Every finding on record at St Augustine Manor

Based on record review, review of the Emergency Medical Service (EMS) Patient Care Report, review of hospital records, review of information from the National Institute of Health, review of information from the Centers for Disease Control, facility policy and interview, the facility failed to ensure Resident #195's vision/eye needs were comprehensively assessed, treated, and monitored to timely identify an acute change in condition and prevent a complication requiring hospitalization. This affected one resident (#195) of three residents reviewed for a change of condition. The facility census was 194.Actual harm occurred on 02/15/26 when Resident #195 was transferred to the hospital due to increased pain to her left eye, purulent drainage and loss of vision. The resident was diagnosed with a corneal ulcer and infection resulting in enucleation (surgical removal of the resident's eye). Prior to the hospitalization, on 02/11/26 Resident #195 was diagnosed by the nurse practitioner to have conjunctivitis. However, between 02/12/26 and 02/14/26 there was no evidence the resident's eye was comprehensively assessed/monitored. On 02/14/26 the resident had left eye redness, her eyelid was matted shut, and her left eye had copious amounts of yellow purulent drainage. Staff identified a contact lens in the left eye that the licensed nurse was unable to remove. An order was received to transfer the resident to the hospital at that time; however, prior to the transfer the contact was removed (discrepancy in facility information as to who actually removed the contact). No assessment by a licensed nurse was completed following the removal of the contact on 02/14/26. Findings include: Review of Resident #195's closed medical record revealed an admission date of 09/23/25 with diagnoses including history of transient ischemic attack (TIA) and cerebral infarction without residual deficits, other incomplete lesion at C2 level of cervical spinal cord, systemic lupus erythematosus, major depressive disorder and type two diabetes mellitus with diabetic neuropathy. Resident #195 was transferred to the facility on [DATE] and did not return to the facility. Review of Resident #195's care plan dated 09/23/25 included Resident #195 had limited physical mobility related to weakness, debility, and used a motorized wheelchair. Resident #195 had a history of a C2 lesion with tetraplegia. The goal included for Resident #195 to remain free of complications related to immobility. Interventions included to provide supportive care and assistance with mobility as needed and document assistance as needed.Review of Resident #195's care plan dated 09/23/25 through 02/15/26 did not reveal evidence Resident #195 had a care plan related to vision or the use of/need for visual appliances.Review of Resident #195's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. The assessment revealed Resident #195 had the ability to see in adequate light and she denied having corrective lenses including glasses or contacts.Review of the CMS (Centers for Medicare and Medicaid Services) RAI version 3.0 Manual Section B for hearing, speech, and vision dated 10/2025 included for planning of care, residents with eyeglasses or other visual appliances should be assisted in accessing them. Use and maintenance should be included in care planning.Review of Resident #195's medical record revealed the facility did not identify the resident used readers to assist with vision.An eye care chart note written by Eye Care Physician #923 dated 12/24/25 included under history of present illness that patient wears cls (contact lenses). The note included Resident #195 had new bifocals ordered pending insurance approval. There were no additional notes regarding Resident #195's contact lenses).Review of Resident #195's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #195 remained cognitively intact. The assessment revealed Resident #195 required (staff) set up and clean-up assistance with eating and oral hygiene and substantial to maximal (staff) assistance with personal hygiene. Resident #195 used a motorized wheelchair and required set up or clean-up assistance once seated in the wheelchair for the ability to wheel 50 feet and make two turns. This assessment included Resident #195 had the ability to see in adequate light and used corrective lenses including contacts, glasses, or magnifying glass.Record review revealed following the 01/26/26 assessment the Resident #195's care plan was not updated to include a visual deficit, interventions for vision, or the use of any type of visual appliance(s) including corrective lenses, contact lenses, glasses/bifocal glasses or magnifying glass.Review of Resident #195's nursing progress notes and assessments dated 01/26/26 through 02/11/26 did not reveal evidence Resident #195 had irritation, redness, pain or drainage in her left eye. Review of a progress note dated 02/11/26 at 4:27 P.M. authored by Nurse Practitioner (NP) #921 revealed Resident #195 developed left eye drainage and redness with no vision loss or eye pain. The note failed to specify when these symptoms were first identified or include any input from the resident about the condition of her eye or symptom development. The note included Resident #195 had conjunctivitis and was ordered Polymixin (antibiotic eye drops) for seven days.Review of Resident #195's nursing progress notes dated 02/11/26 at 4:27 P.M. through 02/14/26 at 7:17 A.M. did not reveal written evidence of Resident #195's left eye being assessed/monitored during this time period. Review of Resident #195's Medication Administration Record (MAR) dated 02/11/26 at 7:46 P.M. revealed Resident #195 was administered hydrocodone-acetaminophen oral tablet 5-325 mg for a pain level of 7 on a pain scale of zero being no pain and ten being the worst pain. (note: the EMAR notes stated it was given for pain but did not specify where the pain was). Review of Resident #195's MAR dated 02/13/26 at 1:05 A.M. revealed she was given hydrocodone-acetaminophen oral tablet 5-325 mg for a pain level of 6. (note: the EMAR notes stated the medication was given for pain but did not specify the location).Review of a progress note dated 02/14/26 at 7:17 A.M. written by Registered Nurse (RN) #709 included Resident #195 was assessed and noted to have left eye redness, her eyelid was matted shut and her left eye had copious amounts of yellow purulent drainage throughout the shift. The note included a contact lens was observed in the left eye and was unable to be removed despite multiple attempts with sterile saline irrigation. Warm compresses were applied for comfort without improvement. Resident #195 had redness around the left eye and the left cheek. The note included NP #920 was able to visualize (however, an interview with this NP conducted by the surveyor revealed the NP stated she was unable to visualize the contact) and a new order to send Resident #195 to the emergency department (ED) was received. The note then included before the order was carried out the day turn aide came in and was able to remove the contact lens and Resident #195 stated she did not want to go to the ED. NP #920 was notified and gave orders to continue treatment as ordered for conjunctivitis. The note failed to contain any additional information as to how the contact lens was removed, written evidence a licensed nurse completed an assessment of the resident's left eye after the aide removed the contact lens or that any education was provided to the resident related to the NP's order for the resident to be sent to the ED when the resident indicated she did not want to go to the ED. Review of Resident #195's nursing progress notes dated 02/14/26 at 7:17 A.M. through 02/15/26 at 1:05 A.M. revealed no written evidence the resident's left eye was assessed/monitored. Review of Resident #195's progress note dated 02/15/26 at 1:05 A.M. written by Licensed Practical Nurse (LPN) #713 included Resident #195 complained of increased pain in her left eye with pain rated a four out of 10. Record review revealed no written evidence of a comprehensive assessment being completed at this time or of the NP or physician being notified of the increased pain. Review of Resident #195's MAR dated 02/15/26 at 1:05 A.M. revealed hydrocodone-acetaminophen oral tablet 5-325 mg was administered for the resident's complaints of pain at this time. Review of Resident #195's progress note dated 02/15/26 at 4:45 A.M. written by LPN #713 revealed Resident #195 continued to have yellow purulent drainage to the left eye. Warm compresses were applied and antibiotic eye drops were administered, with a note to continue to monitor. Record review revealed no evidence of a comprehensive assessment being completed at this time or of the NP or physician being notified of the continued presence of yellow purulent drainage. Review of Resident #195's progress note dated 02/15/26 at 12:07 P.M. written by LPN #320 revealed Resident #195 complained of pain and vision loss in her left eye. Her left eye was noted to be red with yellow drainage. A new order was obtained at this time to send Resident #195 to the ED for evaluation.Review of a Patient Care Report dated 02/15/26 revealed a call was received at 12:07 P.M. and EMS arrived to the resident at 12:20 P.M. Upon arrival the crew found Resident #195 lying in bed and complaining of left eye pain. Per the staff Resident #195 was being treated for pink eye and was now having vision changes and they were worried about permanent damage. Resident #195 was transported to the ED.Review of Resident #195's progress note dated 02/15/26 at 12:20 P.M. and authored by NP #922 revealed on 02/15/26 at 10:56 A.M NP #922 was called for Resident #195's vision loss and severe left eye pain. The note included Resident #195 and her family requested to have her transported to the hospital and she was sent to the ED for evaluation and treatment. Review of Resident #195's progress notes dated 02/15/26 at 12:29 P.M. revealed Resident #195 was transported to the ED. Resident #195's daughter was aware.Review of Resident #195's hospital ED records dated 02/15/26 revealed Resident #195 had vision changes and a corneal ulcer. Resident #195 presented to the ED due to a left corneal ulcer caused by prolonged contact lenses duration for an unknown amount of time. Upon evaluation and collateral from Resident #195's daughter (phone) the note indicated Resident #195 had a contact in her left eye for a prolonged period of time, anywhere from seven to 12 days. On 02/14/26 an aide picked out the contact which irritated the eye. On 02/15/26 Resident #195's eye was erythematous, swollen, had sticky discharge and she could not open her eyelid on her own. The note revealed the resident confirmed she was losing vision in the left eye. Resident #195 stated she wore contact lenses/glasses for years and thought she wore non-daily contacts. On 02/15/26 during the initial exam (completed in the ED) a contact lens was removed from Resident #195's right eye.Review of a Family/Resident Concern Form dated 02/15/26 involving Resident #195 included Family Member (FM) #924 called and complained her mother was in pain for several days. The form included FM #924 was aware NP #921 evaluated Resident #195 in person and ordered Polytrim ophthalmic drops for conjunctivitis. FM #924 was on the phone with Resident #105 on 02/15/26 and heard Licensed Practical Nurse (LPN) #320 tell Resident #195 to stop rubbing her eye, it would make it worse. FM #924 stated something should have been done to alleviate the pain and the facility failed to do the nursing process. FM #924 questioned why NP #921 did not see the contact in Resident #195's eye. Resident #195's assessment and notes were reviewed and there was no evidence Resident #195 had contact lenses. The form included FM #924 had no idea Resident #195 was wearing contact lenses and stated staff did not follow the nursing process. When Resident #195 reported left eye discomfort she was administered pain medication. Review of a late entry progress note dated 02/15/26 at 11:20 P.M. written by NP #920 revealed on 02/14/26 at 6:08 A.M. RN #709 reported Resident #195 had a contact lens stuck in her left eye. RN #709 reported Resident #195 was prescribed antibiotic eye drops for conjunctivitis. Resident #195 was initially having difficulty removing the contact lens; however, the nurse had since successfully removed the contact lens. The plan was to continue the prescribed antibiotic eye drops to the left eye as ordered. The note documented Resident #195 was currently stable. Orders were to continue eye drops as prescribed and notify a clinician of any change in condition. Disposition was to stay at the facility.Review of Resident #195's hospital Ophthalmology Consult Progress note dated 02/17/26 revealed on 02/15/26 Resident #195 had a corneal ulcer of the left eye. Resident #195 reported pain and irritation of the left eye starting one week prior to presentation that gradually worsened until it became unbearable. The note included Resident #195 reported sleeping in contact lenses since 02/11/26 and said she regularly slept in the contact lenses. The note included Resident #195 lived at the facility and said her husband and nursing managed her contact lenses, but at times she could remove them as needed. Resident #195's diagnosis included pseudomonas given contact lens abuse versus fungal given multifocal fluffy white infiltrates and a history of immunosuppression. Cultures on 02/15/26 revealed rare pseudomonas, rare strep mitis-oralis, fungal in process. Resident #195 received antimicrobial therapy.Interview on 03/25/26 at 5:09 P.M. with FM #924 revealed the family member believed Resident #195 was unable to put her contacts in and someone would have to assist her because she had limited mobility in her upper extremities. FM #924 stated she received a call from Resident #195 on either 02/11/26 or 02/12/26 and during the call Resident #195 stated her left eye itched and was very red. FM #924 indicated she called the charge nurse and was told Resident #195 was being treated for conjunctivitis. On 02/15/26 Resident #195 called her and said her left eye was getting worse and she could not see out of it. FM #924 indicated she told Resident #195 to activate her call light and tell the nurse she needed to go to the ED. After 20 minutes Resident #195's call light was answered by LPN #320. LPN #320 was not aware FM #924 was on the phone and the FM heard the LPN tell Resident #195 to quit picking at her eye and that was why it was red. It did not appear that LPN #320 did an assessment before she told Resident #195 to quit picking at her eye. FM #924 stated she told LPN #320 to send Resident #195 to the ED via 911. FM #924 revealed (after arriving to the hospital) she was told Resident #195 had two contacts in her left eye, had a severe corneal abrasion and several different kinds of bacteria in her eye. FM #924 indicated as a result, Resident #195 was having her left eye removed (enucleation) tomorrow. FM #924 revealed Resident #195 told her the nurse tried to scrape the contact out of her eye with a wooden utensil. The family member revealed in the past Resident #195 wore contacts but she could not put them in or take them out due to her limited dexterity. FM #924 indicated she did not know Resident #195 had her contacts in. Interview on 03/26/26 at 10:29 A.M. with LPN #320 revealed on 02/15/26 she had Resident #195 transported to the ED. LPN #320 indicated she did not know Resident #195 had contacts and none of the staff knew Resident #195 had contacts at the facility. LPN #320 revealed when she arrived at the facility on 02/14/26 she was told Resident #195 had a contact in her left eye. Resident #195 was given a compress and was able to get the contact out, but she did not want to go to the ED after the contact was removed. On 02/15/26 Resident #195's left eye was bothering her more, and several times when LPN #320 walked in the room she saw Resident #195 rubbing her eye. LPN #320 indicated she told Resident #195 that she should not rub her eye because it was getting worse and she did not want her to irritate it more. As the day went on Resident #195 left eye became bright red, she was losing her vision, NP #922 was contacted and Resident #195 was transported to the ED via 911. Interview on 03/26/26 at 10:41 A.M. with Registered Nurse (RN) #709 revealed on 02/14/26 when she walked in Resident #195's room she saw a contact case on the nightstand. RN #709 indicated she did not remember seeing the contact case when she previously took care of Resident #195 (the RN did not indicate when she had last cared for the resident specifically). RN #709 stated she asked Resident #195 if she had a contact in her eye and Resident #195 said she put her contact in. Resident #195 indicated she did not remember how long the contact was in her eye, but it had been in for a bit. RN #709 revealed she attempted to remove the contact using sterile saline flushes and warm compresses several times, but it did not come out. RN #709 indicated she did not want to force the contact out. She stated she contacted the physician and received orders to transport Resident #195 to the ED. However, before Resident #195 could be transported to the hospital RN #709 revealed the morning aide was able to get the contact out, but she did not ask how the aide was able to get the contact out. The aide brought the contact out on a towel to show RN #709 she got it out and it was intact, but she stated she did not know the aides name. RN #709 again stated she did not know Resident #195 had contacts and she always had eye glasses on. RN #709 denied assessing or looking at Resident #195's left eye after the contact was removed. RN #709 stated this happened at the end of her shift and she left the facility shortly after this happened. RN #709 stated Resident #195 was alert and oriented and felt the resident would be capable of putting in a contact by herself. However, RN #709 denied ever seeing contact solution or other supplies in Resident #195's room.Interview on 03/26/26 at 2:41 P.M. with the Director of Nursing (DON) revealed Resident #195 had bifocals delivered on 12/31/25. There was no evidence of a vision assessment or care planning related to the resident's vision needs or use of visual appliances at that time or following.Interview on 03/26/26 at 3:05 P.M. with FM #924 revealed Resident #195 was admitted to the facility on [DATE], she did not know Resident #195 had contacts and no one in the family had brought contacts to the facility. FM #324 revealed she did not know when the contacts were put in Resident #195's eye. The FM revealed the resident had not been able to provide any additional information to family about the contact lenses due to her current status and medical care needs associated with her hospitalization.Interview on 03/27/26 at 9:28 A.M. with DON revealed on 02/14/26 she was made aware Resident #195 had a contact in her eye from Unit Manager (UM) #586. The DON revealed she was told everyone kept looking in Resident #195's eye, they could not see anything, then it was able to be visualized and it was swiped out. The DON revealed Certified Nursing Assistant (CNA) #622 was present when the contact came out.Interview on 03/30/26 at 8:41 A.M. with CNA #622 revealed on 02/14/26 she gave Resident #195 a warm cloth to put on her eye, but the CNA denied removing the contact from the resident's eye. CNA #622 stated all she did was sit Resident #195 up and give her a warm cloth for her eye. Resident #195 compressed the warm cloth on her eye, said her eye hurt and wiped her eye for about five to ten minutes and the contact came out on the cloth. CNA #622 revealed she did not know Resident #195 had a contact in her eye or had contacts before this happened. CNA #622 indicated a couple days before Resident #195 was able to get the contact out of her eye her eye was closed and draining but CNA #622 never saw a contact case or contact supplies in Resident #195's room when she cared for her.Interview on 03/30/26 at 9:30 A.M. with Certified Occupational Therapy Assistant (COTA) #550 revealed she was not aware Resident #195 had contacts. During the interview, COTA #550 revealed the resident had mentioned some concerns with eye irritation. However, she did not recall a time frame when Resident #195 complained of eye irritation, but thought it was a few weeks before she left the facility. COTA #550 stated she mentioned the eye irritation to an aide but did not remember which aide she told. COTA #550 indicated Resident #195 told her nursing was aware of her eye irritation. Interview on 03/30/26 at 3:12 P.M. with NP #920 revealed on 02/14/26 she was on-call for the facility and at 6:08 A.M. she saw Resident #195 via a video call. NP #920 indicated she received a page from a nurse that Resident #105 had a contact in her left eye that the nurse was having a hard time removing. NP #920 revealed she could see Resident #195's eye was red, but could not visualize the contact because it was clear and hard to see on the video. NP #920 indicated at 6:12 A.M. she was notified the contact was removed successfully, Resident #195 already had an order for antibiotic eye drops and she told the nurse to monitor Resident #195 for a change of condition.Interview on 03/30/26 at 4:23 P.M. with DON and Assistant Director of Nursing (ADON) #523 revealed one of her responsibilities was monitoring residents visits with Eye Care Physician #923. ADON #523 indicated she read the eye care notes from each visit and if there were orders, the orders would be at the bottom of the notes page, and she would make sure the orders were placed in the system. ADON #523 confirmed Resident #195 had a history of wearing contacts, and it was stated in the eye care notes that she had a history of wearing contact lens. ADON #523 revealed Resident #195 was not wearing contact lenses when she had her visit with Eye Care Physician #923.Interview on 03/31/26 at 1:02 P.M. with Eye Care Physician #923 revealed 12/24/25 was the first and only time he saw Resident #195. Eye Care Physician #923 indicated he couldn't remember the details but Resident #195 must have mentioned she wore contacts (as it was referenced in the note).Interview on 03/31/26 at 1:08 P.M. with Minimum Data Set Nurse (MDS) #317 revealed on 09/30/25 Resident #195's vision was adequate without glasses. MDS #317 stated residents were given a piece of paper with regular size print on it and are asked to read from it. If residents could not see the regular print then larger size print was chosen and if there were any issues the nurse, nurse practitioner or physician would be notified. MDS #317 revealed Resident #195's vision was adequate and when she was asked if she wore appliances like glasses or contacts Resident #195 said no.Interview on 04/01/26 at 10:42 A.M. with MDS #317 confirmed Resident #195 did not have a care plan for vision. MDS #317 stated when Resident #195 was interviewed she did not see reading glasses, Resident #195 did not say she had them, and she wrote down what Resident #195 told her. MDS #317 stated sometimes families bring glasses to the facility after a resident is admitted . MDS #317 revealed after Resident #195 received her bifocals the MDS nurses would have done an exam, but someone would have to tell them Resident #195 had glasses, and the MDS nurses were not told she had glasses. MDS #317 revealed she did not do Resident #195's quarterly assessment on 01/26/26 and could not say why there was no vision care plan initiated after the interview. Interview on 04/01/26 at 3:55 P.M. with MDS #317 revealed she spoke with her assistant who completed Resident #195's MDS assessment on 01/26/26 and her assistant indicated Resident #195 was alert and oriented times four and felt the resident could care for her (vision) appliance. The assistant did not initiate a care plan because she thought Resident #195's vision was adequate without the glasses. Review of the National Institutes of Health (NIH) National Eye Institute guidance dated 06/26/2019 included pink eye or conjunctivitis caused swelling and redness in the inside of the eyelid and the white part of the eye. The eye could also feel itchy and painful. To help eyes feel less dry over the counter eye drops called artificial tears could be used and a cold compress to help with the swelling and redness could also be used. Bacterial pink eye usually gets better in two to five days, but it can take two weeks or more to go away completely. Antibiotics can speed up the healing time.According to the Centers for Disease Control and Prevention (CDC), patients receiving treatment for bacterial conjunctivitis should demonstrate clinical improvement within 24 hours of antibiotic therapy, and lack of improvement warrants further medical evaluation. Authoritative medical literature further indicates that topical antibiotic therapy is intended to reduce the duration of symptoms, with standard treatment courses of approximately 5-7 days, during which symptoms are expected to significantly improve or resolve. Bacterial conjunctivitis typically improves within several days even without treatment; therefore, failure to demonstrate improvement within the expected timeframe while on antibiotic therapy is inconsistent with the anticipated clinical course. Review of the facility policy titled Notification of Changes revised 04/2025 included the facility must inform the resident, consult with the resident's physician and, or notify the resident's family member or legal representative when there was a change requiring such notification. Circumstances requiring notification included a significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status including clinical complications.This deficiency represents non-compliance investigated under Complaint Number 2748620.

Based on interview, record review and review of the facility policy the facility failed to ensure Resident #195's urinary tract infection was treated properly with antibiotics per physician orders. This affected one resident (Resident #195) out of three residents reviewed for antibiotic administration. The facility census was 194.Findings include:Review of Resident #195's closed medical record revealed an admission date of 09/23/25 and diagnoses included history of Transient Ischemic Attack (TIA) and cerebral infarction without residual deficits, other incomplete lesion at C2 level of cervical spinal cord, systemic lupus erythematosus, major depressive disorder and type two diabetes mellitus with diabetic neuropathy. Resident #195 was discharged from the facility on 02/15/26.Review of Resident #195's Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #195 was cognitively intact. Resident #195 required set up and clean-up assistance with eating and oral hygiene and substantial to maximal assistance with personal hygiene. Resident #195 used a motorized wheelchair and required set up or clean-up assistance once seated in the wheelchair for the ability to wheel 50 feet and make two turns. Resident #195 had the ability to see in adequate light and used corrective lenses including contacts, glasses, or magnifying glass. Resident #195 was frequently incontinent of bowel and bladder.Review of Resident #195's care plan dated 02/09/26 included Resident #195 had recurrent urinary tract infections (UTI's). Resident #195's urinary tract infection would resolve without complications by the review date. Interventions included to observe, document and report to the physician signs and symptoms of a UTI such as frequency, urgency, dysuria (burning, pain); to give antibiotic therapy, medications as ordered and monitor and document for side effects and effectiveness; to obtain and monitor lab, diagnostic work as ordered and report results to the physician and follow up as indicated.Review of Resident #195's physician orders dated 01/23/26 at 3:40 P.M. revealed orders for nitrofurantoin macrocrystal (Macrobid - antibiotic medication) oral capsule, give 100 mg by mouth every 12 hours for dysuria for seven days for a UTI. Document any adverse effects of the antibiotic in the IDT notes. Check vital Signs with each administration and document if the signs and symptoms were improving; document a yes or no and if no proceed to the IDT note.Review of Resident #195's progress notes dated 01/23/26 at 3:52 P.M. included Resident #195 was complaining of dysuria and frequency. Nurse Practitioner #921 was notified and new orders were received for nitrofurantoin 100 mg two times a day. A urine specimen for urinalysis and culture and sensitivity was ordered and to not start the antibiotic until the urine specimen was collected. The medication (Macrobid) was scheduled to start on 01/24/26 at 6:00 A.M.Review of Resident #195's Medication Administration Record (MAR) revealed nitrofurantoin macrocrystal (Macrobid) 100 mg was scheduled to start on 01/24/26 at 6:00 A.M. but the first dose was not administered until 01/24/26 at 6:00 P.M. Macrobid 100 mg was not administered on 01/25/26 at either 6:00 A.M. or 6:00 P.M. Macrobid 100 mg was administered on 01/26/26 at 6:00 A.M. but was not administered on 01/26/26 at 6:00 P.M. Macrobid 100 mg was administered on 01/27/26, 01/28/26, 01/29/26 and 01/30/26 at 6:00 A.M. and 6:00 P.M. (note: Resident #195 received 10 antibiotic administrations and not the fourteen that were ordered, and the Macrobid was started before the urine culture was obtained).Review of Resident #195's progress notes dated 01/23/26 through 01/30/26 did not reveal evidence Nurse Practitioner (NP) #921 was notified there was a delay sending Resident #195's urine culture to the lab or the Macrobid was administered before the culture was collected and sent to the lab. There was no evidence NP #921 was notified that Resident #195 did not receive the ordered number of Macrobid 100 mg doses and no evidence this was addressed and orders given.Review of Resident #195's progress notes dated 01/24/26 at 3:45 P.M. revealed an attempt was made to collect Resident #195's urine via a bedpan but the urine specimen was discarded due to contamination with stool. There was no evidence NP #921 was notified.Review of Resident #195's progress notes dated 01/25/26 at 5:03 A.M. revealed Macrobid 100 mg was not administered due to contaminated urine specimen. There was no evidence NP #921 was notified. Review of Resident #195's progress notes dated 01/25/26 at 10:52 P.M. included Resident #195's urine specimen was not obtained due to delayed transportation due to weather. There was no evidence NP #921 was notified.Review of Resident #195's progress notes dated 01/26/26 at 7:30 P.M. revealed the nurse received an order from an unidentified NP to straight cath as needed. Resident #195 had an order for a urinalysis prior to starting antibiotics.Review of Resident #195's lab results for a urine specimen for urinalysis and culture and sensitivity revealed the urine was collected on 01/27/26 at 5:18 A.M. and reported on 01/29/26. Resident #195's urine had greater than 100,000 CFU (Colony Forming Units) per ml of Escherichia Coli and the Escherichia Coli was susceptible to nitrofurantoin (Macrobid).Review of Resident #195's progress notes dated 01/27/26 at 6:10 A.M. revealed Resident #195's urine specimen for urinalysis and culture and sensitivity was obtained via a straight catheter. The urine was yellow and cloudy without a foul odor.Review of a late entry progress note dated 02/03/26 at 6:27 A.M. revealed on 01/28/26 at 6:25 A.M. urine culture was obtained and Resident #195's urine was positive for E.coli. Resident #195 received Macrobid with improvement in her symptoms.Review of Resident #195's progress notes dated 02/11/26 at 4:27 P.M. and written by NP #921 included Resident #195 was treated with a course of Macrobid for a urinary tract infection. Resident #195 stated she continued to get recurrent UTI's and complained of burning with urination again and urinary frequency. Repeat urine specimen for urinalysis and culture and sensitivity.Review of Resident #195's urinalysis results included the urine was collected and reported on 02/12/26 and Resident #195's urine was dense, turbid, had one plus protein, a moderate amount of bacteria, had greater than 25 WBC/HPF (High Power Field), and her leuk esterase was 500 Leu/uL. These results were abnormal.Interview on 04/01/26 at 3:58 P.M. with Assistant Director of Nursing (ADON) #621 confirmed Resident #195's Macrobid was not started on 01/24/26 at 6:00 A.M. as scheduled and indicated the facility had to wait for the Macrobid to be delivered. ADON #621 revealed Resident #195 had a history of recurrent urinary tract infections. ADON #621 indicated on 01/25/26 in the morning the urine specimen was contaminated and could not be sent to the lab and on 01/25/26 in the evening the urine specimen was not picked up due to the weather. ADON #621 revealed the antibiotics were not given because the urine specimen was pending. ADON #621 confirmed Resident #195's Macrobid was administered on 01/24/26 at 6:00 P.M. and on 01/26/26 at 6:00 A.M. and both of the doses were administered before the urine specimen was collected. ADON #621 confirmed Resident #195 did not receive the ordered number of Macrobid 100 mg doses and NP #921 was not notified.Interview on 04/01/26 at 5:00 P.M. with Nurse Practitioner (NP) #921 revealed the nurses knew she was a big [NAME] on urine specimens being obtained before antibiotics were administered because she did not want a skewed culture. NP #921 revealed she was not sure why Resident #195 did not get the full seven days of Macrobid as ordered and she did not recall being called about it. NP #921 indicated she did not know why she was not called about extending the days Resident #195 received the Macrobid because she did not get the full course of antibiotics that were ordered. NP #921 revealed she saw Resident #195 on 01/28/26 and told the nurses to complete the course of Macrobid. NP #921 revealed she could not say one way or the other if not getting the full course of Macrobid ordered on 01/23/26 could be related to Resident #195 recurrent urinary tract infection on 02/12/26. NP #921 indicated the best course of action would have been for the nurses to contact her and inform her Resident #195 did not get the full course of Macrobid and she could make a decision about what to do. Review of the facility policy titled Medication Guide revised 08/2020 included administered medications were consistent with physician's orders including dose, strength, route and frequency.This deficiency represents non-compliance investigated under Complaint Number 2748620.

Based on observation, interview and record review the facility failed to ensure enhanced barrier precautions were followed for Resident #65. This affected one resident (#65) of three residents observed for infection control. The facility census was 194.Findings include:Review of Resident #65's medical records revealed an admission date of 06/08/17 with diagnoses including gastrostomy (feeding tube), right sided paraplegia, muscle weakness and dysphagia (difficulty swallowing).Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had impaired cognition. Resident #65 was dependent with toileting, bathing and transfers. Review of care plan dated 03/18/26 revealed Resident #65 required Enhanced Barrier Precautions (EBP) related to device. Interventions included appropriate signage on residents door, and instruct caregivers to wear disposable gowns and gloves during physical contact with resident. Review of current physician orders for March 2026 revealed Resident #65 was ordered EBP due to device every shift.Observation of medication administration on 03/26/26 at 7:56 A.M. for Resident #65 with Licensed Practical Nurse (LPN) #320 revealed signs posted on Resident #65's door that indicated resident was on Enhanced Barrier Precautions (EBP) and Personal Protective Equipment (PPE) was to be worn that included gown and gloves. LPN had prepared Resident #65's medications and had entered Resident #65's room and had proceed to administer medications via Resident #65's feeding tube and had not donned PPE prior to medication administration. Interview with LPN #320 after medication administration revealed Resident #65 was on EBP related to his feeding tube and stated she should have worn PPE prior to administering the medications.Review of facility policy titled Enhanced Barrier Precautions revised 04/2025, revealed an order for EBP will be obtained for residents with indwelling medical devices that include feeding tubes and PPE is necessary when performing high contact care.

Based on observation, interview and record review, the facility failed to provide hemodialysis care and services consistent with professional standards of practice related to the pre and post dialysis assessment and ongoing communication between the facility and the dialysis center for six (R154, R114, R98, R25, R106, R155) of six residents reviewed for dialysis. Findings include: 1.) Review of Resident #155 electronic Medical Diagnosis form indicated diagnoses of hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease (ESRD) dated 3/7/2023, dependence on renal dialysis dated 3/7/2023 and ESRD dated 8/10/2023. Quarterly Minimum Data Set (MDS) signed and locked on 12/15/23 at 3:00 p.m. indicated Resident #155 was admitted into the facility on [DATE]. The MDS also indicated that Resident #155's Brief Interview for Mental Status (BIMS) Summary Score was 15. According to online website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7984985/ assessed 5/29/2024 indicated, BIMS is a brief cognitive screening measure that focuses on orientation and short-term word recall. It also indicated if an individual had an overall summary score of 13-15, then the individual's mental status was cognitively intact. Physician order dated 3/8/2023 and timed 3:38 p.m. indicated an order for dialysis on Monday, Wednesday, and Fridays at 5:00 a.m. Dialysis Communication form dated 3/11/2024 and 4/5/2024, that were scanned into Resident #155's electronic chart indicated the Dialysis Information section of the form was to be filled out by dialysis. However, this section was not complete and the information regarding if the resident exhibited shortness of breath, nausea/vomiting, cramping, or complaints of pain, and what medications were administered, if treatment was completed without complications, and if resident was assessed by RN to be released back to the unit from dialysis was blank. May 2024 Treatment Administrative Record (TAR) indicated an order with a start date of 3/07/2023 to monitor dialysis catheters every shift and to reinforce if needed every shift. On 5/15/2024 for the day and evening shift the signature slots were blank and there was no documentation the dialysis catheter was monitored, checked, or assessed. During an interview on 5/22/24 at 9:20 a.m., RN #818 said there are times the dialysis department would give the post Dialysis Communication form to the resident and the resident would not always give it to the nurse to review. RN #818 also said this process was not good practice. RN #818 verified she was the nurse in charge of Resident #155 on 5/15/2024 during the day and evening shift and she did not document or sign that she monitored or checked the resident's dialysis catheter on that day. RN #818 said Resident #155 was alert and oriented and would know what the nurses did post dialysis. During an interview on 5/22/2024 at 9:33 a.m., Resident #155 said the facility nurses did not monitor or assess her dialysis catheter daily nor did they do it after she returned from dialysis. During an interview on 5/22/24 at 3:19 p.m., the Director of Nurses (DON) verified the Dialysis Communication Forms that were scanned into the electronic record for Resident #155 for 3/11/2024 and 4/5/2024 were not filled out completely and the post dialysis vital signs and the section that informed the nurse if the resident exhibited shortness of breath, nausea/vomiting, cramping, complaints of pain, medications administered, if treatment was completed without complications, and if resident was assessed by RN to be released from dialysis back to the unit was blank. The DON said those sections were to be completed by the dialysis department after completion of dialysis treatment to ensure the facility nurses have that information to monitor and assess the resident. She also said that her expectation for the nurse was to initial the TAR once the task was completed. During an interview on 5/22/2024 at 9:59 a.m., dialysis Facility Administrator (FA) #300 said it was not their practice to send their dialysis records to the facility. FA #300 said the facility had their own Dialysis Communication Form for them to fill out and send with the resident, and they would complete the dialysis section of the form after dialysis is complete and they would give the form to the resident to give to the nurse once they returned to the unit. FA #300 further said she witnessed Dialysis Communication forms in resident wheelchairs from several days after treatment, therefore she knew that the facility did not get the information. She also said the dialysis center did not call report to the unit or the nurse after treatment of residents because they are not affiliated with the facility, and they were a separate entity. FA #300 further said she has not talked to the facility about their nurses not receiving the post dialysis documentation from the residents because it was not the dialysis centers responsibility to ensure the facility complied. Review of the facility's policy and procedure titled, Maintenance of Clinical Records with an initial date of 12/2022 indicated In accordance with acceptable professional standards of practice, the facility must maintain medical records on each resident that are: complete, accurately documented, and readily accessible. Review of the facility's policy and procedure titled, Care of Dialysis Access Devices with a last initial date of 07/2021 indicated upon return from dialysis, the resident was to have their dialysis site assessed to ensure the dressing was in place and the area surrounding the dialysis site was to be checked for redness, swelling, warmth, bruising, pain, or drainage. 2.) Review of Resident #25 electronic Medical Diagnosis form indicated diagnoses of ESRD and dependence on renal dialysis both dated 3/21/23. Physician order dated 2/26/24 and timed 7:47 a.m., indicated an order for dialysis every Monday, Wednesday, and Friday at 5:15 a.m. An annual MDS that was signed and locked on 2/19/2024 at 1:54 p.m., indicated Resident #25 was admitted into the facility on [DATE]. May 2024 TAR indicated an order with a start date of 10/11/2023 to check bruit and thrill every day on the 7:00 a.m. - 7:00 p.m. and 7:00 p.m. - 7:00 a.m. shift. There were blank slots and no signature documentation on 5/11/2024 and 5/15/2024 for the 7:00 a.m. - 7:00 p.m. to indicate the bruit and thrill was checked. Care Plan with target completion date of 3/8/2024 indicated the resident needed hemodialysis related to ESRD. The intervention was to check bruit and thrill per orders. Dialysis Communication Forms dated 5/3/24, 5/6/2024, 5/8/2024, 5/10/2024, 5/13/2024, and 5/5/2024 indicated the Dialysis Information section of the form was not complete and the information regarding if the resident exhibited shortness of breath, nausea/vomiting, cramping, or complaints of pain, and what medications were administered, if treatment was completed without complications, and if resident was assessed by RN to be released back to the unit from dialysis was blank During an interview on 5/22/24 at 3:55 p.m., the DON verified the Dialysis Communication Forms that were scanned into the electronic record dated 5/3/24, 5/6/2024, 5/8/2024, 5/10/2024, 5/13/2024, and 5/15/2024 did not have the Dialysis Information section completed. She said the dialysis department was supposed to complete that section once the resident completed his or her dialysis treatment. She said the Dialysis Communication forms not being filled out completely, did not show a good continuity of care between the facility and the dialysis department for the residents. During an interview on 5/22/2024 at 12:55 p.m., Licensed Practical Nurse (LPN) #908 said when a resident returned from dialysis she would take the residents vital signs, and make sure the dressing on the graft or fistula was intact. She stated that she does not take the dressing to the fistula off at all, and that the dressing should stay on until the resident went back to dialysis. LPN #908 said that she has worked at the facility for about one year and she does not know how to assess or check dialysis fistulas or graft bruit and thrills. She said that the facility had not trained her on how to assess or monitor bruit or thrills since she started working there. LPN #908 also said that when the residents returned from dialysis the Dialysis Information section of the Dialysis Communication form was not always filled out completely. Review of the facility's policy and procedure titled, Maintenance of Clinical Records with an initial date of 12/2022 indicated In accordance with acceptable professional standards of practice, the facility must maintain medical records on each resident that are: complete, accurately documented, and readily accessible. Review of the facility's policy and procedure titled, Care of Dialysis Access Devices with a last initial date of 07/2021 indicated nursing was to assess bruit and thrill every shift. 3.) Review of Resident #106 electronic Medical Diagnosis form indicated diagnoses of chronic kidney disease, stage 5 dated 10/25/2022, dependence on renal dialysis dated 2/11/24 and ESRD dated 2/21/2024. Physician order dated 5/17/2024 and timed 8:13 a.m. revealed an order for dialysis on Monday, Wednesday, and Fridays at 8:30a.m. Dialysis Communication Forms dated 5/1/24, 5/3/24, 5/15/24, 5/17/24, and 5/20/24, that were scanned into Resident #106's electronic chart indicated the Dialysis Information section of the form was to be filled out by dialysis. However, this section was not complete and the information regarding if the resident exhibited shortness of breath, nausea/vomiting, cramping, or complaints of pain, and what medications were administered, if treatment was completed without complications, and if resident was assessed by RN to be released back to the unit from dialysis was blank. During an interview on 5/22/24 at 3:51 p.m., the DON verified the Dialysis Communication Forms that were scanned into the electronic record for Resident #106 and dated 5/1/2024, 5/3/2024, 5/15/2024, 5/17/2024, and 5/20-2024 did not have the Dialysis Information section filled out completely and the documentation that informed the nurse if the resident exhibited shortness of breath, nausea/vomiting, cramping, or complaints of pain, what medications were administered at dialysis, if dialysis treatment was completed without complications, and if the resident was assessed by RN to be released from dialysis back to the unit was blank. Review of the facility's policy and procedure titled, Maintenance of Clinical Records with an initial date of 12/2022 indicated In accordance with acceptable professional standards of practice, the facility must maintain medical records on each resident that are: complete, accurately documented, and readily accessible. 41749 4.) During observation and interview with R154 on 5/21/24 at approximately 5:05pm, R154 stated he goes to dialysis (a treatment for people whose kidneys are failing). R154 stated, Yes, three times [a week] Monday, Wednesday, Friday. When asked about his dialysis access site, R154 showed the surveyor his right upper arm. The site was covered with a dressing and secured with a tape. R154 stated he would get weighed at the dialysis unit. When asked if staff had been checking his vital signs when he returned from dialysis, R154 stated, No. R154 explained that staff checked him in the morning before but not after his dialysis treatment. Review of R154's Medical Diagnosis in Point Click Care (PCC, healthcare software and electronic health record) included end stage renal disease (kidney failure) and dependence on renal dialysis. Review of R154's quarterly Minimum Data Set (MDS), a federally mandated assessment tool) dated 4/29/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. In the section related to Special Treatments and programs, revealed R154 had received dialysis. Review of R154's care plan with a Review Start Date of 3/19/24 revealed The resident needs hemodialysis r/t [related to] CKD [chronic kidney disease]. Hx [history of] left nephrectomy [surgery to remove a kidney or part of a kidney]. The interventions included check bruit [audible vascular sound associated with turbulent blood flow] and thrill [vibratory sensation felt on skin overlying an area of turbulence] every shift in right arm .Encourage resident to go for the scheduled dialysis appointments .Monitor vital signs per protocol and PRN [as needed], focusing on BP [blood pressure]. Notify MD of significant abnormalities .Monitor/document/report prn any s/sx [signs and symptoms] of infection to access site .No BP draws to right arm d/t [due to] fistula [a connection that is made between an artery and a vein for dialysis access .Resident has dialysis on M-W-F [Monday, Wednesday, Friday] [at] [name of dialysis center] . However, R154's care plan did not identify and include specific parameters for R154's blood pressure, weight and other vital signs. Review of R154's May 2024's Orders revealed the following: - Ensure dialysis communication folder is in resident's possession one time a day every Mon, Wed, Fri (start date 4/26/24) - Resident has dialysis on M-W-F at (name of dialysis center) 4:45 (am) (start date 3/27/24) - Epoetin Alfa-epbx solution [epogen, medication used to treat anemia caused by chronic kidney disease] 10000 units/ml. Use 0.75 ml intravenously one time a day every Mon, Wed, Fri for anemia to be given in dialysis (start date 5/22/23) - No BP draws to right arm d/t fistula placement (start date 5/19/23) - Check Bruit and thrill every shift in right arm (start date 5/19/23) - Monitor Dialysis catheter every shift and reinforce if needed. Right subclavian every shift (start date - 5/19/23). However, the orders did not indicate R154's individualized dialysis prescription including the length of dialysis treatment time and resident's target weight. It did not address the specific parameters for blood pressure, weight and other vital signs. Review of R154's May 2024 Medication and Treatment Administration Records (MAR/TAR) revealed the following: - R154 received dialysis on 5/1, 5/3, 5/6, 5/8, 5/10, 5/13, 5/15, 5/17 and 5/2024. - Bruit and thrill checked every shift - Epoetin Alfa-epbx solution 10000 units/ml. Use 0.75 ml intravenously one time a day every Mon, Wed, Fri for anemia to be given in dialysis was marked given on 5/3, 5/6, 5/8, 5/10, 5/13, 5/15, 5/17, 5/20 and 5/22/24. Further review of R154's May 2024 MAR and TAR revealed no indication that blood pressure was monitored after dialysis treatment. Review of R154's [name of dialysis] SNF [skilled nursing facility] Dialysis Services Communication Forms [form completed for residents receiving dialysis in the unit] revealed incomplete assessments and Epogen had not been documented as administered on 5/1, 5/3, 5/6, 5/8, 5/10, 5/13, 5/15 and 5/17/24 during dialysis. Further review of the dialysis services communication forms revealed the following: 5/1 - post (dialysis) treatment BP = 110/56 5/10 - no pre and post treatment vital signs. The section additional notes indicated patient did not bring this [form] on Monday. 5/15 - post treatment BP = 136/103 5/17 - pretreatment BP = 161/80 and post treatment BP = 167/90 Review of R154's progress notes revealed no monitoring of R154's BP after dialysis on 5/1, 5/15 and 5/17/24 and no documentation that the physician or nurse practitioner had been notified of R154's blood pressure readings. During an interview with the Licensed Practical Nurse (LPN) #922 on 5/22/24 at approximately 2:30pm, LPN #922 stated she was familiar with R154. When asked about the care for the dialysis access site and dressing changes, LPN #922 stated, No. That is strictly dialysis. When asked when she would monitor the vital signs and weight, LPN #922 stated, If it requires to or something is going on. LPN #922 stated, Night shift gets him [ready] for dialysis. When asked how care was coordinated and communicated when there are changes in condition, LPN#922 stated, I notify the NP [nurse practitioner] and a progress note. Absolutely. In an interview with the DON on 5/22/24 at approximately 2:47pm, the DON stated the dialysis staff [from the dialysis center] were different from the dialysis staff providing the treatment on the ventilator section of the nursing home. The DON stated that for the residents with ventilators or tracheostomy who received dialysis, [They are] coming from a different [name of dialysis center] location. Our staff will go back with them and they will complete [the dialysis communication form] together. They start early. When asked about the pre and post dialysis weight, the DON stated, For consistency they get weighed [pre and post dialysis] over there [by dialysis staff]. The DON stated that if there was no pre weight on the communication form, They [dialysis staff] didn't take it. When asked about orders for VS parameters, the DON stated that it would depend on the physician. 5.) During observation on 5/21/24 at approximately 5pm, revealed R98 eating in the dining room. On 5/22/24 at approximately 9:53am, R98 was observed seating in his wheelchair by the waiting area of the dialysis center and was dozing off. When he opened his eyes, the surveyor asked R98 how his treatment went. R98 stated it was okay. Review of R98's electronic health record in PCC revealed an admitted [DATE]. R98's diagnoses included end stage renal disease and dependence on renal dialysis. Review of R98's quarterly MDS dated [DATE] revealed a BIMS score of 15. In the section Special Treatment and Programs revealed R98 had received dialysis. Review of R98's care plan with a review start date of 3/19/24 revealed, The resident needs hemodialysis r/t renal failure. Right AVF. The interventions included Administer medications per order .Check RAVF [right arteriovenous fistula] for bruit and thrill per orders .Do not draw blood or take B/P in R arm: AVF .Encourage resident to go for the scheduled dialysis .Fluid restriction as ordered .Monitor labs and report to doctor as needed .Monitor vital signs per protocol/PRN. Notify MD of significant abnormalities .Monitor/document report PRN any s/sx of infection to access site: Redness, swelling, warmth or drainage .Monitor/document/report PRN for s/sx of the following: bleeding, hemorrhage, bacteremia, septic shock .Monitor/document/report PRN new/worsening peripheral edema . Review of R98's Orders revealed the following: - Vitals Q (every) month and PRN. Notify MD/NP for temp (greater than) 100, HR (heart rate) (greater than) 110 or (less than) 55, SBP (systolic blood pressure) (greater than) 160 or (less than) 90, SpO2 (oxygen saturation) (less than) 92% on currently ordered O2, or for any acute change in condition every day shift (start date 6/1/24) - Ensure dialysis communication folder is in resident's possession one time a day every Mon, Wed, Fri (start date 4/26/24) - Renal Carb (carbohydrates) controlled diet, minced and moist texture, moderately thick consistency (start date 2/26/24) - Resident had dialysis on M-W-F at 4:45am one time a day every Mon, Wed, Fri for ESRD (start date 2/26/24) - 1500 ml (milliliter) Fluid restriction 960 ml DTY (dietary) 360 ml B (breakfast) and L (lunch) 240 ml D (dinner), 540 ml NSG (nursing) 270 ml q shift (start date 2/23/24) - Check RAVF bruit and thrill every shift (start date 2/23/24) - Do not draw blood or take B/P in right arm: AVF (start date 2/23/24) Further review of R98's Orders revealed that the facility failed to indicate individualized dialysis prescription including R98's dialysis length of treatment time and resident's target weight. Review of R98's May 2024 MAR revealed that R98 received dialysis on 5/1, 5/3, 5/6, 5/8, 5/10, 5/13, 5/15, 5/17, 5/20 and on 5/22/24. However, there was no indication of R98's vital signs monitoring including blood pressure and heart rate after dialysis treatment. Review of R98's Dialysis Communication Tool in PCC revealed the following: - No completed communication tool on 5/1, 5/6 and 5/8/24. - 5/3/24: BP = 84/54. The section changes since last dialysis was left blank. - 5/13/24: PR = 54 - 5/17/24: BP = 171/72 - Dialysis information (to be filled out by dialysis) was left blank on 5/10, 5/13, 5/15 and 5/17/24. Review of R98's Dialysis Services Communication Form and Post Treatment Report revealed missing communication forms for 5/3, 5/10 and 5/13/24, and had incomplete assessments on 5/1 and 5/8/24. Review of R98's progress notes revealed no monitoring of R98's BP and heart rate after dialysis on 5/3, 5/13 and 5/17/24 and that physician or nurse practitioner was notified regarding his vital signs. In a joint interview with the Dialysis Facility Administrator (FA) #300 and the Manager of Clinical Services (MCS) #301 on 5/22/24 at approximately 9:57am, FA #300 stated that access site care is before initiation of treatment. When asked about her expectation from nursing home staff after a resident received dialysis, FA#300 stated, CVC [central venous catheter], do not touch. For fistula and graft, no blood draw. The dressing on the site [fistula and graft] can be removed the next day if they had a late treatment. But generally, [it can be removed] the same day. When asked about the vital signs monitoring, FA#300 stated, Pre [dialysis treatment], every half hour and as needed. FA#300 stated that they monitor the weight pre and post dialysis treatment. FA#300 added, That's how much fluid is removed from the patient. When asked about the communication form, FA#300 stated, We complete the same form that were sent with the residents. FA#300 stated, We have a dietician that communicates weekly, discuss lab [laboratory] works weekly ad as needed, weight gain and nutritional needs. When asked if they review the communication form the nursing home, the FA#300 stated, RNs and PCT [patient care technician] review it. They take into consideration the last set of vitals [vital signs]. We do our own set of vitals. When asked about the expectation from the nursing staff after dialysis related to the access sites, FA#300 stated, Verify that the dressing is intact. [For fistula and graft] they have a dressing over the site. We don't want the same dressing when the resident comes back [for dialysis]. FA#300 explained, The residents are bringing the [communication] form and the resident take it back. It is not our responsibility that the nurses get it. I see forms [from previous dialysis treatment] sitting in the residents' wheelchairs [when they come back for the next treatment]. If they did not receive [the communication forms], they can call us. During an interview with the DON on 5/22/24 at approximately 3:34pm, when asked about the process of dialysis communication, the DON stated, Basically when a resident comes back, they email and also call. There is a dialysis communication form down at [name of dialysis center] and that goes into detail. The DON stated that the [name of dialysis center] dialysis communication forms were scanned in the residents' medical record. The surveyor informed the DON of R98's missing communication forms. When asked about the importance of completing those communication forms including the post treatment assessment, the DON stated, You want to monitor after dialysis and assess. The DON stated that resident's weight would be checked by the dialysis nurse to determine how much weight was taken off during the procedure. The DON added that the dialysis nurse would complete another form [Fluid and BP Management Report] during dialysis days. Review of R98's May 2024 Fluid and BP Monitoring Report forms contained pre and post BP, pre and post weight, target weight (weight without the excess fluid that builds up between dialysis treatments), weight loss, IDWG (excessive interdialytic weight gain, usually related to an overload of sodium and water) and UFR (ultrafiltration rate, composite metric of IDWG, treatment time and postdialysis weight, calculated with each dialysis). Review of the same records revealed that R98's target weight was 85.5 kg (kilogram). Further review of 5/1 to 5/20/24 forms revealed that R98's post wt (post dialysis weight) had been out of range ranging from 86.1 to 89.4 kg. 6.) During screening on 5/21/24 at approximately 1:48pm, R114 was observed in bed. R114 stated she had a good lunch. Review of R114's EHR record in PCC revealed an admitted [DATE]. R114's diagnoses included end stage renal disease and anemia in chronic kidney disease and dependence on renal dialysis. Review of R114's MDS dated [DATE] revealed a BIMS score of 4, indicating severe cognitive impairment. In the section Special Treatment and Programs revealed R114 had received dialysis. Review of R114's care plan with a review start date of 1/30/24 revealed, The resident needs hemodialysis d/t ESRD. The Interventions included Check for bruit and thrill per orders .Do not draw blood or take B/P in arm with graft .Encourage resident to go for the scheduled dialysis appointments .Medications per order .Monitor labs and report to doctor as needed .monitor vital signs as ordered. Notify MD of significant abnormalities .monitor/document/report PRN and s/sx of infection to access site .Monitor/document/report PRN for s/sx of renal insufficiency .Monitor/document/report PRN for s/sx of the following: bleeding, hemorrhage, bacteremia, septic shock .Monitor/document/report PRN new/ worsening peripheral edema .offer meals prior to dialysis . Review of R114's Orders revealed the following: - 1500 ml F/R (fluid restriction) 960 ml DTY 360 ml B and L 240 ml D, 540 ml NSG 270 ml q shift (start date 4/2/24) - Epoetin Alfa Injection Solution 10000 unit/ml. Use 1 ml intravenously one time a day every Mon, Wed, Fri for anemia to be administered during dialysis (start date 4/3/24) - Monitor dialysis catheter every shift and reinforce if needed (start date 4/2/24) - Renal Carb controlled diet, regular texture, thin consistency (start date 4/2/24) - Resident has dialysis at 4:45 (am) on M-W-F at (name of dialysis center) (start date 4/3/24) - Vital signs: Notify MD/NP for HR (greater than) 110 or (less than) 55, SBP (greater than) 160 or (less than) 90 .or for any acute change in condition (start date 4/3/24) Further review of R114's Orders revealed that the facility failed to indicate R114's dialysis prescription including the length of dialysis treatment time and resident's target weight. Review of R114's May 2024 MAR and TAR revealed the following: - R114 received dialysis on 5/1, 5/3, 5/6, 5/8, 5/10, 5/13, 5/15, 5/17 and 5/20/24. - VS were checked one time a day on Mon, Wed, Fri at 6am - dialysis catheter was monitored every shift except on 5/11 and 5/15/24 - Epoetin Alfa-epbx solution 10000 units/ml. Use 0.75 ml intravenously one time a day every Mon, Wed, Fri for anemia to be given in dialysis was marked given on 5/3, 5/6, 5/8, 5/10, 5/13, 5/15, 5/17, 5/20/and 5/22/24. Further review of R154's May 2024 MAR and TAR revealed no indication that VS were monitored after dialysis treatment. Review of R114's May 2024 Dialysis Communication Tool revealed R114's heart rates were as follows: 5/6/24 = 49 5/8/24 = 49 5/10/24 = 51 5/15/24 = 50 5/17/24 = 51 5/20/24 = 52 5/22/24 = 52 Review of R114's progress notes revealed no indication that the physician or nurse practitioner was notified of R114's heart rate on the above-mentioned dates. During an interview with the Registered Nurse (RN) #818 on 5/22/24 at approximately 1:32pm, RN#818 stated, [R114] gets hemo [hemodialysis]. When asked about the care for her access site, RN#818 stated, So for her, we just assess her access site. When she gets showers, we cover it. When asked when would nurses monitor R114's vital signs and weights, RN#818 stated that nurses would document in PCC and added, Before she leaves [for dialysis] and after [she comes back from dialysis. The weight for sure, we do pre [dialysis] weight before she goes down. We document pain. It would be the night shift nurse [who prepares the communication form]. They complete it because they send her down. Her [night shift] nurse, she medicates her, do her pre dialysis assessment and at that point the aide takes her to dialysis. They pack her food. When asked if nurses would complete an assessment including the VS and the dialysis access site upon return from dialysis treatment, RN#818 stated, [R114] returns on day shift. We would collect the communication tool. I like to look at it. I check the vitals [vital signs]. I asked how they feel, make sure they did not have pain at the [dialysis access] site. We don't have a particular piece [post dialysis note] in PCC. RN#818 added, That would be every shift vital signs. When asked to whom they would report complications or issues, RN#818 stated, Nephrologist and primary [physician]. We follow the primary [doctor]. When asked about R114's VS parameters and when nurses would notify the physician, RN#818 stated, [R114] is very hypotensive [low blood pressure]. [R114] gets Midodrine for low blood pressure [routine]. We don't have [VS] parameters for her. [R114] blood pressure is low. She runs like that. When asked if VS parameters would be important especially with R114 being hypotensive, RN#818 stated, For sure. Having parameters would be efficient. In an interview with RN#825 on 5/22/24 at approximately 2:05pm, RN#825 confirmed that night shift nurses prepared the dialysis communication tool. RN#825 stated, We get the vitals when they come back from [name of dialysis center]. [Name of main clinician at the dialysis center] she calls me. If there is something going on I tell the nurse and I make the changes for the nurse. [Name of main clinician] is good in letting us know. Sometimes, if there is bleeding, we monitor. When asked if nurses would complete an assessment when a resident returns from dialysis, RN#825 stated, No. The only time is when there is something acute going on. When asked when should nurses notify physician or NP related to VS, RN#825 stated, That is just nursing. We would call for anything below 100 for the systolic to make sure. When asked if nurses should notify physician about low heart rate, RN#825 stated, Yes, any below 60. When asked about the care provided to the dialysis access site, RN#825 stated, We are not allowed to take anything off. If the dressing comes off, we put it back, intact. Tape it up. No labs [and] no blood pressure [on the access site]. When asked if nurses would document assessment after a resident returned from dialysis, RN#825 stated, We document if there is something going on. Review of facility's policy titled Care of Dialysis Access Devices dated 7/21 revealed, 1. Upon return from dialysis, ensure fistula is assessed. Remove dressing if no active bleeding .2. Once dressing is removed, assess site for redness, swelling, bruising and pain. 3. Leave the fistula open to air. 4. Assess bruit and thrill every shift . Review of facility's policy titled Renal Residents with Dialysis dated 2/16 revealed, .7. Nursing staff to monitor for complications related to dialysis and ESRD, such as potential for bleeding, alteration in fluid volume, potential for infection, alteration in nutrition, alteration in skin integrity and the effect of dialysis r/t [related to] medications. 8. Nurse will assess hemodialysis site for s/sx [signs and symptoms] of infection, and to monitor for a bruit and thrill if indicated. 9. Resident will be monitored for s/sx of complications from dialysis upon their return to the facility. 10. The nurse will notify the MD [medical doctor] and the responsible party for any change in the resident's condition. 11. Nurse to communicate with dialysis via communication tool.

Based on observation, record review and interview, the facility failed to maintain dignity and respect at all times for Resident #62 and R448 by ensuring urinary drainage bags were covered. This affected two residents (#62 and R448) of two residents reviewed for dignity. The facility census was 188. Findings include: 1. Review of the medical record for Resident #62 revealed an admitted [DATE] with diagnoses that included quadriplegia, dysphagia, and neuromuscular dysfunction of the bladder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 was alert and oriented to person, place, time, and was dependent on staff for Activities of Daily Living (ADLs). Review of the care plan dated 11/17/16 revealed Resident #62 was at risk for skin breakdown related to quadriplegia with interventions that included providing incontinence care every 2 hours and as needed. Review of the physician orders dated 02/18/24 revealed an order to provide incontinence care every two hours and as needed every shift, change catheter drainage bag every 14 days and as needed every night shift and colostomy care every shift and as needed. Observation on 05/21/24 at 9:26 A.M. revealed Resident #62 foley bag was seen from the hallway outside of his room. Observation revealed a yellow liquid substance (urine) was filled to the 700 cubic centimeter line. No privacy bag was covering the foley bag. Observation revealed multiple staff and residents walking and/or ambulating past his room. Observation and Interview on 05/21/24 at 12:15 P.M. with Licensed Practical Nurse (LPN) #611 revealed Resident #62 foley bag was seen from the hallway, uncovered, exposing the resident's urine. LPN #611 revealed foley bags were only covered when being transported outside of rooms. LPN #611 confirmed and verified the above findings. Interview on 05/22/24 at 8:24 A.M. with LPN #433 revealed Resident #62 had a stoma that was connected to a urinary drainage bag and was to be changed every 2 hours or as needed. LPN #433 revealed all urinary drainage bags were to be covered with a privacy bag. Review of the facility document titled Toileting revised April 2023 revealed the facility and a policy in place that if a resident required assistance, staff were to follow the plan of care. Review of the document revealed the facility did not implement the policy. Review of the facility document titled Resident Rights dated June 2022 revealed the facility had a policy in place that residents had a right to a dignified existence. Review of the document revealed the facility did not implement the policy in regard to the allegation. 41749 2. During screening on 5/21/24 at approximately 9:43am, R448 was observed in bed. R448's urinary drainage bag was observed halfway filled with yellowish urine output. R448's door was open, and the uncovered drainage bag was facing the doorway, exposing R448's urine. R448's drainage bag was not covered, attached to the lower bed frame, and could easily be viewed from R448's doorway. Another surveyor confirmed the observation. Review of R448's health record revealed an admitted [DATE]. Review of R448's baseline care plan dated 5/18/24 revealed a care plan was developed related to indwelling urinary catheter. However, there was no evidence that a cover or privacy bag was addressed in the baseline care plan. Review of R448's Kardex (documentation system that gives a brief overview of individual resident care) revealed Bladder/Bowel. Catheter: the resident has 16Fr [French] 5 cc [cubic centimeter] indwelling urinary catheter. Position catheter bag and tubing below the level of the bladder and check for kinks at least q [every] shift. Empty foley catheter every eight hours and record output. Five-day bladder diary. However, there were no instructions on how to protect R448's dignity. During an interview with State tested Nursing Assistant (STNA) STNA #421 on 5/22/24 at approximately 1:05PM, STNA #421 revealed she was familiar with R448. When asked about the care and resident needs, STNA #421 stated they used the Kardex. When asked how she provided privacy for residents with catheter and urinary drainage bag, STNA#421 stated, We close the door. We have a bath blanket or sheet to put over them. We have a Foley [catheter] cover. In an interview with the Licensed Practical Nurse (LPN) #824 on 5/22/24 at approximately 1:12pm, when asked how staff including STNAs knew what kind of care they need to provide to residents, LPN #824 stated, When they [staff] come from another floor, they get a report from the aides [outgoing STNA] and they get a report from me. When asked how they would protect R448's privacy who had a catheter and was using a drainage bag, LPN #824 stated, You won't let it sit on the floor. Dignity, that's the whole purpose of that. When asked to check R448's Kardex if provision of a cover or privacy bag had been included, LPN #824 stated, No. But they know. I don't know if that's a Kardex thing. When asked how STNA would know to provide privacy bag for residents with catheters and urinary drainage bags, LPN #824 stated, They should know that. In an interview with the Director of Nursing (DON) on 5/22/24 at approximately 3:13pm, the DON confirmed that R448's Kardex did not include the use of privacy bag. The surveyor informed the DON of the above-mentioned observation. When asked if staff should provide a cover or privacy bag for the urinary drainage bag, the DON stated, It depends if the resident requests for a privacy bag [for a resident who is inside his/her room]. The DON added, Maybe we need re-education too [for the nursing assistant that needed the re-education]. Review of the facility policy titled Maintenance of Urinary Catheters dated 10/14 revealed .When the resident is out of their [sic] room, a foley bag cover must be in place . However, the policy did not instruct how to protect the dignity of residents with urinary drainage bags while inside their rooms when visible by residents and visitors from the hallway when the door is open.

Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan, physician orders, and interventions of monitoring and evaluation was in place for Resident #144's hand restraint. This affected one resident (Resident #144) of two residents reviewed for restraint use. The total census was 188. Findings include: Record review of Resident #144 revealed he admitted to the facility 10/04/23 and had diagnoses including sepsis, dementia, and tracheostomy status. Review of Resident #144's comprehensive care plan revealed the resident had a tracheostomy due to respiratory failure with an intervention initiated on 10/17/23 for bilateral hand mitts at all times to prevent decannulation. Remove and provide care every two hours and as needed. The care plan had not been revised and did not include specific interventions as to how often to monitor and evaluate the use of the restraint. Review of Resident #144's restraint assessment dated [DATE] revealed he required PRN (as-needed) mitt restraints to minimize risk for pulling out tracheostomy tubing due to agitated behavior and risk for serious injury or death. Review of Resident #44's Minimum Data Set assessment dated [DATE] revealed he was rarely or never understood and did not use restraints. Review of Resident #144's nurse practitioner note dated 05/21/24 revealed the resident had an unwitnessed JP ('Jackson Pratt') drain dislodgement and was to receive a trial of mitt restraints for two hours and to remove them if there was no restlessness or agitation. Review of Resident #144's active and discontinued orders revealed no evidence the restraints were ordered. Record review of Resident #144's progress notes and assessments revealed no specific documentation of when the restraints were applied and removed, no documentation of notification made to family of restraint use, and no monitoring or evaluation of the resident while the restraint was in use. Observation of Resident #144 on 05/21/24 at 10:05 A.M. revealed he was not interviewable. He wore a mitt restraint (a restraint made to prevent the wearer from closing their fingers around an object) on his right hand. The restraint was no longer present during a follow-up observation at 4:32 P.M. Interview with Licensed Practical Nurse #937 on 05/21/24 at 4:39 P.M. revealed she recalled Resident #144 had a history of needing mitt restraints but he had not needed them recently until this morning. She did not apply the restraint this morning, but did take them off the resident at roughly 12:00 P.M. Interview with the Director of Nursing on 05/22/24 at 2:25 P.M. confirmed Resident #144 did not receive any documented orders, monitoring, or family notification for the restraint use on 05/21/24. Review of the facility's restraint use policy updated 04/2024 revealed it stated restraints required an order when used for a period in excess of six hours. The facility was to determine the direct monitoring and supervision used during the period of restraint. Following surveyor intervention, the facility acquired a paper order dated 05/21/24 for the resident to trial hand mitts for two hours to the right hand and remove if there was no restlessness or agitation.

Based on observation, record review, interview, facility policy review, and review of the Centers for Disease Control (CDC) guidance, the facility failed to maintain proper infection control procedures for enhanced barrier precautions and failed to ensure the multi-use glucometer blood testing (BGT) machine was disinfected and sanitized effectively to prevent the potential for cross-contamination of blood borne pathogens. This affected Resident #162 who was in enhanced barrier precautions of 28 residents with physician orders for enhanced barrier precautions residing on the fourth floor including Resident #25, #31, #33, #63, #87, #91, #146, #149, #159, #162, #180, #196, #198, #200, #354, #358, #454, #455, #456, #457, #459, #460, #462, #463, #466, #468, #469 and had the potential to affect an additional eighteen residents residing on the 4th floor who were not in enhanced barrier precautions or isolation precautions and the finding affected Resident #166 who received a BGT on the 2 West Unit and had the potential to affect two additional residents (Residents #99 and #143) who receive BGT's on the 2 West unit. The census was 197. Findings include: 1. Review of the medical record for Resident #162 revealed an admitted [DATE]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed resident had impaired cognition and required extensive assistance for bed mobility, transfer, dressing, toilet, and hygiene. Review of physician order dated 04/18/23 revealed the resident #162 was to be on enhanced barrier precautions due to wounds with no end date. Observation on 05/07/23 at 8:56 A.M. revealed an enhanced barrier precaution sign on Resident #162's door with yellow caddy hanging on door with (PPE) to include gowns, gloves, masks. Licensed Practical Nurse (LPN) #742 walked into the room and took the blood pressure, pulse, administered medications, and assisted resident with opening items on the breakfast tray. LPN #742 did not have on the required PPE of a gown and gloves while providing direct care. Interview on 05/07/23 at 8:58 A.M. with LPN #742 verified she did not don personal protective equipment (PPE) before entering room to take vital signs, administer medications and assisted with opening meal items. LPN #742 stated she thinks the resident is in isolation for open areas, but he doesn't have any open areas. LPN #742 confirmed there was a sign on the door stating resident was in enhanced barrier precautions. LPN #742 reported she did not know why he was in enhanced barrier precautions. The facility procedure is to wear a gown and gloves with patient contact when the sign is on their door. On 05/08/23 at 1:20 P.M. notified Administrator regarding observation concern of staff not doing (PPE) for enhanced barrier precaution while providing direct care to Resident #162. Interview on 05/09/23 at 2:01 P.M. ADON/Infection Control Preventionist verified enhanced barrier precautions staff are to wear the following (PPE) to include gown, gloves, and surgical mask when providing care to the resident. Before exiting the room to doff gown, gloves, and surgical mask and perform hand hygiene. After exiting the room to apply a new surgical mask from the yellow caddy handing on the door with PPE included. Interview on 05/10/23 at 7:16 A.M. with Administrator verified for enhanced barrier precautions staff are to wear the following PPE to include gown, gloves, and surgical mask when providing care to the resident. Before exiting the room to doff gown, gloves, and surgical mask and perform hand hygiene. After exiting the room to apply a new surgical mask from the yellow caddy handing on the door with PPE included. Review of facility policy, Enhanced Barrier Precautions, revised 08/2022, revealed implementation of enhanced barrier precautions to make gowns and gloves available immediately outside of the resident's room. Review of the CDC guidance updated 09/27/22 titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic revealed health care personnel who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). 34297 2. Review of Resident #143's medical record revealed she was readmitted on [DATE] with diagnoses including diabetes mellitus, endocarditis and muscle weakness. Review of Resident #143's physician orders revealed an order dated 02/14/23 to administer lispro (fast acting insulin) per sliding scale if the blood glucose test (BGT) was 150 to 200 inject two units; 201 to 250 inject four units; 251 to 300 inject six units; 301 to 350 inject eight units; 351 to 400 inject 10 units and if greater than 401 inject 12 units and call the physician subcutaneously before meals and at bedtime for diabetes. Review of Resident #166's medical record revealed he was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including type one diabetes mellitus with hyperglycemia, chronic respiratory failure and major depressive disorder. Review of Resident #166's physician orders revealed an order dated 03/23/23 revealed to administer lispro per sliding scale and if the BGT was 150 to 200 inject two units; 201 to 250 inject six units, 251 to 300 inject eight units; 301 to 350 inject 10 units, 351 to 400 inject 14 units and call the physician for a BGT above 400 before meals and at bedtime related to type one diabetes mellitus with hyperglycemia. Observation on 05/07/23 at 11:03 A.M. with LPN #756 completed a BGT test for Resident #143 with a result of 116 and the resident did not require insulin. Observation on 05/07/23 at 11:07 A.M. revealed LPN #756 sanitized the BGT machine with an alcohol wipe (70% isopropyl alcohol). Observation on 05/07/23 at 11:08 A.M. revealed LPN #756 obtained Resident #166's blood sugar using the BGT machine with a result of 255. She then sanitized the glucometer with an alcohol wipe. Observation on 05/07/23 at 11:16 A.M. revealed LPN #756 adminsitered eight units of humalog to Resident #166 for a BGT of 255. Interview on 05/07/23 at 11:30 A.M. with LPN #756 confirmed she did not have the appropriate sanitizing wipes in the medication cart so she used an alcohol wipe to sanitize the glucometer following Resident #143's blood sugar and then she obtained Resident #166's blood sugar using the improperly sanitized BGT machine. She also confirmed she did not have the appropriate sanitizing wipes for the morning medication pass and she used the alcohol wipes to clean the glucometer after she completed BGT's for Residents #143, #166 and #99 during the morning medication pass. She acknowledged the alcohol wipe did not disinfect the BGT machine to prevent the potential for cross-contamination of blood borne pathogens per the facility policy. Review of the Blood Glucose Testing policy revised 10/14 indicated to clean the machine with a bleach wipe. This deficiency represents non-compliance investigated under Complaint Number OH00141614.

Based on observation, record review and interview the facility failed to ensure call lights were within reach and accessible for Residents #14, and #72. This affected two residents (#14 and #72) of 197 residents reviewed for call light placement. The facility census was 197. Findings include: 1. Record review revealed Resident #14 was admitted on [DATE] to the facility with diagnoses that included but not limited to seizures, hemiplegia, epilepsy, and multiple fractures of the pelvis. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 was moderately cognitively impaired and required extensive assistance of two staff for mobility, transfer, and toilet. Observation on 05/07/23 at 11:45 A.M. revealed Resident #14 was lying in bed. Resident #14's call light was observed lying on nightstand and not within reach of resident. Resident # 14 stated that she was getting over pneumonia. At the time of observation, Licensed Practical Nurse (LPN) #626 verified call light was out of reach and that Resident #14 can utilize call light. Review of care plans dated 09/28/20 with a revision date of 07/05/22 revealed Resident #14 had a potential risk for falls related to impaired mobility. Interventions include but are not limited to making sure the resident's call light is within reach and encouraging the resident to use it for assistance as needed. 2. Record review revealed Resident #72 was admitted on [DATE] to the facility with diagnoses that included but not limited to heart failure, paranoid schizophrenia, dementia, and repeated falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #72 was cognitively intact and required extensive assistance of two staff for mobility, transfer, and toilet. Observation on 05/07/23 at 10:49 A.M. revealed Resident #72 was lying in bed. Resident #72's call light was observed lying on the floor and not within reach of the resident. At time of observation, State tested Nurse Aide (STNA) #800 verified call light was out of reach and that Resident #72 can utilize call light. Review of care plans dated 01/31/19 with a revision date of 08/03/22 revealed Resident #14 had a potential risk for falls related to weakness and falls prior to admission. Interventions include but are not limited to a working and reachable call light.

Based on observation, record review and interview, the facility failed to ensure wound care was completed as ordered. This finding affected one (Resident #143) of three residents reviewed for wounds. Findings include: Review of Resident #143's medical record revealed she was readmitted on [DATE] with diagnoses including diabetes, difficulty in walking and chronic obstructive pulmonary disease. Review of Resident #143's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited intact cognition. Review of Resident #143's physician orders revealed an order dated 02/20/23 to cleanse the left lower extremity skin tear with normal saline, pat dry, apply an adaptic (non stick dressing) followed by a foam dressing three times a week and as needed. The wound care was due every day shift on Monday, Wednesday and Friday. Review of Resident #143' treatment administration records (TARS) from 05/01/23 to 05/08/23 revealed the skin tear wound treatment was documented as completed on 05/05/23 on the TAR. Observation on 05/07/23 at 10:24 A.M. revealed the dressing on Resident #143's left shin skin tear was dated 05/03/23. Interview on 05/05/23 at 10:25 A.M. with Licensed Practical Nurse (LPN) #756 verified the skin tear dressing was not completed on 05/05/23 as ordered but it was documented as completed on the TAR.

Based on observation, record review and interview, the facility failed to ensure Resident #165's pressure relieving foam boots were implemented as ordered. This finding affected one (Resident #165) of two residents reviewed for pressure wounds. The facility census was 197. Findings include: Review of Resident #165's medical record revealed he was admitted on [DATE] with diagnoses including muscle weakness, aphasia following a cerebral infarction and diabetes insipidus. Review of Resident #165's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited a memory problem. The medical record did not reveal current pressure ulcer wounds. Review of Resident #165's physician orders revealed an order dated 11/28/22 for pressure reduction boots to the bilateral feet as a preventative measure and check for placement. Review of Resident #165's Skin Care Plan indicated he was at risk for the development of skin breakdown and the intervention dated 11/29/22 indicated to apply pressure reduction boots to both feet as a preventative measure. Check placement every shift. Review of Resident #165's medication administration records (MARS) and treatment administration records (TARS) from 05/01/23 to 05/08/23 revealed the pressure reduction boots placement checks were scheduled twice daily from 7:00 A.M. to 7:00 P.M. and 7:00 P.M. to 7:00 A.M. Observation on 05/07/23 at 10:17 A.M. revealed Resident #165 was lying in bed. His right foot was observed outside of the sheet and his foot was lying on the bed with no pillow in place. He did not have a pressure reduction boot on his right foot during the observation. Interview on 05/07/23 at 10:22 A.M. with Licensed Practical Nurse (LPN) #636 confirmed Resident #165's pressure reduction boots were not on his bilateral feet and he was lying in bed with both heels on the bed. She denied he had skin breakdown or pressure ulcers. Observation on 05/09/23 at 8:20 A.M. revealed Resident #165 was lying in bed and his bilateral heels were observed on the bed. He did not have pressure reduction boots in place. Interview on 05/09/23 at 8:24 A.M. with Assistant Director of Nursing (ADON) #634 confirmed Resident #165's bilateral pressure reduction boots were not implemented per the order. Review of the Prevention of Skin Breakdown policy revised 08/18 indicated the charge nurse would communicate with the caregivers related to appropriate prevention measures including, but not limited to turn and reposition orders, incontinence care, pressure reduction devices and input from nutrition.

Based on record review and interview, the facility failed to ensure Resident #193 was provided adequate supervision during care to prevent a fall. This finding affected one (Resident #193) of two residents reviewed for falls. The facility census was 197 Findings include: Review of Resident #193's medical record revealed he was admitted [DATE] and readmitted on [DATE] with diagnoses including post traumatic seizures, muscle weakness and aphasia. Review of Resident #193's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated he exhibited severe cognitive impairment and required extensive two person assist for bed mobility and toilet use. He required total dependence two person assist for transfers and total dependence one person assist for dressing and eating. Review of Resident #193's physician orders revealed an order dated 11/16/22 and discontinued 05/04/23 to transfer the resident with a Hoyer mechanical lift with the assistance of two staff members every shift. Review of Resident #193's Morse Fall Scale form dated 12/26/22 revealed the resident was high risk for falls. Review of Resident #193's Un-Witnessed Fall Investigation form dated 01/25/23 at 11:53 A.M. indicated the resident was observed sitting on the floor with his legs stretched out in front of him on the right side of the bed. The nurse observed the resident's bed in a raised position with a Hoyer pad on the bed. Review of Resident #193's progress note dated 01/25/23 at 3:32 P.M. authored by Registered Nurse (RN) Unit Manager #708 indicated at approximately 11:53 A.M., the nurse was informed the resident was on the floor. Upon entering the resident's room, the nurse observed the resident sitting on the floor, with his legs stretched out in front of him on the right side of the bed. Non-skid socks were on his bilateral feet. The nurse observed the resident's bed to be locked and in a raised position with a Hoyer pad on the bed. The State tested Nurse Aide (STNA) indicated she provided the resident with personal care, placed a Hoyer pad underneath the resident and turned around to get assistance as well as the Hoyer mechanical lift when she heard a loud noise and observed the resident on the floor. Resident #193 was sent to the hospital and no apparent injuries were noted. Interview on 05/09/23 at 9:23 A.M. with RN Unit Manager #708 indicated the STNA told her that Resident #193 was on the floor. She assessed the resident with no apparent injuries. She confirmed his bed was in a high position. Interview on 05/09/23 at 9:41 A.M. with Rehab Director #797 indicated Resident #193 did not have an attention span and would try to jump out of the bed at any given moment. Telephone interview on 05/09/23 at 9:46 A.M. with STNA #900 stated she was providing personal care to Resident #193 with the bed in a high position and then left the room to get assistance with transferring the resident using a Hoyer mechanical lift. She indicated she was outside of the room when she heard a crash and observed Resident #193 on the floor. She denied Resident #193 had any injuries. Review of the Fall Management policy dated 11/16 indicated the facility would identify residents who were at risk for falls and would develop a Plan of Care and implement resident-specific interventions to manage falls and to try to keep the resident free from injury.

Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5% (percent). This finding affected two (Residents #75 and #125) of six residents observed for medication administration. A total of 26 medications were administered with two errors for a medication error rate of 7.69%. Findings include: 1. Review of Resident #125's medical record revealed he was readmitted on [DATE] with diagnoses including type two diabetes, end stage renal disease and muscle weakness. Review of Resident #125's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited intact cognition. Review of Resident #125's physician orders revealed an order dated 10/09/22 to administer lispro insulin (fast acting) if the blood sugar was zero to 149 administer then administer no units; 150 to 199 administer one unit; 200 to 249 administer two units, 250 to 299 administer three units, 300 to 349 administer five units, 350 to 399 administer seven units and if greater than 400 call the provider. Administer the insulin before meals for diabetes mellitus. Observation on 05/07/23 at 8:12 A.M. with Registered Nurse (RN) #737 of Resident #125's medication administration revealed eight medications were administered with one error. She checked his blood sugar using a glucometer blood glucose testing (BGT) machine with a result of 164. She stated she had to go to the medication storage room for the lispro insulin. Upon entering the resident's room, the breakfast tray was sitting on the bedside table and the meal was 100% consumed. Interview on 05/07/23 at 8:26 A.M. with RN #737 indicated she was unaware Resident #125's breakfast tray had arrived. She also confirmed she obtained the BGT after the breakfast meal was consumed and administered the insulin after the breakfast meal. She also indicated she did not administer Resident #78 or #71's insulin prior to the breakfast meal because she had been busy and she had yet to administer the insulin. She confirmed all meal trays had been delivered. 2. Review of Resident #75's medical record revealed he was admitted on [DATE] with diagnoses including unspecified dementia, muscle weakness and difficulty in walking. Review of Resident #75's MDS 3.0 assessment dated [DATE] revealed he exhibited a memory problem. Review of Resident #75's physician orders revealed an order dated 07/24/21 for cholecalciferol tablet (vitamin D3) administer 75 mcg (micrograms) by mouth one time a day for a deficiency (3000 units). Observation on 05/07/23 at 8:20 A.M. revealed Licensed Practical Nurse (LPN) #672 administered six medications to Resident #75 with one error. LPN #672 administered vitamin D3 1000 units (one tablet) and the order was for vitamin D3 3000 units (three tablets). Interview on 05/07/23 at 8:25 A.M. with LPN #672 confirmed she did not administer Resident #75's correct dosage of vitamin D3. A total of 26 medications were administered with two errors for a medication error rate of 7.69%. Review of the Medication Administration Times policy revised 10/14 indicated medication administration would be scheduled according to the resident's preference, past history and manufacturer's recommendations and physician orders.

Based on record review, observation, and interview, the facility failed to ensure pressure relieving interventions were effectively utilized to prevent the development of a stage two pressure ulcer for Resident #133, who was at risk for development of pressure ulcers. This affected one of three residents reviewed for pressure ulcers. Findings include: Review of Resident #133's medical record revealed she was admitted to the facility on [DATE], discharged to the hospital on 12/16/21 and readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #133's Braden Scale for prediction/risk of pressure ulcer development dated 12/07/21 indicated she was at risk for skin breakdown. Review of Resident #133's nursing admission assessment form dated 12/07/21 revealed her skin was intact when she was admitted to the nursing facility. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the five day admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #133 required extensive assist with two staff members for bed mobility, transfers and toilet use. Review of a nursing progress note dated 12/14/21 at 2:39 P.M. indicated, per Resident #133's daughter's request, the wound nurse was to assess Resident #133 in regards to her left heel and sacrum areas. The nurses' note indicated the wound nurse was notified and visited Resident #133. The physician was also notified and visited Resident #133. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .M. revealed Resident #133 complained her left heel hurt. The physician indicated they were not sure if this was a new area. The physician documented Resident #133's left leg was elevated on a pillow, but her left heel was observed resting on the bed. A dark, tender area was observed on Resident #133's left heel and the skin was intact. The physician documented in this note that a deep tissue injury (DTI), a persistent non-blanceable deep red, maroon or purple discoloration of intact or non-intact skin resulting from unrelieved pressure resulting in damage or injury to the soft tissue and may also appear as a fluid filled blister, was noted to Resident #133's left heel and was discussed with the wound nurse. The physician indicated nursing staff were to pad and protect the left heel, float the heel (off the bed surface, also know as offloading) and follow the wound weekly. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . and an order dated 12/23/21 to cleanse the left heel with normal saline, pat dry and apply a foam dressing every other day. Review of the admission MDS assessment dated [DATE] revealed Resident #133 exhibited moderate cognitive impairment. Review of the handwritten Skin Status Sheet assessment revealed Resident #133 had a facility acquired, stage two pressure ulcer, a partial thickness skin loss with exposed dermis which presents as a shallow crater or an intact blister on her left heel and was identified on 12/14/21. The first assessment column was dated 12/15/21 and indicated the pressure ulcer measured 3.0 centimeters (cm) long by 3.0 cm wide with no depth and presented as an intact blister. This assessment indicated there was no drainage, the peri-wound was intact and the tissue was described as boggy and warm. Review of the computerized Registered Nurse (RN) admit/readmit/change in condition wound assessment revealed Resident #133 had a change in condition on 12/14/21. A stage two pressure injury was identified on Resident #133's left heel as a facility acquired pressure ulcer. This assessment also indicated the pressure ulcer was a stage two, intact blister measuring 3 cm by 3 cm. Preventative measures which were to be in place included offloading of extremities, use of pillows or positioning device, and turn and reposition routine schedule. The causative factors section to list factors contributing to the alteration in skin integrity was blank. Review of the Skin Breakdown Care Plan dated 12/15/21 indicated Resident #133 was at risk for the development of skin breakdown with interventions including provision of incontinence care every two hours, pressure reducing devices on her bed/chair, monitoring of her nutritional status and turn/reposition every two hours or more often as needed. Resident #133 was discharged to the hospital on 12/16/21 and readmitted to the nursing facility on 12/23/21. Review of Resident #133's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/23/21, Resident #133's computerized Admission/Readmission assessment, section C for skin integrity, indicated Resident #133's left heel had an intact blister measuring 3.2 cm long by 3.0 cm wide and a foam dressing was applied. The computerized RN admit/readmit/change in condition wound assessment dated [DATE] revealed Resident #133's left heel remained a stage two pressure ulcer and measured 1.5 cm long by 2.0 cm wide with 0.1 depth. The surface of the pressure ulcer was crusted over 100%. There was no active drainage or odor. Resident #133 was to repositioned every two hours with side turns and with pillow placement under each calf to float her heels off of the mattress. Observation on 01/03/22 at 8:53 A.M. revealed Resident #133 was sitting up in a wheelchair. Resident #133 complained of pain in her left heel. She was leaving for [CONDITION(S)] and her heel pressure ulcer and treatment were not able to be observed. The handwritten wound assessment dated [DATE] indicated Resident #133's pressure ulcer remained a stage two and measured 1.5 cm by 2.0 cm with 0.1 cm depth. The wound bed was 100% crusted. There was no drainage, no tunneling/undermining, the wound had defined parameters and the peri-wound was intact. Resident #133 rated her pain a one, on a pain scale of zero to 10. The wound consult assessment dated [DATE] indicated Resident #133 was seen for the first time for her in-house acquired stage two pressure ulcer to her left heel. The consult indicated Resident #133 had neuropathies, an alteration due to nerve damage, in her lower legs/feet, which could impair the person's sensation and movement. Risk factors included impaired decreased mobility and decreased functional abilities. Recommendations under the Plan Orders section directed staff to elevate heels off mattress in bed with pillows or heel offloading boots. Telephone interview on 01/05/22 at 7:41 A.M. with an RN, Assistant Director of Nursing (ADON) #817, indicated Resident #133 tested positive for COVID-19 on 01/04/22. ADON #817 said Resident #133 and declined permission for the surveyor to observe her pressure ulcer and treatment provision. Interview on 01/05/22 at 9:24 A.M. with RN, Wound Nurse #815, indicated the physician informed her Resident #133's heel was resting on the bed and the resident had an acquired left heel pressure wound. Wound Nurse #815 indicated upon assessment, it was not a DTI but an intact blister, which was a stage two pressure ulcer. Interview on 01/05/22 at 10:25 A.M. with the Director of Nursing (DON) indicated the facility was not aware of Resident #133's left heel pressure ulcer until 12/14/21, when the daughter requested staff to assess her mother. This deficiency substantiates Complaint Number OH 477.

Based on record review and interview the facility failed to ensure advance directives for Resident #64 were accurately and consistently noted throughout the resident's medical record. This affected one resident (#64) of one resident reviewed for advance directives. Findings include: Review of the medical record for Resident #64 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #64's electronic physician's orders [REDACTED]. Review of the hard copy of medical record for Resident #64 revealed a signed advance directive for Do Not Resuscitate Comfort Care (DNRCC), care that eases pain and suffering but no resuscitative therapies. Interview on 12/03/19 at 8:52 [NAME]M. with Unit Manager (UM) #400 confirmed a DNRCC-Arrest order was noted in the electronic record and a DNRCC directive was noted in the hard copy of the medical record. Follow up interview on 12/03/19 at 11:24 [NAME]M. with UM #400 revealed Resident #64's desired advance directive was DNRCC-Arrest, and the social worker marked the wrong box on the advance directive in the hard chart. Interview on 12/04/19 at 4:03 P.M. with Licensed Practical Nurse (LPN) #401 revealed if she was unaware of a residents code status she could look for advance directives/code status under the patients name in the electronic medical record, and also in a sleeve in the front of the hard copy of the chart.

Based on observation, record review and interview the facility failed to ensure Resident #72, who had a urinary (Foley) catheter had timely orders, assessments and documentation of care appropriate for the management of the catheter. This affected one resident (#72) of one resident reviewed for urinary catheter care. Findings include: Record review for Resident #72 revealed the resident was admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. Review of the diagnosis list revealed no [DIAGNOSES REDACTED]. Review of the resident's progress notes revealed on 10/12/19 the resident experienced [MEDICAL CONDITION] and staff inserted a Foley. There were no physician orders received in regards to the Foley to remain in place or to receive regular hygienic care and/or bag changes until 12/04/19. The record included no specific documentation of Foley care, Foley bag changes, or assessment for potential to restore bladder functions or remove the Foley catheter. Observation of a Foley care procedure for Resident #72 by State tested Nursing Assistant (STNA) #402 on 12/04/19 at 9:02 [NAME]M. revealed the resident had a Foley catheter in place. There were no signs of infection noted. Interview with Registered Nurse #403 on 12/04/19 at 2:25 P.M. confirmed the above findings. Review of the facility urinary catheter maintenance policy, dated 10/2014 revealed Foley bags in the facility were to be changed every two weeks.

Based on observation, record review and interview the facility failed to provide Resident #171 with a comfortable home like environment. This affected one resident (#171) of 79 residents who resided on the second floor unit. Findings include: A tour of the environment was conducted with the Outside Electrical Contractor, (OEC) #500 who was an employee of the facility's maintenance team was conducted on 12/05/19 from 12:05 P.M. to 12:20 P.M. During the tour, observation of Resident #171's room revealed wall damage under the face bowl in need of plastering, sanding and painting. While standing in front of the face bowl, the bottom portion of the wall to the right was damaged and the lath and plaster screen used for wall plastering was exposed. Review of the daily maintenance work request log from 10/2019 to 12/5/2019 revealed no request for maintenance work for the room belonging to Resident #171. Interview with (OEC) #500 on 12/05/19 at 12:21 P.M. revealed all staff were responsible for reporting any maintenance concerns regarding the residents' room. Moreover, the maintenance department does not have the man power to conduct routine room checks for a large facility like this one and was dependent upon aides, nurses, and housekeeping to report concerns in the maintenance log book. The findings were confirmed with (OEC) #500 during the interview and repair work for the damaged walls would be taken care of.

Based on record review and interview, the facility failed to maintain acceptable parameters of nutrition, including monitoring and ensuring accurate resident weights for one resident (Resident #44) who was receiving enteral (feeding tube) nutrition. Actual Harm occurred when Resident #44 sustained a significant weight loss. This affected one resident (Resident #44) of seven residents reviewed for nutrition. The facility identified 29 residents receiving enteral feeds. The facility census was 196. Findings include: Review of Resident #44's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was cognitively impaired. A nurse practitioner note dated 03/12/18 revealed Resident #44 had a laryngeal mass and was not a surgical candidate at this time. Review of Resident #44's weights revealed on 01/04/18 the resident weighed 157.2 pounds, on 02/09/18, 156.0 pounds; on 03/12/18,163.6 pounds; on 04/13/18, 177.2 pounds; on 05/04/18,137.8 pounds; on 05/23/18, 144.4 pounds and on 06/06/18 the resident weighed 129.8 pounds. \The facility provided weights for (MONTH) (YEAR) not uploaded to the electronic medical record of 146.2 pounds and 140.6 pounds. This was indicative of a 14.1% significant weight change. There was a delay of approximately three weeks for a re-weight to be completed for the 05/04/18 weight. Review of Resident #44's weights also revealed limited documentation available regarding what scale was used to obtain the weights. Review of Resident #44's nutritional assessments dated 02/13/18 and 03/12/18 indicated her usual body weight was between 156 and 160 pounds. No specified scale for the obtained weights was noted in the assessments. Review of Resident #44's dietary progress notes completed by Registered Dietitian (RD) #301 dated 04/30/18 revealed a weight of 177.2 pounds, questioned the validity of the weight and noted a request for a re-weight. While a weight was obtained on 05/04/18, no progress note or assessment was completed until 05/28/18 when the monthly weight of 137.8 pounds was indicative of a 15.8% significant weight loss in two months. The re-weight of that weight at 144.4 pounds was indicative of a 11.8% significant weight loss in two months. The dietary progress note dated 05/28/18 questioned the validity of the weights and stated Resident #44 was to be weighed as a mechanical (Hoyer) lift. A dietary note dated 06/06/18 revealed a weight of 129.8 pounds, questioned the validity of the weight and stated the resident was weighed on the standing scale. Resident #44's enteral feeds were increased to provide an additional 60 calories per day and the resident was started on weekly weights at that time. Review of Resident #44's plan of care revealed the resident had unintended weight loss and suspected weight fluctuations due to being on the standing scale. The resident was to be weighed twice a week as an intervention but no scale was specified for these weights. Interview on 10/17/18 at 3:02 P.M. with RD #300, RD #301 and Nurse Practitioner (NP) #302 revealed re-weights were done if there was a five pound weight discrepancy and a list was given to the unit manager to facilitate obtaining the weights. RD #301 acknowledged the weight discrepancies during May, (YEAR) and stated she thought one weight was a mechanical lift weight and one was a wheelchair weight but did not know how Resident #44 was weighed unless it was documented. RD #301 stated even though there was significant weight loss Resident #44 was still within a normal body mass index (BMI) so she did not feel the need to be aggressive with Resident #44's enteral feeding and verified no changes were made to the feeding until 06/06/18. NP #302 stated with Resident #44's laryngeal mass, the resident could have a higher caloric need. Interview on 10/17/18 at 4:40 P.M. with the Assistant Director of Nursing (ADON) and Quality Assurance Nurse (QAN) #303 revealed when monthly weights were obtained, the scale used was also documented. The ADON and QAN #303 also shared the floor dietitian was responsible for determining the need for a re-weight. Phone interview on 10/18/18 at 9:57 A.M. with Registered Nurse/Unit Manager (RN/UM) #305 revealed Resident #44 had been weighed in a wheelchair and had weekly weights due to weight loss. RN/UM #305 stated the registered dietitian was responsible for asking for re-weights. Review of the facility policy titled Nutrition Documentation revised July, (YEAR) revealed progress notes were to be completed as needed according to change in weight and other significant changes. Review of the facility policy titled Weight Loss/Gain revised July, (YEAR) revealed if there was a five pound variance, it was mandatory to obtain a re-weight. Review of the facility policy titled Weight Measurements revised November, 2014 revealed the monthly weight worksheets designated the scale assigned to obtain the resident's weight and nutrition services would notify nursing if intervention was needed.

Based on observation, interview and record review, the facility failed to implement appropriate infection control interventions/procedures for two residents, Resident # 79 and Resident #177, who were on contact isolation. This affected two on contact isolation and had potential to affect all 68 resident residing on unit three. The facility census was 196. Findings include: Review of Resident # 79's medical record revealed a readmission date of [DATE] and [DIAGNOSES REDACTED]. CRE can be spread from person to person by touch or by direct contact with contaminated objects and surfaces (for example clothing, cell phones, door handles). A physician's orders [REDACTED]. Observation of Resident #79's room on 10/17/18 at 9:54 A.M. revealed a contact precaution sign with Personal Protective Equipment (PPE) hanging on the door. Registered nurse (RN) # 306 walked into the resident room without putting on a gown or gloves prior to walking in the room. An interview on 10/17/18 at 9:56 A.M. with RN #306 revealed that she did not believe that she had to wear PPE going into a room because the roommate (Resident #177) was on contact precautions but unaware that Resident # 79 was also on contact precautions for CRE. RN#306 stated that she was going to verify with the DON. On 10/17.18 at 10:05 A.M. RN #306 came to this surveyor and stated that she should have gowned and gloved when going into the room. An interview on 10/17/18 at 2:00 P.M. with RN #303 revealed that Resident #79 and Resident #177 were cohorting and were both on contact precautions for CRE.

Based on interview and record review, the facility failed to notify the office of the Long-Term Care Ombudsman of Resident #142 transfers to the hospital. This affected one of one resident reviewed for hospitalization and including 25 additional residents that were transferred to the hospital of which 11 residents transferred in (MONTH) (YEAR) (Residents # 61, #91, #92, #93, #138, #142, #187, #197, #208, #209 and #502) were not sent to the Ombudsman within 30 days. Findings include: Review of the medical record revealed Resident #142 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the census tab in the electronic record revealed he was admitted to the facility on [DATE]. She was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. She was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. She was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Interview with the Assistant Director of Nursing on 10/18/18 at 2:00 P.M. revealed the facility was sending transfers to the Ombudsman local office. The local Ombudsman's office stated transfer notices did not have to be sent to the local Ombudsman's office anymore and the facility did not realize that transfer notices still had to be sent to the state Ombudsman's office. On 10/18/18 at 12:04 P.M. the Director of Nursing sent hospital transfers to the office of the Long-Term Care Ombudsman and provided documented evidence of 26 resident transfers were sent with 11 residents transferred in early (MONTH) (YEAR) (Residents # 61, #91, #92, #93, #138, #142, #187, #197, #208, #209 and #502) were not sent within the 30 days requirement.

Based on record review and resident and staff interview, the facility failed to ensure Resident Rights were maintained regarding medication administration. This affected Resident #166 and had the potential to affect to affect an additional 199 residents currently residing in the facility. The facility census was 200 residents. Findings include: Resident #166 was admitted to the facility on [DATE] and identified to be his own responsible party. Medical history included [MEDICAL CONDITION], age related physical debility, abnormal gait and mobility, depression, [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of arteries of lower extremities, and Type 1 Diabetes Mellitus. Review of the quarterly Minimum Date Set (MDS) assessment dated [DATE] assessed Resident #166 to be cognitively intact, with no mood or behaviors noted. The resident required the assistance of one staff for activities of daily living, was frequently incontinent of bladder and always continent of bowel. The resident received no routine pain medications, had no skin breakdown, and received a diuretic (water pill) and an antipsychotic medication. Review of the concern log for the past 90 days identified an incident dated 03/23/18 involving Resident #166 who received insulin medication in error. This incident correlated with a self report incident (SRI) submitted to The Ohio Department of Health On 03/23/18. Review of the incident report investigation revealed on 03/22/18 at 9:30 P.M., Resident #166 was given 48 units of insulin ([MEDICATION NAME]), along with a stool softener ([MEDICATION NAME]) a central nervous system drug ([MEDICATION NAME]) and a suppository ([MEDICATION NAME]). The medications were ordered for his roommate, Resident #165. Resident #166 was sent to the hospital for observations. No negative results were identified for Resident #166 after receiving the medications by facility staff or hospital staff. The facility conducted nurse education regarding medication administration and Registered Nurse (RN) #412, received a disciplinary corrective write-up. Review of the (MONTH) (YEAR) monthly physician orders [REDACTED]. Review of the (MONTH) (YEAR) monthly physician orders [REDACTED]. On 03/30/18 at 1:00 P.M., Resident #166 was interviewed in his room. He was watching television, sitting in his wheelchair, and invited this surveyor in to sit and visit. Resident #166 confirmed he got his roommate's insulin in error and went to the hospital. Resident #166 stated he did not suffer any negative outcome and was just observed at the hospital. Resident #166 stated I told the nurse the medications were for my roommate but she just lifted by shirt and gave the medicine in my stomach. I don't have any hard feelings toward the nurse and I feel fine. I have diabetes but don't take insulin. I do have [MEDICAL CONDITION]. Resident #166 had clear speech, was clearly understood, and a very pleasant gentleman, wishing this surveyor a blessed Easter holiday when exiting the room. On 03/30/18 at 1:30 P.M., the roommate, Resident #165 was in the dining room after lunch. He was interviewed and did not express any concerns related to medication administration. On 03/30/18 at 3:30 P.M., an interview was conducted with the administrator and the director of nursing (DON). The DON confirmed that Resident #166 was alert and oriented and the nurse should have not proceeded to administer the medications when the resident told her the medications, including the insulin would be for his roommate, Resident #165. This deficiency substantiates Complaint Number OH 065.