Every finding on record at St Mary of the Woods

Based on medical record review, observation, interviews, facility policy review, and review of the Centers for Disease Control (CDC) guidelines, the facility failed to implement and/or maintain appropriate transmission-based and enhanced barrier precautions. This affected two residents (Residents #6 and #7) of two residents reviewed for infection control precautions. The facility census was 50.Findings include: 1. Review of the medical record for Resident #7 revealed he was admitted to the facility on [DATE] with diagnoses that included zoster ocular disease, herpes viral ocular disease, and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. Resident #7 required some assistance from staff for activities of daily living (ADLs). Review of the progress note dated 08/08/26 at 2:05 P.M. revealed Resident #7 reported experiencing diarrhea two to three times in the morning. Resident #7 received new orders to send a stool sample on 08/10/26 for Clostridioides Difficile (C. diff) testing (a communicable disease). Review of physician orders dated 08/08/26 revealed Resident #7 had an order to collect stool samples and to be sent to the laboratory on 08/10/26 for C. diff testing and to discharge the order once collected. Review of the care plan dated 08/10/26 revealed Resident #7 had a C. diff test completed and was awaiting the results with interventions that included remaining in contact precautions (to prevent the spread of germs passed by touching a resident or their environment) until results were available and for staff to adhere to contact precautions. Review of the physician orders dated 08/10/26 revealed Resident #7 was placed on contact precautions until C. diff results were in. Observation on 08/12/26 at 8:37 A.M. revealed Resident #7 had a contact precautions sign hanging outside his door and a plastic bin with personal protective equipment (PPE) located inside. The sign instructed staff to don and doff PPE including mask, gloves, and gown when entering and exiting Resident #7's room. Certified Nursing Assistant (CNA) #606 was observed inside of Resident #7's room without any PPE on. Interview on 08/12/26 at 9:05 A.M. with CNA #606, as she exited Resident #7's room, revealed he was on contact precautions due to being tested for some type of bacteria in his urine and the protocol was for staff to wear gloves and a gown. CNA #606, when asked why she was without PPE in the room, stated, I had to get his blood pressure reading. CNA #606 revealed PPE should be put on prior to entering the room and taken off in the bathroom prior to exiting the room. CNA #606 confirmed and verified Resident #7's contact precautions and her lack of wearing the required PPE while obtaining his blood pressure in the resident's room. Interview on 08/12/26 at 9:10 A.M. with Resident #7's wife revealed she was unsure why he was on contact precautions and needed to be tested, but confirmed CNA #606 had entered the room and was without PPE. Interview on 08/12/26 at 9:13 A.M. with Licensed Practical Nurse (LPN) #907 revealed Resident #7 was being checked for C. diff and staff were to wear a gown and gloves when entering his room. LPN #907 stated a mask was not required because Resident #7 was not tested for something that was airborne. LPN #907 revealed Resident #7 had pending test results for C. diff and stated until the results were known, staff were to follow PPE protocol for C. diff. LPN #907 confirmed and verified the above findings at the time of the interview. Interview on 08/12/26 at 9:19 A.M. with Housekeeper (HKP) #911 revealed she cleaned resident rooms every day and those with contact precautions were cleaned utilizing PPE. HKP #911 revealed when cleaning Resident #7's room, she was required to wear a gown, gloves, and a mask. HKP #911 revealed staff were not to remove any PPE until exiting the room. Review of the progress note dated 08/12/26 at 10:14 A.M. revealed Resident #7's C. diff results were negative, and he was no longer in isolation. Review of the facility policy titled, Infection Prevention and Control Program revised October 2022, revealed the facility had a policy in place to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. All staff should implement standard precautions and assume that all residents were potentially infected or colonized with an organism that could be transmitted while providing resident care services and all staff should use personal protective equipment (PPE). 2. Observation on 08/12/26 at 9:00 A.M. revealed Resident #6's room did not have a posted sign which would indicate transmission-based precautions or enhanced barrier precautions (EBP). Record review of Resident #6 revealed he was admitted to the facility on [DATE] and had diagnoses including one stage four (full-thickness) pressure ulcer, MRSA (Methicillin-resistant Staphylococcus aureus infection, a multi-drug resistant organism or MDRO), and urinary incontinence. He had no active physician orders for EBP or other infection precautions. The most recent wound assessment dated [DATE] revealed he had a current stage four pressure ulcer on his sacrum which was present on admission. Interview with LPN #405 on 08/12/26 at 10:23 A.M. confirmed the above findings and verified Resident #6 having a stage four pressure ulcer should be on EBP. (The facility then posted an EBP sign on Resident #6's door and initiated relevant orders.) Record review of the Center for Disease Control (CDC) website page titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated 04/02/24 revealed gown and gloves were indicated for nursing home residents with wounds when providing high-contact care due to the risk of transferring MDROs between residents. Review of the facility's infection prevention and control program policy dated 03/2025 revealed all staff were to assume that all residents are potentially infected with organisms that could be transmitted over the course of providing services. Residents were to be placed on transmission-based precautions as recommended by current CDC guidelines.

Based on record review, observation, facility policy review, and interview, the facility failed to ensure staff followed physician orders when administering Resident #26's and Resident #44's respiratory aerosol treatments. This affected two residents (#26 and #44) out of three residents reviewed for respiratory care. The facility census was 43. Findings include:1. A review of Resident #44's clinical record revealed an admission date of 02/18/26 with diagnoses including chronic obstructive pulmonary disease, emphysema, high blood pressure and cholesterol, atherosclerotic heart disease, esophagitis, peripheral vascular disease, stage IV chronic kidney disease, hyperparathyroidism secondary to renal origin, radiculopathy (spinal nerve compression), cataract, malaise, pupillary abnormality, and dysphagia (trouble swallowing). Resident #44 was discharged from the facility to her private residence on 02/25/26.A review of Resident #44's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #44 was alert and oriented with mild cognitive impairment, needed assistance with all activities of daily living and experienced shortness of breath at rest, with exertion, and while lying flat.Resident #44's hospital record dated 02/17/26 indicated she was admitted to the hospital with a diagnoses of exacerbation of chronic obstructive pulmonary disease with increased dyspnea on exertion and altered mental status. Symptoms had progressed per Resident #44's daughter since her fall 10 days ago with no traumatic injury noted. Resident #44's used five liters of oxygen continuously per nasal cannula to maintain an appropriate oxygen saturation. Resident #44 would need physical and occupational therapy to increase strength and functionality in acute and long-term care facilities. Resident #44 had experienced increased generalized weakness limiting participation in physical and occupational therapy sessions at home. Resident #44 required two-person assistance with transfers and mobility with increased continuous home oxygen.A review of Resident #44's physician orders dated 02/01/26 to 02/28/26 indicated to administer 3 milliliters of Ipratropium,-albuterol inhalation solution 0.5-2.5 (3) milligram/milliliter (combination of two bronchodilators) via inhalation orally five times a day while awake. Nurse to remain with resident the full 15 minutes during the respiratory treatment to monitor respiratory status. Administer continuous oxygen at five liters per minute.A review of Resident #44's nursing progress note dated 02/22/26 at 9:15 P.M. indicated Resident #44's family talked to the physician and requested to have Resident #44 sent to the hospital for an evaluation and treatment. The physician instructed the nurse on duty to send Resident #44 to the hospital for fluid overload, kidney failure and hypoxia. The Director of Nursing (DON) was notified of the situation and family concerns. A review of Resident #44's nursing progress note dated 02/22/26 at 9:36 P.M. revealed the family reported that they found Resident #44 hooked up to his nebulizer and not the oxygen. The family reported Resident #44 was disconnected from oxygen for a long period of time, was blue with oxygen saturation measured at 47 percent. The nurse on duty at that time implemented several interventions to return Resident #44 to her baseline breathing status. The oxygen saturation level increased to 97 percent. Resident #44 was noncompliant during the night and removed her oxygen per nasal cannula. Resident #44 would be monitored to maintain oxygen saturation above 93 percent throughout the night.An interview with Resident #44's daughter-in-law on 06/01/26 at 8:50 A.M. revealed Resident #44 had gone to the hospital after sustaining a fall at home. The hospital discharged Resident #44 to the facility for rehabilitation due to weakness and planned to return home upon discharge from the facility. Resident #44 daughter-in-law stated she was unable to remember the exact date when the family visited Resident #44 in her room and found her with the aerosol mask applied to her face and no oxygen was being administered with the aerosol treatment. Resident #44 was slumped over with her arm reaching for her oxygen tubing. There were no staff members in the room with Resident #44 during the respiratory aerosol treatment administration. Resident #44's daughter-in-law stated she reported the incident to the nurse (unnamed) and DON.An interview with Licensed Practical Nurse (LPN) #53 on 06/01/26 at 12:27 P.M. revealed she had reported to the DON that Resident #44's family was upset about the administration of Resident #44's respiratory aerosol treatment without her oxygen. LPN #53 stated the family told her Resident #44 had blue color, but when she assessed Resident #44, she was not blue and was alert and oriented. LPN #53 applied oxygen, and Resident #44 gradually returned to her baseline. An interview with LPN #51 on 06/01/26 at 2:09 P.M. revealed Resident #44's family had complained to her that they had entered Resident #44's room and found Resident #44 without her oxygen per nasal cannula and had the aerosol treatment mask still in place. Resident #44's family had reported Resident #44's oxygen saturation was low. LPN #51 stated residents with continuous oxygen were supposed to receive their prescribed oxygen during aerosol inhalation respiratory treatments.An interview with LPN #50 on 06/01/26 at 3:02 P.M. stated she was the nurse assigned to provide care for Resident #44 on 02/21/26 during the day shift from 6:30 A.M. to 7:00 P.M. LPN #50 verified the above findings and stated she had administered Resident #44's respiratory aerosol inhalation treatment at around 4:00 P.M. on 02/21/26 and verified she did not remain with Resident #44 during the treatment. LPN #50 stated Resident #44 was noncompliant with keeping her oxygen infusion during the respiratory aerosol treatment earlier in the day and generally didn't like to have her oxygen infusing at the time she received her respiratory aerosol treatments. LPN #50 could not remember if she encouraged Resident #44 to wear her oxygen during her aerosol respiratory treatment. LPN #50 could not remember how low Resident #44's oxygen saturation dropped, but it was less than 93 percent. Oxygen was administered to Resident #44, and her oxygen saturation normalized. Resident #44 was alert and talking during the incident and her lips had not turned a blue color. LPN #50 verified she should have remained with Resident #44 during the respiratory aerosol treatment. LPN #50 stated Resident #44 returned to her baseline mentation and respiratory status after the incident.An interview with the DON on 06/01/26 at 2:29 P.M. revealed she was notified by LPN #53 of the above incident and had conducted an investigation of the incident. The DON agreed LPN #50 should have stayed with Resident #44 during the respiratory aerosol treatment and agreed LPN #50 failed to follow the physician order and facility policy for administration of a respiratory aerosol treatment.2. A review of Resident #26's clinical record revealed an admission date of 05/29/26 with diagnoses including left kidney cancer with acute kidney failure and stage IV chronic kidney failure, high blood pressure, cholesterol and calcium level, cardiac pacemaker, gastroesophageal reflux disease, anxiety, depression, malnutrition with dehydration, hyperparathyroidism secondary to renal origin, and enlarged prostate with obstructive and reflux uropathy.A review of Resident #26's physician orders dated 05/01/26 to 06/01/26 indicated to administer ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml inhaled orally four times a day for shortness of breath and wheezing. Nurse to observe the resident during the full 15 minutes during the respiratory aerosol treatment for any change in condition.An interview with Resident #26 on 06/01/26 at 10:01 A.M. revealed the nurses did not stay with him to observe for changes in his condition during his respiratory aerosol treatments that he remembered. Resident #26 stated the respiratory aerosol treatments helped him breathe easier.An observation of LPN #52 administering Resident #26's respiratory aerosol treatment (ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml) on 06/01/26 at 11:48 A.M. revealed LPN #52 failed to perform a respiratory assessment prior to the administration of the respiratory aerosol treatment and failed to observe Resident #26 during the administration of the respiratory aerosol treatment for any changes in condition. An interview with LPN #52 on 06/01/26 at 11:56 A.M. verified she should have performed a respiratory assessment pre and post treatment and observed Resident #26 during the administration of the respiratory aerosol treatment. LPN #52 verified she failed to follow the physician's orders and did not perform an assessment of Resident #26's lungs before administering the respiratory aerosol treatment or observe Resident #26 during the administration of the respiratory aerosol treatment.A review of the facility policy titled Nebulizer Therapy dated 04/01/2022 indicated the policy was for nebulizer treatments to be administered by nursing staff as ordered by the physician using proper technique and standard infection control precautions. The policy explanation and compliance guidelines included to verify the practitioner's order and gather appropriate equipment and medication. Maintain infection control practices and obtain the resident's vital signs and perform a respiratory assessment to establish a baseline. Assemble tubing, nebulizer cup, and mouthpiece per manufacturer's specifications and ensure all connections were secured tightly. Place premeasured medication in the nebulizer cup and connect the nebulizer machine to the power source and turn the machine in the on position. Observe the resident for any change in condition during the treatment. Document the date, time and duration of the therapy, type of medication, oxygen flow, vital signs and respiratory treatment along with teaching provided to the resident. Clean and sanitize equipment after administration and perform a respiratory assessment post-treatment.This deficiency represents non-compliance investigated under Complaint Number 3027973.

Based on observation, policy review, and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 32 out of 36 residents who ate meals in the facility's kitchen. Four residents (Residents #1, #4, #10 and #24) received enteral nutrition and did not receive meals from the kitchen. The facility census was 36. Observations during the initial tour of the kitchen on 08/25/25 from 10:27 A.M. through 10:50 A.M. revealed the wall behind the grill and stove had grease built-up with food spattered, the deep [NAME] shield on the side of the deep [NAME] had half inch thick grease built up. The hood screens above the grill and stove had heavy grease buildup and the stove had burnt food and flood splatter all over it. The shelf under the steam table had grease buildup and food particles, also, the nine casserole dishes on the shelf were dirty with dried food. The reach-in cooler floor was wet with food particles on the floor and water was dripping from the vent on the ceiling, the outside of the cooler had brown fingerprints and liquid and food splatters on it. The shelf where the microwave was had crumbs and grease build-up. The outside of the ice cream freezer was dirty with brown and black spots and there were seven open three-gallon ice cream containers in the freezer with no lids on them. The floor under the prep table and storage area had black buildup and food particles. The walls in the kitchen were dirty with splatters of brown and black liquids and dirty handprints. Interview on 08/25/25 at 10:51 A.M. with Executive Chef #312 verified all dirty areas. Executive Chef #312 verified he did not have a cleaning schedule and does not know when the kitchen is being cleaned. Executive Chef #312 verified the hood screens are to be cleaned weekly but was unable to say when the last time the hood screens were cleaned. Executive Chef #312 verified he did not have any log on when the hood screens were last cleaned. The Executive Chef #312 stated the stove is used and it should be cleaned daily. He verified it did not look like the stove had been cleaned for a while. The Executive Chef #312 verified the kitchen was excessively dirty and needed a good cleaning. The Executive Chef #312 verified the above findings. Review of the facility policy, Kitchen Cleaning Schedules, dated 08/01/21 revealed cleaning tasks are identified and incorporated into a regular schedule. Cleaning schedules include kitchens, serving areas, and dining rooms. Employees are trained on proper cleaning and completion of tasks on the schedule. Hood filters are cleaned weekly. Cabinets and drawers are cleaned as part of a regular schedule and Walls are to be spot cleaned on an as-needed basis and washed yearly.

Based on medical record review, interviews, and review of facility policy, the facility failed to ensure the resident personal privacy and confidentiality of medical records was maintained. This affected one resident (#63) of two residents reviewed for medical record release. The facility census was 36. Findings include: Interview with Resident #58's Family Member (FM) on 08/27/25 at 1:32 P.M. revealed she received Resident #58's medical records as requested from the facility, however; it also included another Resident's (#63) personal information, date of birth , insurance, diagnoses, and complete care plan. Review of medical record package sent to Resident #58's FM by facility verified Resident #63's private information and medical information were included in the packet for Resident #58. Interview with the Director of Nursing (DON) on 08/27/25 at 1:15 P.M. verified the medical record requested for Resident #58 also contained Resident #63's personal private and clinical information sent from the facility. The DON also informed Resident #63's family of the breech in confidentiality and release of private information. Review of facility policy titled, Release of Medical Records Policy. dated May 2022 revealed all medical records will be released with a valid request and in accordance with state and federal laws. This deficiency represents non-compliance investigated under Complaint Number 2562366.

Based on record review, staff interviews, and facility policy, the facility failed to provide necessary respiratory care and services in accordance with professional standards of practice and facility policy. This affected one resident (#58) of three residents reviewed for oxygen administration. The facility census was 36.Review of medical record for Resident #58 revealed an admission date of 04/01/25 with diagnoses of acute respiratory failure with hypoxia, Parkinson's disease, heart failure with ejection fraction of 42%, dysphagia, history of falls, hypertension, myocardial infarction, and cognitive deficits.Review of the Minimum Data Set (MDS) assessment for Resident #58 dated 04/04/25 revealed the resident had cognitive decline as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. The resident was assessed to require some assistance for Activities of Daily Living (ADLs) but maximum assistance with hygiene/toileting needs related to shortness of breath with minimal exertion. Resident also required continuous oxygen per nasal cannula at two to three liters per minute.Record review of progress notes on 04/04/25 for Resident #58 revealed when the resident was having shortness of breath and restlessness with an oxygen saturation of 87-89%, the nurse placed a simple mask on the resident but left the oxygen flow rate at 3 liters per minute while awaiting the ambulance to transfer the resident to the hospital.Record review of the ambulance run report on 04/04/25 revealed when the squad arrived the resident's oxygen saturation at 89% with oxygen flow rate listed at only 1 liter per minute via simple mask. Squad immediately increased the flow rate to 8 liters per minute and the resident became more responsive. Re-assessment of pulse oximetry revealed the oxygen saturation was up to 93%. The resident was then transferred to the hospital and admitted with a diagnosis of respiratory failure.Interview on 08/26/25 at 8:19 A.M. with Licensed Practical Nurse (LPN) #406 stated she was aware of various oxygen flow rates for different oxygen delivery systems but could only state the parameters for nasal cannulas from one to five liters per minute. LPN #406 could not state what the flow rate would be for a simple mask or when she would place on a resident.Interview on 08/27/25 at 8:31 A.M. with LPN #387 was unable to state the flow rate parameters for the facilities oxygen delivery systems. LPN #387 stated he has never used a simple mask for a resident and only has used nasal cannulas.Interview of 08/27/25 at 2:06 P.M. with LPN #351 was unable to state the flow rate parameters for the facilities oxygen delivery systems. LPN #351 also had knowledge deficits related to the use of a simple mask.Observation of the facility's respiratory supply room revealed a large amount of respiratory equipment including nasal cannulas, high flow nasal cannulas, simple masks, aerosol treatment masks, and a non-rebreather mask.Interview with contracted Respiratory Therapist (RT) #516 on 08/27/25 at 3:40 P.M. revealed he was not onsite but supports the facility by setting up respiratory equipment for residents who need continuous positive airway pressure (CPAP), bilevel positive airway pressure (BIPAP) or tracheostomy oxygen set up with suctioning. He will also set-up water humidification for oxygen delivery systems that require humidification due to higher oxygen needs. RT #516 educates the staff on trach care and suctioning and performs the initial inner cannula exchange for trach residents. He stated he has not provided education to staff on oxygen flow rates. Interview with the Director of Nursing (DON) on 08/27/25 at 3:55 P.M. verified RT #516 is available to assist staff but he is contracted from Respiratory Partners who supply the equipment and oxygen concentrators to the facility. The DON stated she had not done education with staff regarding flow rates for the various oxygen delivery systems at the facility.Review of facility policy titled, Oxygen Administration, dated April 1, 2022 revealed a simple mask can deliver concentrations of 35-50% oxygen and requires a minimum of 5 liters/minute for use to prevent the resident from rebreathing carbon dioxide.This deficiency represents non-compliance investigated under Complaint Number 2562366.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure an indwelling urinary catheter was stabilized and maintained in a manner to prevent urinary tract infection ([CONDITION(S)]). This affected one resident (#17) out of three residents reviewed for an indwelling urinary catheter. The facility census was 45. Findings include: Review of the medical record for Resident #17 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #17's admission Minimum Data Set (MDS) 3.0 assessment, dated 05/01/22, revealed Resident #17 was cognitively intact. Resident #17 required the extensive assistance of two staff members for bed mobility and transfers. Resident #17 had an indwelling catheter for urine and was always continent of bowel. Review of the plan of care, dated 04/26/22, revealed the resident had an indwelling urinary catheter due to urinary retention. Interventions included positioning catheter bag below level of bladder, manipulating tubing as little as possible during care, reporting UTIs, and changing the catheter per physician order. Review of physician orders, dated 04/26/22, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 06/21/22 at 11:16 A.M. revealed Resident #17 sitting in her wheelchair with her urinary catheter drainage bag sitting next to her on the wheelchair seat. The urinary catheter drainage bag was not secured to the chair and the drainage tube was looping upward and stationary in a position above the resident's bladder. Interview and observation on 06/21/22 at 11:21 A.M. with Licensed practical Nurse (LPN) #905 verified the aforementioned findings. LPN #905 further verified the drainage tube was kinked which prevented urine from flowing through the drainage tube, and the Foley catheter stabilization device/lock normally located on Resident #17's inner thigh had become unattached and unsecured. LPN #905 retrieved and replaced the stabilization device. Review of the facility policy titled Infection Control Program, reviewed January 2022, revealed an important facet of infection prevention includes educating staff and ensuring they adhere to proper techniques and procedures.

Based on observation, interview,record review, and review of facilities policy, the facility failed to notify and obtain physician orders for the use of oxygen for one resident (Resident #14) of three residents reviewed. The facility census was 45. Findings include: Record review for Resident #14 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Minimum Data Set (MDS) for Resident #14 dated 06/02/22 revealed resident had moderately impaired cognition and required extensive assistance for bed mobility transfers and mobility. Record review of the progress note dated 06/19/22 at 10:29 A.M. completed by Licensed Practical Nurse (LPN) #906 revealed State tested Nursing Assistant (STNA) was toileting (Resident #14) and while washing (Resident #14) hands with the STNA, (Resident #14) knees felt weak and was lowered to ground. STNA called for the nurse, and nurse assessed (Resident #14). Patient stated her legs gave out. Vital signs were 128/75, 97%, two liters of oxygen, respirations were 16. No complaints of pain or shortness of breath. Record review of the physician orders for June 2022 revealed Resident #14 had no orders for use of oxygen. Observation on 06/21/22 at 10:53 A.M. revealed Resident #14 was sitting up in a recliner chair. A nasal cannula connected to a concentrator running at two liters per minute was lying on the bed next to Resident #14. Resident #14 revealed she was unsure how to put the cannula back on. Interview on 06/21/22 at 10:54 A.M. with LPN #906 revealed Resident #14 was to be wearing oxygen continuously at two liters per minute per nasal cannula. Observation with LPN # 906 verified the oxygen tubing was lying on the bed and revealed the therapy department must have forgot to put the oxygen back on after the therapy session. Observation revealed LPN #906 placed the nasal cannula back on Resident #14 to provide oxygen at two liters per minute. Observation on 06/22/22 at 09:05 A.M. revealed Resident #14 was sitting in the recliner chair. Resident #14 was wearing oxygen at two liters per minute per nasal cannula. Observation on 06/22/22 at 2:03 P.M. revealed Resident #14 was sitting in the recliner chair. Resident #14 was wearing oxygen at two liters per minute per nasal cannula. Interview on 06/22/22 at 2:42 P.M. with Certified Occupational Therapy Assistant (COTA) #908 confirmed she worked with Resident #14 on 06/21/22. COTA #908 confirmed she worked with Resident #908 without the use of oxygen. COTA #908 confirmed Resident # 14 did not have orders for oxygen. COTA #908 confirmed Resident #14's oxygen saturation was 95 with activity and did not require oxygen. Interview on 06/22/22 at 2:56 P.M. with LPN #906, verified Resident #14 did not have physician orders for the use of oxygen. LPN #906 revealed on 06/19/22 Resident #14 had a [CONDITION(S)] episode. LPN #906 revealed at that time she put oxygen at two liters per minute on Resident #14 as a nursing judgement. LPN #906 confirmed Resident #14 had been wearing the oxygen since 06/19/22. LPN #906 confirmed she did not update the physician or the Certified Nurse Practitioner (CNP) that she applied the oxygen or continued use of the oxygen. Interview on 06/22/22 03:07 P.M. with CNP #907 confirmed she or Resident #14's physician was not aware Resident #14 had been wearing oxygen that was initiated 06/19/22 and continued. CNP #907 confirmed the nursing staff could initiate the use of oxygen in an emergency but should have notified the physician or CNP within 24 hours, not four days, to obtain an order. Record review of the facility policy titled, Care Standards Oxygen Therapy dated January 2022, revealed oxygen will be administered per physician order by qualified personnel. In an emergency situation, the licensed nurse may administer no more than four liters of oxygen until the physician can be notified for further orders.

Based on medical record review, observation, and staff interview, the facility failed to ensure tube feeding poles and pumps were maintained in a clean and sanitary manner. This affected two (Resident #1 and #3) of three residents reviewed for tube feedings. The facility identified four residents who utilized tube feeding poles and pumps. The facility census was 45. Findings include: 1. Review of the medical record for Resident #1 revealed an admitted [DATE] with diagnoses including unspecified dementia without behavioral disturbance, gastrostomy status, and dementia with Lewy bodies. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and received tube feedings. Review of the plan of care initiated 02/02/22 revealed Resident #1 was at nutritional/hydration risk due to receiving 100% of nutrition and hydration via tube feeding. Interventions included [MEDICATION(S)] 1.5 at 60 milliliters (ml) per hour for 14 hours from 6:00 P.M. to 8:00 A.M. Observation on 02/28/22 at 8:49 A.M. of Resident #1's room revealed a tube feeding pole in the room. The tube feeding pole was observed to have dried formula on the pole, the pump, and the base of the pole. In addition, there was a black, dust-like substance on the back of the pump. 2. Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses included fracture of the sixth cervical vertebra, fracture of lower end of left humerus, fracture of nasal bones, and gastrostomy status. Review of the plan of care initiated 02/23/22 revealed Resident #3 was at nutritional/hydration risk due to receiving 100% of nutrition and hydration from tube feeding. Interventions included give tube feeding per the physician orders. Review of the physician orders for Resident #3 revealed Resident #3 received tube feeding of Pivot 1.5 at 90 ml per hour to run nocturnally from 4:00 P.M. to 8:00 A.M. Observation on 02/28/22 at 9:25 A.M. of Resident #3's room revealed a tube feeding pole in the room. The tube feeding pole was observed to have dried formula on the pole, the pump, and the base of the pole. Interview on 02/28/22 at 10:08 A.M. with Licensed Practical Nurse (LPN) #101 revealed Resident #1 and Resident #3 both received nocturnal tube feedings and both feedings ended at 8:00 A.M. LPN #101 stated she noticed both feeding poles and pumps were dirty when she turned them off this morning, but she had not had time to clean them yet. Interview on 02/28/22 at 1:25 P.M. of the Director of Nursing (DON) verified Resident #1's tube feeding pole and pump were dirty. The DON stated the equipment should be cleaned after each use. This deficiency substantiates Complaint Number OH 230.

Based on observation, record review, resident and staff interview, and policy review, the facility failed to ensure administered medications were taken by the residents. This affected one resident (#18) of one resident reviewed for self-administration of medication, with the potential to affect seven additional residents (#10, #11, #16, #21, #32, #35, and #41) who were identified by the facility as being cognitively impaired, and independently mobile. The facility census was 37. Findings include: Review of Resident #18's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively impaired. Additional review of Resident #18's medical record revealed there was no self-medication assessment, a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 11/18/21 at 8:05 A.M. of Resident #18's room revealed a medication cup on the resident's tray table with pills in the cup. Interview with Resident #18 at the time of the observation revealed the pills were prescription medications that were left on her tray table and she had not taken them yet. Interview on 11/18/21 at 8:40 A.M., with the Licensed Practical Nurse (LPN) #201 revealed the medications were left at the bedside for Resident #18 to take, she was a long-term regular resident and had not thought anything about leaving the medication. Interview on 11/18/21 at 11:12 A.M. with the Assistant Director of Nursing (ADON) #209 verified the medication pills were left on Resident #18's bedside table in a cup. The ADON #209 verified the resident was not approved to self-administer medication. Review of facility policy titled General Dose Preparing and Medication Administration, dated 01/01/13, revealed facility staff should not leave medications or chemicals unattended. This deficiency substantiates Complaint Number OH 336.

Based on review of a hospital occupational therapy progress note, review of a nursing admission assessment, facility self-reported incident (SRI) investigation, review of a staff witness statement, staff and resident interviews and review of facility policy, the facility failed to treat a resident with respect and dignity when staff refused to allow a resident to use the bathroom. This affected one (#31) of three residents reviewed for dignity. The facility census was 43. Findings include: Review of the medical record for Resident #31 revealed an admission date of [DATE]. Resident #31 was discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Review of a hospital occupational therapy progress note dated 11/17/20, revealed the resident required the supervision of one staff for a sit to stand transfer with a front-wheeled walker. The resident required the supervision of one staff and verbal cues during toileting. The resident was noted with normal balance while siting and good balance while standing. Review of the nursing admission assessment dated [DATE] at 9:28 P.M., revealed the resident was oriented to person, place and time. The resident was noted as alert, friendly and cooperative. Review of the admission bowel and bladder assessment revealed the resident was continent of bowel and bladder and used the toilet. The resident had adequate hearing and vision with glasses. The resident was able to communicate clearly. Review of the admission functional status revealed the resident could transfer and ambulate with a one person assist and used a walker. Review of the fall risk assessment revealed the resident had no history of falls in the previous six months. The resident had no dizziness or [MEDICAL CONDITION]. The residents was assessed as not having a high risk for falls. Review of the SRI dated 11/24/20 at 9:59 A.M., revealed education was completed for an employee who admitted telling the resident she could not use the bathroom until therapy had done their evaluation. Review of a witness statement by State tested Nursing Assistant (STNA) #170 dated 11/24/20, revealed on 11/18/20, she told Resident #31 she could not get out of bed until she was evaluated by therapy. The resident then began to get up again to use the bathroom. STNA #170 stated she told the resident she could put her on the bed pan. The resident said no and tried to get up again. STNA #170 stated she gently put her arm out in front of her, away from her but securing her to not fall. STNA #170 stated she reported to Licensed Practical Nurse (LPN) #240 and LPN #260 about what happened. Telephone interview on 11/24/20 at 3:35 P.M. with Resident #31, stated after she arrived at the facility, Nursing Assistant (NA) #180 took her to the bathroom. Resident #31 stated around midnight she asked to get out of bed to use the bathroom. Resident #31 stated the nursing assistant said she could not get out of bed per protocol until she had a therapy evaluation. Resident #31 stated the nursing assistant came back with a bedpan which she refused. Interview on 11/24/20 at 10:50 A.M., with STNA #170, stated there was a new admission who was upset that she was here. She stated the resident said we can't get people out of bed per protocol until therapy evaluates them. STNA #170 stated the resident was trying to get out of bed and she told the resident therapy needed to evaluate her first. STNA #170 stated she told the resident she could get up and move around tomorrow. STNA #170 stated the resident was irate. STNA #170 told the resident she would get the nurse. STNA #170 stated as she went to leave the room, the resident tried to get up and was teetering. STNA #170 stated she placed an arm out in front of the resident as she thought she would have to catch her. STNA #170 told the resident she was going to fall then the resident sat back down. STNA #170 stated she never touched the resident. STNA #170 stated she told LPN #240 the resident was trying to get out of bed. Interview on 11/24/20 at 11:39 A.M. with LPN #240, stated STNA #170, told him the resident was trying to get out of bed to use the bathroom and she had put an arm up to prevent her from falling. LPN #240 stated he told the nursing assistants if a resident wanted to go to the bathroom, then take them to the bathroom. Interview on 11/30/20 at 3:35 P.M. with the Director of Nursing (DON), stated the nursing assistant should have got a report from the nurse on the assistance level the resident needed. The DON revealed there was no protocol to use a bed pan until evaluated by therapy. The DON stated a resident can go to the bathroom unless they have restrictions. Review of the undated facility policy titled, Resident Rights, revealed it was the policy of the facility to ensure residents had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility.

Based on review of a facility self-reported incident (SRI), review of employee witness statements, resident and staff interviews, and review of the facility policy, the facility failed to implement their abuse policy requiring staff to timely report an allegation of resident abuse. This affected one (#31) of three residents reviewed for abuse. The facility census was 43. Findings include: Review of the medical record for Resident #31 revealed an admission date of [DATE]. Resident #31 was discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Review of the SRI dated 11/24/20 at 9:59 A.M., revealed on the morning of 11/24/20, the Administrator received notification of an abuse complaint. Conversations from 11/18/20 and 11/19/20 with the police detective and the Administrator were about 911 calls and a report made to the fire department. The detective confirmed no 911 calls were received/made by the resident and no concerns were relayed to the fire department. The detective stated there was an ongoing investigation with no concerns at this time. Based on a conversation with the detective and the Administrator at 10:00 A.M. on 11/24/20, the detective had interviewed the resident on the evening of 11/19/20 in the hospital. The resident said a nursing assistant used her forearm to push the resident back in bed. Review of a witness statement by State tested Nursing Assistant (STNA) #170, dated 11/24/20, revealed on 11/18/20, she told Resident #31 she could not get out of bed until she was evaluated by therapy. The resident then began to get up again to use the bathroom. STNA #170 stated she told the resident she could put her on the bed pan. The resident said no and tried to get up again. STNA #170 stated she gently put her arm out in front of her, away from her but securing her to not fall. STNA #170 stated she reported what happened to Licensed Practical Nurse (LPN) #240 and LPN #260 about what happened. Review of a witness statement by LPN #240 dated 11/24/20, revealed on 11/19/20, the nurse from dayshift (LPN #260) said Resident #31 told her the STNA's had pushed her down into bed. LPN #240 stated he told both STNA's on his shift what the resident told the other nurse. Telephone interview on 11/24/20 at 3:35 P.M., revealed Resident #31 stated approximately 12:00 A.M. on 11/19/20, she moved her leg as if to get up and the nursing assistant whacked her across the chest and knocked her down in the bed. Resident #31 stated she dialed 911 and the fire squad answered the phone but another staff took the phone out of her hand. The resident stated she called 911 again to pick her up. The resident stated she told two of the emergency responders what had happened. Interview on 11/24/20 at 10:50 A.M. with State tested Nursing Assistant (STNA) #170, stated Resident #31 was trying to get out of bed and she told the resident that therapy needed to evaluate her first. STNA #170 stated the resident was irate. STNA #170 told the resident she would get the nurse. STNA #170 stated as she went to leave the room, the resident tried to get up and was teetering. STNA #170 stated she placed an arm out in front of the resident and thought she would have to catch her. STNA #170 told the resident she was going to fall, then the resident sat back down. STNA #170 stated she never touched the resident. STNA #170 stated she told LPN #240, the resident was trying to get out of bed. STNA #170 stated she was at the nursing desk and LPN #240 told her the new admission was saying you did something to her. STNA #170 stated LPN #240 told her the resident said she was pushed. Interview on 11/24/20 at 11:39 A.M. with LPN #240, stated on 11/18/20, his shift started at 11:00 P.M. LPN #240 stated Resident #31 was sent to the hospital. LPN #240 stated after the resident was sent out, LPN #260 told him the resident said one of the STNA's pushed her back into the bed. LPN #240 stated he told the STNA's what LPN #260 had said. LPN #240 stated he talked to the Director of Nursing (DON) the next day. LPN #240 stated he told the DON he was not sure what had happened because he was on break. LPN #240 stated he notified the DON what LPN #260 said about the STNA pushing the resident back into bed. Interview on 11/24/20 at 12:11 P.M. with Nursing Assistant (NA) #180, stated on 11/18/20 and into 11/19/20, she cared for Resident #31. NA #180, stated the resident never mentioned any concerns, any abuse or any pushing. NA #180 stated she had not heard any concerns until she got a telephone call from the law enforcement detective. NA #180 stated the law enforcement detective called her on 11/20/20 at 9:58 A.M. NA #180 stated she returned the call to the detective on 11/20/20 at 11:35 A.M. The detective stated there was a complaint against her about being rough with a patient. NA #180 stated the detective told her the resident said a bed pan was on the floor and no one would take her to the bathroom and the resident said she was pushed back into the bed. NA #180 stated on 11/20/20 at 12:12 P.M., she called the Administrator and told him she was upset and asked what was going on, and asked him if she could come to work. NA #180 stated she told the Administrator there was an allegation of her being rough with a patient. Interview on 11/30/20 at 3:35 P.M. with the Director of Nursing (DON), stated she received a text on 11/19/20 from LPN #240 stating he had sent Resident #31 out to the hospital. The DON stated when she spoke with LPN #240, he never reported any allegations of abuse. The DON also stated LPN #260, NA #180 and STNA #170 also never reported any abuse allegations. The DON stated if the resident alleged something then the staff should have reported it to me. The DON verified the facility abuse policy required staff to immediately report allegations of abuse. Interview on 11/20/20 at 3:52 P.M. with the Administrator, stated a law enforcement detective had called him wanting to talk to staff about some alleged 911 calls from a resident. The Administrator stated the law enforcement detective had not informed him of an abuse allegation. The Administrator also stated staff had not notified him on 11/19/20, of an abuse allegation. Review of the facility policy titled, Abuse Prevention Program Policy & Procedure, revised 11/2018, revealed staff would report to their supervisor of potential characteristics or inappropriate behaviors by staff/resident or any that could potentially increase risk for abusive behavior. Further review of the abuse policy revealed all alleged or suspected violations were to be reported immediately to the Administrator or Director of Nursing, who were responsible to notify required officials and any other agencies in accordance with State law through established procedures. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were to be reported immediately, but not later that two hours after the allegation was made if the events that cause the allegation involve abuse or result in serous bodily injury.

Based on review of a facility self-reported incident (SRI), review of employee witness statements, resident and staff interviews, and review of the facility policy, the facility failed to timely report an allegation of resident abuse. This affected one (#31) of three residents reviewed for abuse. The facility census was 43. Findings include: Review of the medical record for Resident #31 revealed an admission date of [DATE]. Resident #31 was discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Review of the SRI dated 11/24/20 at 9:59 A.M., revealed on the morning of 11/24/20, the Administrator received notification of an abuse complaint. Conversations from 11/18/20 and 11/19/20 with the police detective and the Administrator were about 911 calls and a report made to the fire department. The detective confirmed no 911 calls were received/made by the resident and no concerns were relayed to the fire department. The detective stated there was an ongoing investigation with no concerns at this time. Based on a conversation with the detective and the Administrator at 10:00 A.M. on 11/24/20, the detective had interviewed the resident on the evening of 11/19/20 in the hospital. The resident said a nursing assistant used her forearm to push the resident back in bed. Review of a witness statement by State tested Nursing Assistant (STNA) #170, dated 11/24/20, revealed on 11/18/20, she told Resident #31 she could not get out of bed until she was evaluated by therapy. The resident then began to get up again to use the bathroom. STNA #170 stated she told the resident she could put her on the bed pan. The resident said no and tried to get up again. STNA #170 stated she gently put her arm out in front of her, away from her but securing her to not fall. STNA #170 stated she reported what happened to Licensed Practical Nurse (LPN) #240 and LPN #260 about what happened. Review of a witness statement by LPN #240 dated 11/24/20, revealed on 11/19/20, the nurse from dayshift (LPN #260) said Resident #31 told her the STNA's had pushed her down into bed. LPN #240 stated he told both STNA's on his shift what the resident told the other nurse. Telephone interview on 11/24/20 at 3:35 P.M., revealed Resident #31 stated approximately 12:00 A.M. on 11/19/20, she moved her leg as if to get up and the nursing assistant whacked her across the chest and knocked her down in the bed. Resident #31 stated she dialed 911 and the fire squad answered the phone but another staff took the phone out of her hand. The resident stated she called 911 again to pick her up. The resident stated she told two of the emergency responders what had happened. Interview on 11/24/20 at 10:50 A.M. with State tested Nursing Assistant (STNA) #170, stated Resident #31 was trying to get out of bed and she told the resident that therapy needed to evaluate her first. STNA #170 stated the resident was irate. STNA #170 told the resident she would get the nurse. STNA #170 stated as she went to leave the room, the resident tried to get up and was teetering. STNA #170 stated she placed an arm out in front of the resident and thought she would have to catch her. STNA #170 told the resident she was going to fall, then the resident sat back down. STNA #170 stated she never touched the resident. STNA #170 stated she told LPN #240, the resident was trying to get out of bed. STNA #170 stated she was at the nursing desk and LPN #240 told her the new admission was saying you did something to her. STNA #170 stated LPN #240 told her the resident said she was pushed. Interview on 11/24/20 at 11:39 A.M. with LPN #240, stated on 11/18/20, his shift started at 11:00 P.M. LPN #240 stated Resident #31 was sent to the hospital. LPN #240 stated after the resident was sent out, LPN #260 told him the resident said one of the STNA's pushed her back into the bed. LPN #240 stated he told the STNA's what LPN #260 had said. LPN #240 stated he talked to the Director of Nursing (DON) the next day. LPN #240 stated he told the DON he was not sure what had happened because he was on break. LPN #240 stated he notified the DON what LPN #260 said about the STNA pushing the resident back into bed. Interview on 11/24/20 at 12:11 P.M. with Nursing Assistant (NA) #180, stated on 11/18/20 and into 11/19/20, she cared for Resident #31. NA #180, stated the resident never mentioned any concerns, any abuse or any pushing. NA #180 stated she had not heard any concerns until she got a telephone call from the law enforcement detective. NA #180 stated the law enforcement detective called her on 11/20/20 at 9:58 A.M. NA #180 stated she returned the call to the detective on 11/20/20 at 11:35 A.M. The detective stated there was a complaint against her about being rough with a patient. NA #180 stated the detective told her the resident said a bed pan was on the floor and no one would take her to the bathroom and the resident said she was pushed back into the bed. NA #180 stated on 11/20/20 at 12:12 P.M., she called the Administrator and told him she was upset and asked what was going on, and asked him if she could come to work. NA #180 stated she told the Administrator there was an allegation of her being rough with a patient. Interview on 11/30/20 at 3:35 P.M. with the Director of Nursing (DON), stated she received a text on 11/19/20 from LPN #240 stating he had sent Resident #31 out to the hospital. The DON stated when she spoke with LPN #240, he never reported any allegations of abuse. The DON also stated LPN #260, NA #180 and STNA #170 also never reported any abuse allegations. The DON stated if the resident alleged something then the staff should have reported it to me. The DON verified the facility abuse policy required staff to immediately report allegations of abuse. Interview on 11/20/20 at 3:52 P.M. with the Administrator, stated a law enforcement detective had called him wanting to talk to staff about some alleged 911 calls from a resident. The Administrator stated the law enforcement detective had not informed him of an abuse allegation. The Administrator also stated staff had not notified him on 11/19/20, of an abuse allegation. Review of the facility policy titled, Abuse Prevention Program Policy & Procedure, revised 11/2018, revealed staff would report to their supervisor of potential characteristics or inappropriate behaviors by staff/resident or any that could potentially increase risk for abusive behavior. Further review of the abuse policy revealed all alleged or suspected violations were to be reported immediately to the Administrator or Director of Nursing, who were responsible to notify required officials and any other agencies in accordance with State law through established procedures. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were to be reported immediately, but not later that two hours after the allegation was made if the events that cause the allegation involve abuse or result in serous bodily injury.

Based on record review, observation, and staff interview, the facility failed to maintain a drainage bag for an indwelling urinary catheter in a manner to ensure the dignity of one (#285) out of three residents reviewed for personal privacy. The census was 48. Findings include: Review of Resident #285's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Observation of Resident #285 on 05/28/19 at 8:50 A.M. and 3:43 P.M., on 05/29/19 at 10:20 A.M., 11:50 A.M.,1:09 P.M., and 2:23 P.M., and on 05/30/19 at 8:50 A.M. revealed the resident was in his room lying in bed. Resident #285's catheter bag was attached to the bed frame facing the open door and without a cover. Interview on 5/30/19 at 8:50 A.M., with the Director of Nursing verified the observation of Resident #285's catheter bag being in view of the hallway and not covered.

Based on record review and staff interview, the facility failed to develop an initial baseline plan of care for one (#288) of 12 residents reviewed for initial baseline plans of care. The facility census was 48. Findings include: Review of Resident #288's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. It causes blood clots, can cause organ damage and death), [MEDICAL CONDITIONS], stage 3, [MEDICAL CONDITION] disorder, and [MEDICAL CONDITION] without behavioral disturbance. The record contained no evidence Resident #288 had an Initial Baseline Plan of Care developed until 05/29/19. Interview with the Director of Nursing (DON) on 05/29/19 at 10:20 A.M. verified she could not find any documented evidence the facility developed a baseline plan of care for Resident #288.

Based on observation, resident interview, family interview, staff interview and record review, the facility failed to provide assistance with activities of daily living of bathing, hygiene, and opening food packets for one (#291) of 12 residents reviewed for showers. The facility identified 48 residents who required staff assistance or were dependent for bathing and 26 residents who required assistance or were dependent for eating. The facility census was 48. Findings include: Review of Resident # 291 medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident # 291's plan of care, dated 05/22/19, revealed the resident had limited ability to perform his activities of daily living, including bathing, hygiene, and eating. The goal was for the resident to be well-groomed and dressed appropriately with proper hygiene maintained. Interventions included to provide assistance with activities of daily living. Observation on 05/28/19 at 12:20 P.M. revealed Resident #291's fingernails were soiled, his teeth were not brushed, and his hair was combed but not clean. On 05/29/19 at 10:50 A.M., 1:09 P.M. and 4:50 P.M., Resident #291 was observed seated in a recliner chair with dry, cracked, lips, his teeth not brushed, his fingernails remained dirty, and his hair was greasy and uncombed. Interview on 05/29/19 at 4:50 P.M. the Director of Nursing verified the unkempt appearance of Resident #291. Additionally, interview with Resident #291's family member on 05/28/19 at 11:00 A.M. revealed Resident #291 had vision problems. Since admission the staff have brought in his meal trays, opened up the silverware, and expected the resident to feed himself. Staff do not open packets for him and he has trouble getting the food items open. Resident #291's family member stated he has stayed with the resident to make sure he eats and receives care. Observation on 05/28/19 at 12:20 P.M. of Resident #291's lunch meal revealed the resident was in bed with his lunch tray setting on the bedside table out of reach and to his left side. The tray contained two small packets of peanut butter and three packets of saltine crackers. No other food items were on the tray. The peanut butter and crackers had not been opened and the silverware was out of the resident's reach. Interview at the time of the observation on 05/28/19 at 12:20 P.M., Resident #291 it was his choice to have the peanut butter and crackers and not the full lunch meal. He stated he was hungry, could not see the food packets and could not open the packets. Resident Interview on 05/28/19 at 12:30 P.M., Registered Nurse (RN) #509 verified the observation of Resident #291 and his food packages.

Based on record review, staff interview, resident interview, and review of facility policy, the facility failed to ensure pain medication were available and administered timely for one (#187) of two residents reviewed for pain. The facility identified 27 residents who required pain management. The facility census was 48 residents. Findings include: Review of the medical record revealed Resident #187 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the baseline care plan included improving pain and ambulation. Review of the nurses' note dated 05/25/19 at 2:40 P.M. revealed Resident #187 arrived to the facility status [REDACTED]. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. The 2:00 P.M. and 10:00 P.M. doses for 05/25/19 were not administered with the notation, drug/item not available; all three doses on 05/26/19 were marked as not administered and not available; and the 6:00 A.M. dose on 05/27/19 was marked as not administered and not available. Review of a prescription for [MEDICATION NAME], dated 05/28/19, was noted to not have been faxed to the pharmacy until 05/30/19. Review of the (MONTH) 2019 MAR indicated [REDACTED]. The MAR indicated [REDACTED].M. Review of a fax of a prescription dated 05/23/19 for [MEDICATION NAME] was noted to be received by the facility on 05/24/19. Interview on 05/28/19 at 10:13 A.M., Resident #187 revealed she was admitted to the facility on [DATE] at 1:30 P.M. and did not receive her [MEDICATION NAME] until nearly 6:00 A.M. on 05/26/19. The facility had to obtain the medicine from the pharmacy. Resident #187 shared she had been at the facility previously and had trouble with her pain medications at that time as well. Interview on 05/30/19 at 4:17 P.M., Licensed Practical Nurse (LPN) #506 revealed when a new resident came into the facility, the prescriptions needed to be sent as quickly as possible so the pharmacy could fill the orders. LPN #506 nurses can obtain an authorization to pull medication from the facility's contingency box and the process would not have taken more than several hours. Interview on 05/30/19 at 4:57 P.M. and 5:24 P.M., the Assistant Director of Nursing (ADON) confirmed the [MEDICATION NAME] script was received by the facility on 05/24/19 and verified the medication should have been filled timely. Review of the facility's policy titled Medication Pass, revised (MONTH) 2019, revealed all new medication orders were to be started after the next regular medication delivery time unless ordered now.

Based on record review, observation, staff interview, visitor interview, and review of facility policy, the facility failed to ensure information signage was properly posted on the door of a room with contact isolation and failed to ensure visitors were educated on the need for precautions when visiting one (#285) three residents on contact isolation precautions. The facility census was 48. Findings include: Review of Resident #285 medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #285 was on contact isolation for [MEDICAL CONDITIONS]. Review of Resident #285's Initial Base Line Plan of Care dated 05/20/19, revealed the resident was on isolation for [MEDICAL CONDITION], ([MEDICAL CONDITION]). Interventions included gown, gloves and handwashing. Observation of Resident #285 on 05/28/19 at 8:50 A.M. revealed the resident was in his room in bed with the call light within reach. The educational precautionary signage alerting the public of a potential for precautions was posted on the inside of the door and when the door was closed was not visible to warn visitors from entering the room. Interview with Licensed Practical Nurse (LP) #511 on 05/28/19 at 8:50 A.M. verified the lack of signage on the door for Resident #285. An additional observation on 05/28/19 at 1:50 P.M. revealed the two visitors were seated talking with Resident #285 in his room. Neither visitor had a gowns on. From the doorway the surveyor asked if the visitors were aware the resident was on isolation. Both visitors stated the saw the sign, but no one told them what the needed to do. Both visitors stated the nurse came in and did not say anything to them about putting on gowns. Interview on 05/28/19 at 1:57 P.M. the Administrator verified Resident #285 was on isolation and required to have his visitors wear gowns. The Administrator verified the visitors required additional education to find to nurse for guidance when a resident was on isolation. Interview with the Director of Nursing (DON) on 05/28/19 at 2:00 P.M. verified Resident #285 was on contact isolation which included all visitors and staff to wear gowns while visiting the resident. Review of the facility policy titled Isolation- Categories of transmission-Based Precaution, dated 12/20/15, revealed Contact- Based Precaution are for resident who are known or suspected to be infected or colonized with infectious agents, including certain epidemiologically pathogens, which require additional control measures to effectively prevent transmission. Wear a disposable gown upon entering the Contact Precaution room. Gown is to be donned prior to entering resident's room and removed prior to exiting.

Based on record review, staff interview, review of the facility's self-reported incidents and review of facility policy, the facility failed to implement their abuse policy by not reporting an allegation of misappropriation to the State Agency, the Ohio Department of Health. This affected one (#47) of three residents reviewed for abuse. The facility census was 46. Findings include: Review of the closed medical record for Resident #47 revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Resident #47 received two tablets on each of three occasions on 07/22/18 during the day shift. Review of the narcotic record revealed two [MEDICATION NAME] tablets were signed as wasted on 07/22/18 at 4:30 P.M. with two signatures next to the word wasted. Interview on 02/11/19 at 11:35 A.M. with the Director of Nursing (DON) revealed in (MONTH) (YEAR), a nurse had been suspected of replacing narcotic pain medication with a non-prescription medication instead of wasting it as she claimed she had. The DON stated a new nurse, Licensed Practical Nurse(LPN) #224, was cosigning the wasting of [MEDICATION NAME] with LPN #222 at her request, after which she told LPN #223 who was supervising that she didn't actually see the medication because LPN #222 put it in the sharps container quickly. The DON stated LPN #224 saw the sharps container was nearly empty as it had recently been replaced so she removed it from its holder and took the whole container to the supervisor who dumped it out. She stated since there was only one syringe in there and said the pills were actually Tylenol but put them back in the sharps container. She stated the investigation was completed by Registered Nurse #217 in her absence since she was on vacation but she had been notified by phone. The DON stated Registered Nurse #217 came to the facility on [DATE] at 6:15 P.M. and notified the police of alleged missing [MEDICATION NAME] tablets. Further interview on 02/11/19 at 1:35 P.M. with the DON confirmed that the facility did not file a Self-Reported Incident (SRI), notifying the state agency of the misappropriation of the two [MEDICATION NAME] tablets. Review of the facility's SRIs from 07/01/19 through 02/08/19 revealed there was no SRI reported involving Resident #47 and misappropriation of the narcotic pain medications. Review of the facility's abuse policy, revised (MONTH) (YEAR), revealed the facility was to report allegations of abuse to the State Agency and law enforcement. This deficiency substantiates Complaint Number OH 990.

Based on record review, staff interview, review of the facility's self-reported incidents and review of facility policy, the facility failed to report an allegation of misappropriation of medication to the State Agency, the Ohio Department of Health. This affected one (#47) of three residents reviewed for abuse. The facility census was 46. Findings include: Review of the closed medical record for Resident #47 revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Resident #47 received two tablets on each of three occasions on 07/22/18 during the day shift. Review of the narcotic record revealed two [MEDICATION NAME] tablets were signed as wasted on 07/22/18 at 4:30 P.M. with two signatures next to the word wasted. Interview on 02/11/19 at 11:35 A.M. with the Director of Nursing (DON) revealed in (MONTH) (YEAR), a nurse had been suspected of replacing narcotic pain medication with a non-prescription medication instead of wasting it as she claimed she had. The DON stated a new nurse, Licensed Practical Nurse(LPN) #224, was cosigning the wasting of [MEDICATION NAME] with LPN #222 at her request, after which she told LPN #223 who was supervising that she didn't actually see the medication because LPN #222 put it in the sharps container quickly. The DON stated LPN #224 saw the sharps container was nearly empty as it had recently been replaced so she removed it from its holder and took the whole container to the supervisor who dumped it out. She stated since there was only one syringe in there and said the pills were actually Tylenol but put them back in the sharps container. She stated the investigation was completed by Registered Nurse #217 in her absence since she was on vacation but she had been notified by phone. The DON stated Registered Nurse #217 came to the facility on [DATE] at 6:15 P.M. and notified the police of alleged missing [MEDICATION NAME] tablets. Further interview on 02/11/19 at 1:35 P.M. with the DON confirmed that the facility did not file a Self-Reported Incident (SRI), notifying the state agency of the misappropriation of the two [MEDICATION NAME] tablets. Review of the facility's SRIs from 07/01/19 through 02/08/19 revealed there was no SRI reported involving Resident #47 and misappropriation of the narcotic pain medications. Review of the facility's abuse policy, revised (MONTH) (YEAR), revealed the facility was to report allegations of abuse to the State Agency and law enforcement. This deficiency substantiates Complaint Number OH 990.

Based on observation, record review, and staff interview, the facility failed to ensure medications were administered as ordered which resulted in a 6.89% error rate. This affected one (Resident #120) of six residents observed for medication administration. The facility census was 33. Findings included: Observation of medication administration on 10/21/15 at 10:15 A.M., revealed LPN #100 administered six oral medications to Resident #120. One of the medications administered was one chewable aspirin pill (81 milligrams). Another medication administered to Resident #120 was one Vitamin D capsule (1000 units). Review of Resident #120's medical record revealed monthly physicians orders dated 10/15/15 included an order for [REDACTED]. Interview on 10/21/15 at 10:05 A.M., with LPN #100 verified she gave Resident #120 a chewable aspirin when the physicians order was for an [MEDICATION NAME] coated aspirin. LPN #100 also verified she gave Resident #100 one Vitamin D instead of two as ordered by the physician.

Based on observation, record review, review of facility wound care protocols, and staff and resident interview, the facility failed to implement assessed pressure relief to Resident #16's heels to prevent the development of an avoidable stage four pressure ulcer to the left heel. This deficient practice caused one (#16) of two residents identified by the facilty to have in-house acquired pressure ulcers to experience actual harm. A total of eight records were reviewed out of a current facility census of 20 residents. Findings include: Review of Resident #16's medical record revealed the resident was admitted to the facility on [DATE] from the hospital following surgical repair of a left [MEDICAL CONDITION]. Additional [DIAGNOSES REDACTED]. The initial Minimum Data Set (MDS) assessment, dated 06/27/10, assessed Resident #16 to be non ambulatory, required assist of two staff for bed positioning and transfers, had limited range of motion of the left leg, and had a Stage IV pressure ulcer. The pressure ulcer risk assessment (Braden Scale) completed on 06/20/10, identified Resident #16 with a score of "16" (mild risk). The resident was bedfast and had very limited mobility (occasional slight changes in body or extremity position but unable to make frequent or significant changes independently). The Braden Scale assessment tool was provided by the director of nursing (DON) on 09/15/10. The tool indicated that protecting heels was an intervention to be initiated for all scores of mild, moderate, high and very high risk residents. Review of the resident's plan of care (POC) dated 06/23/10, revealed the POC did not identify any individual interventions had been initiated to protect heels at the time of admission. Review of the weekly pressure ulcer log identified Resident #16 was assessed with [REDACTED]. The DON was interviewed on 09/15/10 at 3:30 P.M. She verified Resident #16 acquired an in-house pressure ulcer to his left heel. She stated he was "very unique" to position, due to his [DIAGNOSES REDACTED]. She confirmed the only pressure reducing intervention initiated upon admission was the standard pressure reducing mattress (standard for all residents admitted to the facility.) She stated individualized interventions of an air mattress, pad and protect heels, and floating heels off bed using pillows were not initiated until after the wound was discovered on 06/26/10. On 09/16/10 at 1:30 P.M., Resident #16 was interviewed and the left heel treatment was observed. He confirmed he was bedfast when he was first admitted to the facility following hip repair surgery. He confirmed he no longer had any hip pain, but now had left heel pain. Observation of the left heel dressing change at this time revealed a black scabbed heel, the size of a half dollar, with edges beginning to pull away from the heel bed. The old dressing had light yellow and blood stained drainage. There was no odor. During the dressing change, Resident #16 reported some discomfort, but stated he recently received [MEDICATION NAME] (Tylenol) for pain and the treatment was tolerable. He stated he now has a special Velcro, hard sole shoe he wears during the day when self propelling his wheel chair. At night, he reported he wears a padded boot to keep the left heel elevated off the bed. Review of the facility's Wound Care Protocol dated May 2008 noted pressure ulcer reduction and prevention included to raise heels off bed with pillows or with heel/foot protective devices. The facility failed to prevent an an avoidable in-house acquired left heel pressure ulcer for Resident #16. Individualized interventions were not implemented after the resident was assessed to be at risk for pressure ulcer development at the time of admission. The facility did not implement their wound care protocol of protecting the heels with heel/foot devices and/or elevating heels off the bed with pillows.