging wounds including infected wounds as it stimulates the cleansing of wounds in the [MEDICAL CONDITION] phase and facilitates the natural wound healing process. Weekly measurements continued for both wounds and no staging of the wounds was found. On 11/25/11 an open wound was found on the resident's left hip measuring 1.0 cm by 1.0 cm with description of "greenish wound bed, pink tissue surrounding and small amount of yellow drainage." The skin condition reports revealed all of the three wounds were worsening. On 11/07/11 the first buttock wound now measured 2.0 cm by 1.0 cm and indicated that "both areas are combined now." On 12/05/11 the left hip wound indicated it to measure 3.0 cm by 3.0 cm with "slough around edges." The initial ordered treatment did not change with the worsening of the wounds. The physician was not notified regarding the worsening of the wounds. No record of the resident being turned and repositioned was found in the resident's medical record, the treatment administration record, or documented in the nursing notes. During tour of the facility on 12/21/11 at 9:30 A.M., Resident #40 was found sitting in a wheelchair in her room, next to her bed. The resident was dressed in slacks and a red top and wore glasses. The surveyor attempted to interview the resident but she was unable to answer any questions appropriately. The resident was confused to place and was frequently moaning. Resident #40 was removed from her room and taken to the main dining room where she remained until after the lunch meal and after surveyor request to observe a dressing change to her wounds. At 1:15 P.M., Resident #40 was observed still sitting in her wheelchair up against a wall along side of other residents, across from the nursing station. An employee from an outside company was found in her room changing her bed mattress to an air mattress at this time. During interview with the director of nursing (DON) on 12/21/11 at 1:30 P.M. outside of Resident #40's room, she stated the "old wound nurse was suppose to be taking care of this and the new mattress but she did not." She stated the wound nurse resigned from employment last week and "that is when I took over." She stated that Resident #40, "should of had an air mattress on her bed some time ago." On 12/21/11 at 1:50 P.M., Resident #40 was placed into her bed by two state tested nursing assistants (STNA's). Licensed Practical Nurse (LPN) #1 came into the resident's room with dressing supplies. She wiped the over bed table with a wet paper towel and placed the dressings and her scissors directly onto the table with no barrier beneath them (no disinfectant type cleaner was used to clean the table). LPN #1, who had just removed supplies from a treatment cart and cleaned off a table, did not wash her hands but did put on a pair of gloves. She removed a dressing off of the left hip wound to expose a large, dark necrotic center, yellow/white boarder around opening and a bright red area around the entire wound. LPN #1 cleaned the wound with a normal saline solution, patted it dry with a sterile gauze dressing, removed her gloves, did not wash her hands, put on new gloves and measured the hip wound. The wound was now found to measure 2.4 cm by 4.2 cm. (further worsened), with a 2.0 cm bright red area around the wound. LPN #1 took off her gloves and without washing her hands she touched the Mesalt dressing with her fingertips and began to pick it up to cut a piece to place on the wound. The surveyor stopped LPN #1, informed her that she just directly touched the Mesalt dressing and asked her to wash her hands. LPN #1 returned to the resident with clean hands and a new Mesalt dressing. She again put on a pair of gloves, picked up the scissors off of the table and cut a circular size piece of the Mesalt dressing and placed it onto the wound. She applied an adhesive dressing over the wound and removed her gloves. LPN #1 again did not wash her hands but put on new gloves and removed the dressing off of the resident's left buttock wound. The large wound had a dark brown center with yellow streaks of slough within the wound. Bright red tissue surrounded the wound. She changed her gloves again without washing her hands and measured the buttock wound. The wound was found to measure 5.0 cm by 7.0 cm with 1.0 cm depth (also worsened). LPN #1 cleansed the wound with normal saline solution, patted it dry with a gauze dressing and removed her gloves. Again without washing her hands, she put on new gloves, picked up the contaminated scissors off of the table, cut a large circular piece of the Mesalt dressing and placed it into the wound. She then applied a thin, wafer like, [MEDICATION NAME] dressing ([MEDICATION NAME]) onto the wound. She removed her gloves, did not wash her hands, removed a pen from her pocket then put it back in her pocket, went out of the room to retrieve a marker from her treatment cart, and wrote the date and her initials onto the dressing. At 2:20 P.M., LPN #1 verified that she did not wash her hands after taking off gloves, had directly touched the Mesalt dressing with her fingers to cut it and had used contaminated scissors directly off the table. LPN #1 stated, "it is our policy to wash hands after removing gloves." 2. Resident #15 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Upon admission the resident was assessed to require an extensive assistance by two staff members for bed mobility, transferring (mechanical lift transfer), and toileting. On 09/26/10 the resident developed a coccyx wound and a treatment was initiated. Review of skin condition reports dated 11/21/11 revealed a right inner buttock wound measuring 0.3 cm by 0.8 cm with description of "tiny shearing inner right buttock." On 12/12/11 the skin sheet revealed the wound to have worsened to measure 2.0 cm by 2.0 cm with serosanguinous drainage noted. The physician was not notified and the treatment was not assessed and changed. A second skin condition report dated 12/05/11 revealed a left inner buttock wound measuring 0.8 cm by 0.4 cm with description as "shearing." During tour of the facility on 12/21/11 at 9:00 A.M., Resident #15 was observed lying in her bed with the head of the bed elevated. The resident was lying on an air mattress directly onto her back. Prior to the lunch meal at 11:30 A.M., Resident #15 was gotten up into a recliner chair and taken into the main dining room. She remained in the dining room after the lunch meal, seated in the recliner until following an activity event. At 3:10 P.M. the resident was brought back to her room. STNA #2 and STNA #3 used a mechanical lift to transfer the resident from the chair back into her bed. The resident was placed onto the air mattress with a thick incontinence pad and a folded in four bath blanket between the resident and the mattress. LPN #4 brought supplies into the resident's room and placed them onto a paper towel barrier on the resident's over bed table. She washed her hands and put on a pair of gloves. She removed the dressing off of the resident's right buttock. The wound was found a two large wounds with a superficial open area extending between the wounds. The top wound had yellow colored slough within the wound and measured 2.0 cm by 2.5 cm, and the bottom wound had red and yellow drainage with a white/yellow center measuring 2.0 cm by 2.0 cm. (worsening wounds). LPN #4 cleaned the wounds with a normal saline solution, patted them dry with gauze, and removed her gloves. She did not wash her hands. She then opened the [MEDICATION NAME] dressing package and cut through a calcium alginate dressing into two smaller pieces and placed the two calcium dressings directly into the open wounds. She took off her gloves, did not wash her hands, put on new gloves, and placed the [MEDICATION NAME] dressing over the entire two wound area. LPN #4 removed her gloves and without again washing her hands she put on a new pair of gloves. She removed a pen from her pocket and wrote the date and time on the dressing, removed her gloves and finally washed her hands. At 3:45 P.M., LPN #4 verified that she did not wash her hands after the removal of gloves as she should have done. On 12/21/11 at 3:50 P.M., review of the facility policy and procedure for "handwashing" (no date indicated) revealed "the use of gloves does not replace handwashing" and that "appropriate 10 to 15 second handwashing must be performed under the following conditions including: after removing gloves." On 12/21/11 at 3:55 P.M., review of the facility protocol regarding wound care revealed information on what to do for each type of wound (i.e.: skin tear, partial thickness wound, full thickness wound, necrotic tissue, arterial ulcers, venous status ulcer and [MEDICAL CONDITION]). Most all of the information about each type wound treated indicated to "change per physician's order," which indicated to notify the physician and possibly change type of treatment being used. At 4:15 P.M. the facility DON was taken to Resident #15's room to verify that Resident #15 was lying on an air mattress with thick incontinence pad and folded in four bath blanket between her and the air mattress. This deficiency substantiates Complaint Number OH 469.