Every finding on record at Twilight Gardens Nursing and Rehabilitation

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure residents were included in care plan conference meetings. This affected four (#24, #50, #9, #13) of four residents reviewed for care planning. The facility census was 77. 1.Review of the medical record for Resident #24 revealed an admission date of 02/04/26. Diagnoses included depressive disorder, anxiety, type two diabetes mellitus, and chronic kidney disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. Further review of the MDS assessments revealed the resident discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the resident's assessments from 02/04/26 through 03/19/26 revealed no documentation the resident had a care plan conference and no documentation the resident was invited to attend a care plan conference. Interview on 03/18/26 at 1:26 P.M. with Resident #24 revealed she had not been invited to participate in care planning meetings. Interview on 03/18/26 at 4:44 P.M. with Social Service Designee (SSD) #215 revealed residents should have care conference meetings upon admission, quarterly, and as needed. SSD #215 revealed letters were sent to the residents and their representatives. SSD # 215 revealed care conferences were usually held within seven days of admission. Interview on 03/19/25 at 8:19 A.M. with SSD #215 verified Resident #24 had not had a care conference as it must not have been scheduled. SSD #215 revealed being behind with care planning conferences for the new resident admissions. 2. Review of the medical record for Resident #50 revealed an admission date of 02/24/26. Diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, dependence on renal dialysis, dependence on ventilator status, gastrostomy status, and urinary incontinence. Review of the MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the care plan dated 03/18/26 revealed the resident was admitted to the facility for long term care. Interventions included to invite the resident and family to care conferences to discuss status and care. Review of the resident's assessments from 02/24/26 through 03/19/26 revealed no documentation the resident had an admission care plan conference and no documentation the resident/resident representative was invited to attend a care plan conference. Interview on 03/19/25 at 8:19 A.M. with SSD #215 verified Resident #50 had not had a care conference since admission. SSD #215 revealed she was behind with care conferences for the newly admitted residents. 3. Review of the medical record for Resident #13 revealed an admission on [DATE]. Diagnoses included paranoid schizophrenia, generalized anxiety disorder, and major depressive disorder. Review of the quarterly MDS 01/23/26 revealed Resident #13 had intact cognition, and was dependent on care for toileting, bathing, and transferring. Review of the care plan dated 07/17/25 revealed Resident #13 was admitted to the facility for long term care. Interventions included inviting the resident and family to care conference to discuss status and care, and address issues and concerns as they arise. Review of the medical record for Resident #13 revealed a Multidisciplinary Care Conference on 09/02/25 that was not completed. Further review of the Multidisciplinary Care Conference revealed there were no further care conferences held till 11/11/25. Interview with the DON on 03/19/26 at 11:50 A.M. confirmed that on 09/02/25 there was no documentation for the care conference, and no further care conference was held until 11/11/25. 4. Review of the medical record for Resident #9 revealed an admission date on 02/02/24. Diagnoses included paranoid schizophrenia, exudative age-related macular degeneration to the right eye, anxiety, and major depressive disorder. Review of the quarterly MDS dated [DATE] revealed Resident #9 had intact cognition. Resident #9 was independent with ADLs. Review of the care plan dated 02/02/24 revealed Resident #9 was admitted to the facility for long term care. Interventions included addressing issues and concerns as they arise, inviting the resident and family to care conferences to discuss status and care. Review of the medical record for Resident #9 revealed a Multidisciplinary Care Conference on 06/17/25 that was not completed. Interview on 03/19/26 at 11:50 A.M. with DON confirmed the Multidisciplinary Care Conference on 06/17/25 was not completed and care conferences were to be held every 90 days. Review of the facility policy titled, Care Plans, Comprehensive Person Centered dated 10/10/22, revealed the comprehensive, person-centered care plan is developed within seven days of the completed of the MDS assessment, and no more than 21 days after admission. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care.

Based on review of the medical record, observation, staff interview, and policy review, the facility failed to ensure personal protective equipment (PPE) was worn while providing care to a resident with physician orders for enhanced barrier precautions (EBP). This affected one (#50) of three residents reviewed for infection control. The facility census was 71. Review of the medical record for Resident #50 revealed an admission date of 02/24/26. Diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, dependence on renal dialysis, dependence on ventilator status, gastrostomy status, and urinary incontinence. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for toileting and personal hygiene. The resident was always incontinent of bladder. Review of a physician order dated 02/26/26 revealed Resident #50 had an order for enhanced barrier precautions. Review of the care plan dated 03/18/26 revealed Resident #50 was on EBPs secondary to increased risk for potential infection related to tracheostomy, gastrostomy, and wounds. Interventions included for staff to follow enhanced barrier precautions, hand hygiene before and after delivery of care, observe residents for signs and symptoms of infection, and educated resident and caregiver regarding infection prevention. Observation on 03/19/26 at 9:27 A.M. revealed Certified Nursing Assistant (CNA) #508 was providing care for Resident #50. CNA #508 was wearing gloves and was not wearing a gown. Further observation revealed the resident had a sign posted on the door indicating the resident was on enhanced barrier precautions and for staff to wear a gown and gloves during high contact resident care including hygiene and incontinence brief changes. Continued observations revealed PPE was available in an organizer bag hanging on the door. Interview on 03/19/26 at 9:29 A.M., CNA #508 verified he was providing incontinence care for Resident #50. CNA #508 verified the resident was on EBP and he was not wearing a gown while providing resident care. CNA #508 stated he forgot.Interview on 03/19/26 at 10:31 A.M., Infection Preventionist (IP) #250 revealed Resident #50 was on EBP and staff should be wearing a gown and glove during care. IP #250 revealed CNA #508 only worked on Unit One. Review of the facility policy Enhanced Barrier Precautions, dated 08/2022, revealed enhanced barrier precautions were utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. EBPs should be used for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Staff should wear gown and gloves during high contact resident care activities when contact precautions do not otherwise apply. High contact resident care activities require the use of gown and gloves for EBPs include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use and wound care.

Based on medical record review, staff interview, and policy review, the facility failed to initiate a baseline care plan. This affected one (#24) of four residents reviewed for care planning. The facility census was 77. Review of the medical record for Resident #24 revealed an admission date of 02/04/26. Diagnoses included depressive disorder, anxiety, type two diabetes mellitus, and chronic kidney disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. Review of the resident's assessments revealed no documentation a baseline care plan was initiated upon admission. Interview on 03/19/26 at 8:25 A.M. with the Director of Nursing (DON) verified Resident #24 had no baseline care plan in place within 48 hours of admission. Further interview with the DON revealed the baseline care plan task was listed on the resident's admission checklist for the clinical staff to complete.Review of the facility policy, Care Plans-Baseline, revised 03/2022, revealed a baseline plan of care to meet the resident's immediate health and safety needs would be developed for each resident within forty-eight hours of admission. The baseline care plan would be used until the staff could conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan.

Based on record review, staff interview, and policy review the facility failed to notify a family member when a Resident (#22) was transferred to the hospital emergency department. This affected Resident #22 on two separate occasions. This had the ability to affect all residents. The facility census was 77.Findings include:Review of Resident #22's medical record revealed an admission date of 07/09/25. Diagnoses included chronic obstructive pulmonary disease, congestive heart failure, and chronic renal failure.Review of Resident #22's quarterly Minimum Data Set (MDS) dated [DATE] revealed she had a low cognitive function. Resident #22 was dependent on staff for activities of daily living.Review of Resident #22's most recent care plan revealed the resident had a behavior problem evidenced by being physically and verbally abusive toward staff and refusing treatments.Review of Resident #22's contact information revealed she was her own responsible party. Daughter #1 was the resident's first emergency contact and her authorized Health Insurance Portability and Accountability Act (HIPAA) contact. Daughter #2 was listed as another emergency contact. Review of Resident #22's Respiratory Therapy (RT) note dated 09/03/25 at 1:00 A.M. revealed the RT entered the resident's room for routine rounding. Resident #22 was on oxygen at six liters and her blood oxygen saturation level (SpO2) was 84 percent (%). The RT suctioned the with no improvement in oxygenation as Resident #22's SpO2 continued to drop and the resident exhibited intermittent jerking of the extremities, and was very drowsy. Resident #22 failed to respond to verbal stimuli and had minimal response to physical stimuli. The primary nurse was updated and was asked to come into the room and assess Resident #22. RT continue to suction via in-line catheter, was taken off the ventilator, and suctioned again. The resident's SpO2 dropped to between 74-85% so the decision was made to begin providing manual bag assisted ventilation, the ambu bag was hooked up to an oxygen tank at 15 liters. Resident #22 was bagged, lavaged, and suctioned which produced a large amount of thick cream colored mucus. Resident #22 was placed back on the ventilator as the resident's SpO2 was at 95%, but as soon as the resident was put back on the ventilator the resident's oxygen saturation started to decrease almost immediately so the staff went back to bagging, and called emergency medical services. When emergency medical services arrived, they took over ventilating the resident and transferred the resident to the hospital.Review of Resident #22's progress note dated 09/03/25 revealed the resident was hospitalized for sepsis due to a urinary tract infection. The note was absent of family notification.Review of Resident #22's RT progress note dated 09/07/25 revealed the resident failed to participate with the respiratory care. A small amount of secretions were removed from the tracheostomy and a nebulizer treatment was given. The resident's SpO2 was in the low 80 percentile on six liters of oxygen after the breathing treatment. The oxygen was increased to 10 liters and the residents SpO2 rose to 94%. Resident #22 was noted to have edema in her fingers and was was lethargic compared to her normal anxious energetic behaviors associated with the daily procedure. Emergency medical services were again called and the resident was transferred to the hospital emergency department for evaluation. Review of the medical record was void of Resident #22's emergency contacts being notified of the transfer.Review of the Quality Improvement Tool dated 09/03/25 and 09/07/25 related to the hospital transfers revealed no mention of the family of Resident #22 being notified of either of the transfers.Interview with Registered Nurse (RN) #112 revealed anytime a resident is transferred to the hospital a progress note should be placed in the electronic medical record and the family was immediately notified.Interview with the Director of Nursing on 01/22/26 at 1:55 P.M. verified Resident #22's medical record was absent of family notification of the resident's hospital transfer on both 09/03/25 and 09/07/25. Review of the facility policy titled Change in a Resident's Condition or Status dated 01/22/22 revealed unless otherwise instructed by the resident, a nurse will notify the resident's representative when it is necessary to transfer the resident to a hospital/treatment center.This deficiency represents non-compliance investigated under Complaint Number 2707152.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure the facility kitchen was maintained in a sanitary manner. This had the potential to effect all residents who eat food from the facility kitchen. The facility identified eight (#1, #22, #65, #71, #73, #75, #129, and #132) residents who do not consume anything by mouth. The facility census was 74. Findings Include: Observation on 04/12/25 at 9:15 A.M. revealed the epoxy on the concrete floor in front of the walk-in freezer was peeling and water was pooling between the lifted epoxy and the concrete floor. Observation on 04/12/25 at 9:17 A.M. revealed an unidentified dark brown-black substance covering the wall to the right of the walk-in freezer door. Concurrent observation revealed an unidentified dark brown-black substance on the wall to the left of the walk-in freezer. An interview on 04/12/25 at 9:25 A.M. with Dietary Supervisor #430 verified the above findings. Review of the facility policy titled, Sanitization, with a revision date of 10/2008, revealed the food service area shall be maintained in a clean and sanitary manner.

Based on medical record review and staff interview the facility failed to ensure pressure ulcer treatments were completed as ordered. This affected one (#14) of three residents reviewed for pressure ulcers. The facility census was 74. Findings Include: Review of Resident #14's medical record revealed an admitted [DATE] with diagnoses including infection and inflammatory reaction due to a indwelling urethral catheter, need for assistance with personal care, generalized muscle weakness, chronic osteomyelitis, acute kidney failure, malignant neoplasm of the bladder, anxiety, stage four pressure ulcer (full-thickness skin and tissue loss) of the right buttock, stage four pressure ulcer of the left buttock, neuromuscular dysfunction of the bladder, hypertension and and stage four pressure ulcer of the right hip. Resident #14 was discharged on [DATE]. Review of the most recent Minimum Data Set (MDS) assessment, dated 02/28/25, revealed Resident #14 was cognitively intact. Review of Resident #14's physician order dated 02/25/25 to 03/05/25 for the left buttock pressure ulcer revealed to cleanse with wound cleanser, apply calcium alginate with silver, and cover with a bordered foam dressing every night shift for wound care and as needed for wound care. Review of Resident #14's February and March 2025 treatment administration record (TAR) revealed the treatment for the left buttock pressure ulcer was not documented as completed on 02/28/25, 03/01/25, 03/02/25, and 03/03/25. Review of Resident #14's physician order dated 02/28/25 to 3/05/25 for the right outer buttock pressure ulcer revealed to cleanse with wound cleanser, apply calcium alginate with silver, and cover with a boarded foam dressing every night shift for wound care and as needed for wound care. Review of Resident #14's February and March 2025 TAR revealed the treatment for the right outer buttock pressure ulcer was not documented as completed on 02/28/25, 03/01/25, 03/02/25, and 03/03/25. Review of Resident #14's physician order dated 02/28/25 through 03/05/25 for the right ischium pressure ulcer revealed to cleanse with wound cleaner, apply calcium alginate with silver, and cover with boarded foam dressing every night shift for wound care and as needed for wound care. Review of Resident #14's February and March 2025 TAR revealed the treatment for the right ischium pressure ulcer was not documented as completed on 02/28/25, 03/01/25, 03/02/25, and 03/03/25. Review of Resident #14's physician order dated 03/05/25 to 03/26/25 for the right hip pressure ulcer revealed to cleanse with Dakin's solution, pack the wound with Dakin's moistened fluffed gauze, and then cover with bordered foam dressing every day and night shift for wound care. Review of Resident #14's March 2025 TAR revealed the treatment to the right hip pressure ulcer was not documented as completed on 03/07/25 for the 7:00 A.M. to 7:00 P.M. shift, 03/08/25 for the 7:00 P.M. to 7:00 P.M. shift, 03/09/25 for the 7:00 A.M. to 7:00 P.M. shift, 03/13/25 for the 7:00 A.M. to 7:00 P.M. shift, 03/16/25 for the 7:00 A.M. to 7:00 P.M. shift, and 03/26/25 for the 7:00 P.M. to 7:00 A.M. shift. Review of Resident #14's physician order dated 03/05/25 to 03/26/25 for the left ischium pressure ulcer to cleanse with Dakin's solution, pack the wound with Dakin's moistened fluffed gauze, then cover with bordered foam dressing every day and night shift for wound care. Review of Resident #14's March 2025 TAR revealed the wound treatments for the left ischium pressure ulcer was not documented as completed on 03/07/25 for the 7:00 A.M. to 7:00 P.M. shift, 03/08/25 for the 7:00 P.M. to 7:00 P.M. shift, 03/09/25 for the 7:00 A.M. to 7:00 P.M. shift, 03/13/25 for the 7:00 A.M. to 7:00 P.M. shift, 03/16/25 for the 7:00 A.M. to 7:00 P.M. shift, and 03/26/25 for the 7:00 P.M. to 7:00 A.M. shift. Review of Resident #14's physician order dated 03/05/25 to 03/26/25 for the right ischium pressure ulcer to cleanse with Dakin's solution, pack wound with Dakin's moistened fluffed gauze, then cover with a bordered foam dressing every day and night shift for wound care. Review of Resident #14's March 2025 TAR revealed the wound treatments for the right ischium pressure ulcer revealed the treatment was not documented as completed on 03/07/25 for the 7:00 A.M. to 7:00 P.M. shift, 03/08/25 for the 7:00 P.M. to 7:00 P.M. shift, 03/09/25 for the 7:00 A.M. to 7:00 P.M. shift, 03/13/25 for the 7:00 A.M. to 7:00 P.M. shift, 03/16/25 for the 7:00 A.M. to 7:00 P.M. shift, and 03/26/25 for the 7:00 P.M. to 7:00 A.M. shift. Interview on 04/24/25 at 1:05 P.M. with the Director of Nursing (DON) verified Resident #14's wound care treatments were not completed as ordered on the aforementioned dates in February and March 2025. This deficiency represents non-compliance investigated under Complaint Number OH00163741.

Based on medical record review, staff interview, and policy review, the facility failed to ensure pharmacy recommendations were reviewed by the physician timely. This affected two (#34 and #40) of five residents reviewed for unnecessary medications. The facility census was 74. Findings included: 1. Review of Resident #34's medical record revealed a most recent admitted [DATE]. Diagnoses included traumatic hemorrhage of the brain, acute respiratory failure with respirator dependence, diabetes mellitus, and congestive heart failure. Review of Resident #34's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderately intact cognition. The resident was identified as receiving antianxiety, antidepressant, anticoagulant, antibiotic, and diuretic medications. Review of Resident #34's medical record revealed a physician's order dated 07/17/24 for the antianxiety medication lorazepam one (1) milligram (mg) twice daily for anxiety. The order was discontinued on 12/17/24. Review of Resident #34's medical record revealed a physician's order dated 06/05/24 for the antianxiety medication buspirone oral tablet 7.5 mg to be administered three times a day via percutaneous endoscopic gastrostomy (PEG) tube. Review of Resident #24's monthly Medication Regimen Review dated 11/05/24 revealed the pharmacist recommended a gradual dose reduction attempt for lorazepam and buspirone. Further review of the physician's response revealed the physician agreed for the gradual dose reduction on 01/25/25 which was over 11 weeks from the time the recommendation was given. Interview with the Director of Nursing (DON) on 04/23/25 at 2:25 P.M. verified Resident #34's monthly Medication Regimen Review dated 11/05/24 failed to be addressed timely and was not reviewed by the physician nor certified nurse practitioner until 01/25/25. 44454 2. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE]. Diagnoses included schizophrenia, lack of coordination, anxiety, post-traumatic stress disorder, bipolar disorder, and personality disorder. Review of the quarterly MDS assessment, dated 01/20/25, revealed Resident #40 was cognitively intact. The resident received an antidepressant. Review of Resident #40's prescribed medication list for February 2024 through July 2024 identified an order dated 02/10/24 for mirtazapine 15 mg oral table with instructions to give one tablet by mouth at bedtime related to bipolar disorder, current episode depressed. Review of the pharmaceutical recommendation made to the attending physician for Resident #40 on 04/05/24, revealed the pharmacist asked if the physician felt a reduction could be attempted on the mirtazapine at that time. The recommendation was not reviewed and signed by the physician until 07/23/24. Interview on 04/23/24 at 5:25 P.M. with the DON verified the recommendation was made on 04/05/24 and there was no evidence it was reviewed by the physician until 07/23/24. The DON reported the facility's policy did not include a timeframe for when pharmaceutical recommendations should be reviewed. Review of the facility policy titled, Medication Regimen Reviews, revised April 2007, revealed the consultant pharmacist would provide a written report to physicians for each resident with an identified irregularity.

Based on observation, medical record review, resident and staff interview, and facility policy, the facility failed to complete nail care for a dependent resident. This affected one (#34) of two residents reviewed for activities of daily living (ADLs). The facility census was 74. Findings included: Review of Resident #34's medical record revealed an admitted [DATE]. Diagnoses included traumatic hemorrhage of the brain, acute respiratory failure with respirator dependence, diabetes mellitus, and congestive heart failure. Review of Resident #34's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderately intact cognitive function and required moderate to partial assistance was required with personal hygiene. Review of Resident #34's care plan revealed the resident had an ADLs self-care performance deficit related to the disease process. The resident required staff assistance to complete ADLs tasks daily. Observation on 04/21/25 at 11:42 A.M. revealed Resident #34 was lying in bed with her feet uncovered. The hallux (large toe) on both feet were noted to have nail growth approximately one-half inch past the top of the toes. The four smaller toes had nail growth approximately one-third of an inch past the top of the toes. Interview with Resident #34 on 04/21/25 at 11:43 A.M. revealed she wished to have her toenails trimmed, but staff failed to do so. Interview with Social Service Director #285 on 04/22/25 at 1:17 P.M. revealed the resident who was admitted to the facility in December 2024 had failed to see the podiatrist since that time. The resident/family had signed authorization for podiatry to care for Resident #34's toenails and feet. Interview with Certified Nurse Aide (CNA) #413 on 04/22/25 at 1:31 P.M. during observation of Resident #34's toenails verified the nails were approximately one- half inch above the top of both large toes. Further observation revealed, under both nails was a thick black substance that CNA #413 verified. CNA #413 verified the smaller toes had overgrown nails which were approximately one-third of an inch beyond the top of the toes. Review of Resident #34's progress notes dated 01/01/25 through 04/23/25 revealed no mention of nail care nor signs discolored toenails. Review of the facility policy titled, Care of Fingernails/Toenails, dated October 2010, revealed the purpose of the procedure was to clean the nail bed, to keep nails trimmed, and to prevent infections. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. Watch for and report any changes in the color of the skin around the nail bed, blueness of the nails, any signs of poor circulation, cracking of the skin between the toes, any swelling, bleeding, etc.

Based on observation, interview and record review, the facility failed to follow the dietitian approved menu for 20 (Residents #12, #19, #23, #34, #36, #38, #45, #47, #64, #65, #66, #73, #81, #233) and failed to provide the approved pureed menu to seven (Residents #3, #14, #17, #40, #48, #57, #70) who received a pureed diet. The facility census was 73. Findings include: Observation on 10/17/23 at 11:02 A.M. of Food Service Director (FSD) #200 making pureed seasoned cream of rice revealed when asked what seasonings were added to the cream of rice, FSD #200 stated she usually just adds butter and was unsure of what seasoned cream of rice meant on the spreadsheet. FSD #200 confirmed she had not used the recipe to prepare the seasoned cream of rice. Observation on 10/17/23 at 11:10 A.M. of FSD #200 making the pureed pork stir fry revealed FSD #200 used a six-ounce scoop to scoop out nine servings to puree. When FSD #200 was asked if the menu spreadsheet had the food items combined, she stated no. FSD #200 stated on 10/11/23, the menu had sweet and sour pork with Asian blend vegetables and saffron rice. FSD #200 stated she made too much, so she froze it and was using it in place of the scheduled menu item. Review of the scheduled menu items revealed pork stir fry with oriental vegetables, saffron rice, an egg roll, and mandarin oranges. FSD #200 stated since she had the leftovers, she decided to use it for the menu instead. When asked how FSD #200 ensured the correct portions for the pureed diets, she stated she figured she would use a six-ounce scoop which would provide about 4 ounces of vegetables and two ounces of meat. When asked how she knew it was the correct portion of each, FSD #200 confirmed she was unsure if the amounts and nutritional value were comparable to the listed menu items. FSD #200 confirmed the menu spreadsheet listed a number eight scoop (half cup) of pureed pork, a number eight scoop (half cup) of pureed green beans and a number eight scoop (half cup) of pureed carrots separately and not combined. Observation on 10/17/23 at 11:25 A.M. of FSD #200 pureeing bread revealed she used seven hot dog buns and added an unmeasured amount of hot water twice from a coffee pot from the coffee machine. FSD #200 confirmed she did not use a recipe and just eyes it to get a creamy, smooth consistency. Observation on 10/17/23 from 11:32 A.M. to 12:40 P.M. revealed the posted menu items were pork stir fry with oriental vegetables, saffron rice, egg roll, and mandarin oranges. Sweet and sour pork mixed with Asian vegetables, saffron rice, and an eggroll were used instead. Further observation continued as dietary staff plated the lunch meal from a steam table in the kitchen. At 12:15 P.M., FSD #200 announced she was running out of the sweet and sour pork stir fry and would need to substitute other items to complete tray line service. 20 residents (#12, #19, #23, #34, #36, #38, #45, #47, #64, #65, #66, #73, #81, and #233) did not receive the main entree and received substitutions. FSD #200 stated she would use what she had left of the lasagna from dinner the night before and give the rest grilled cheese sandwiches. Five residents received lasagna with green beans and fifteen residents received a grilled cheese sandwich and saffron rice with no vegetables. Interview on 10/17/23 at 12:55 P.M. with FSD #200 confirmed the pureed menu items were mixed together and not separate as listed on the facility posted menu. FSD #200 verified she did not follow the listed menu items and did not follow the approved recipes to prepare the lunch meal. FSD #200 confirmed she used frozen leftovers from a previous meal as a substitute and ran out before the end of tray line. FSD #200 also confirmed she was unsure if the substitutions met the dietary requirements for the meals. Interview on 10/19/23 at 10:56 A.M. with Registered Dietitian #904 confirmed the replacement of the grilled cheese sandwich and saffron rice did not have the same nutritional value as the posted menu items for lunch on 10/17/23 and were not equivalent items for substitution. Review of the facility policy dated July 2019 titled, Pureed Diet, revealed it may be necessary to add liquid instead of thickening the food. Liquids used include gravies, broth, juices, or milk. Water is not used since it causes flavor loss, resulting in poor intake.

Based on observation, interview, facility document review, facility policy review, and review of the current Center's for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff wore the appropriate Personal Protective Equipment (PPE) when caring for COVID-19 positive residents. This affected three (Resident #52, #5, #29) of three residents reviewed for COVID-19. In addition, the facility failed to ensure staff maintained appropriate infection control during tube feed administration for Resident #1. This affected one (Resident #1) of two residents reviewed for tube feeding. The facility census was 73. Findings include: 1. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE]. Diagnoses at the time of survey included but were not limited to COVID-19, muscle weakness, schizophrenia, lack of coordination, shortness of breath, anxiety, and type II diabetes mellitus. Review of the nursing progress notes revealed the resident tested positive for COVID-19 on 10/15/23. Observation on 10/16/23 at approximately 11:55 A.M. revealed Resident #52 had signage on the door of their room, indicating they were on droplet precautions. State tested Nurse Aide (STNA) #322 delivered a lunch meal tray to Resident #52. Prior to entering the room, STNA #322 donned (put on) a disposable gown, gloves, and an N95 mask over top of the medical-surgical mask she was wearing. Prior to leaving the room, STNA #322 doffed the gown, gloves, and N95, while continuing to wear the medical-surgical mask. Interview on 10/16/23 at 12:05 P.M. with STNA #322, verified Resident #52 was positive for COVID-19 and staff were required to wear an N95 mask into the room. 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses at the time of survey included but were not limited to COVID-19, Extended Spectrum Beta Lactamase (ESBL) resistance, dysphagia, depression, muscle weakness, history of falling, mild intellectual disabilities, cognitive communication deficit, restlessness and agitation, and insomnia. Review of the nursing progress notes revealed the resident tested positive for COVID-19 on 10/08/23. 3. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses at the time of survey included but were not limited to COVID-19, Alzheimer's disease, dementia, dysphagia, speech disturbances, muscle weakness, need for assistance with personal care, cognitive communication deficit, and type II diabetes mellitus. Review of the nursing progress notes revealed the resident tested positive for COVID-19 on 10/12/23 and was in isolation. Observation on 10/16/23 at approximately 12:00 P.M. revealed Licensed Practical Nurse (LPN) #308 entered the shared room of Resident #5 and #29. Prior to entering the room, LPN #308 put on a disposable gown, gloves, and a N95 mask over top of the medical-surgical mask she was wearing. Upon leaving the room, LPN #308 was no longer wearing the gown, gloves, or N95, and was wearing a medical-surgical mask which was below her nose and mouth. LPN #308 stated I am sweating, and pulled her mask up over her nose and mouth. Interview on 10/16/23 at 12:24 P.M. with LPN #308 verified Resident #5 and #29 were positive for COVID-19 and staff were required to wear an N95 mask into the room. LPN #308 reported she normally wore an N95 over top of a medical-surgical mask, and took off the N95 while still wearing the medical-surgical mask prior to leaving the room. Interview on 10/18/23 at 7:05 A.M. with the Infection Preventionist (IP) #260 revealed staff were required to wear an N95 mask into the rooms of residents who were positive for COVID-19. IP #260 reported staff were not supposed to wear an N95 mask over a medical-surgical mask because the N95 mask would not be effective. IP #260 also reported staff were to take any mask off prior to leaving the room, not just peel one off. Interview on 10/19/23 at 9:53 A.M. with Regional Nurse #903 revealed there was current CDC guidance which indicated staff could wear an N95 or medical-surgical mask when entering the rooms of residents who had COVID-19. Review of a facility-provided one-page document from the CDC numbered CS 316124-A, titled Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, dated 06/01/20, revealed preferred PPE included an N95 or high respirator and an acceptable alternative was a facemask. Review of the CDC guidance numbered CS 316124-A, and dated 06/01/20, revealed a second page regarding donning and doffing of PPE was attached, and stated Put on a NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a respirator is not available). Review of the CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 05/08/23, revealed health care personnel who entered 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). Review of the facility-provided list of residents who tested positive for COVID-19, verified Resident #5, #29, and #52 tested positive for COVID-19 on the aforementioned dates. Review of the facility policy titled Isolation - Initiating Transmission-Based Precautions, revised August 2019, revealed Transmission-Based Precautions (TBP) were initiated when a resident developed signs and symptoms of a transmissible infection, arrived for admission with symptoms of an infection, or had a laboratory confirmed infection and was at risk of transmitting the infection to other residents. The policy also stated when TBP were implemented, the Infection Preventionist (or designee) would clearly identify the type of precautions, the anticipated duration, and the PPE that must be used. Review of the facility policy titled Infection Control Guidelines for All Nursing Procedures, dated 12/29/20, revealed staff would wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. 47990 4. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included cerebral palsy, acute and chronic respiratory failure with hypoxia, and muscle weakness. Resident #1 had a tracheostomy (a surgically-created airway in the front of the neck, into the trachea, in which a tube is placed to provide a patent airway), was dependent on a mechanical ventilator for breathing. and had a gastrostomy tube. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 was able to make himself understood, which included the ability to express ideas and wants. Resident #1 was also identified to be able to understand others. Resident #1 was identified to have a feeding tube and received nutrition and hydration by enteral (tube feeding) route. Review of physician's orders for Resident #1 revealed an order dated 10/06/23 for nothing by mouth (NPO). Resident #1 had an order dated 10/06/23 for Jevity 1.5 (a tube feeding formula) to run continuously at 55 milliliters per hour per gastrostomy tube. Resident #1's medications were ordered to be administered through his gastrostomy tube. Observation on 10/16/23 at 11:14 A.M. of Agency Licensed Practical Nurse (LPN) #801 at Resident #1's bedside. LPN #801 was observed with an irrigation syringe in one ungloved hand, and Resident #1's feeding tube in her other ungloved hand. Agency LPN #801 stated she had just administered medications and proceeded to reconnect Resident #1 to his ordered tube feeding. LPN #801 held out her hands in front of her body in a cupped motion, with liquid visible on both of her bare, ungloved hands. LPN #801 proceeded into Resident #1's bathroom to wash her hands. Interview on 10/16/23 at 11:17 A.M. with LPN #801 verified she did not wear gloves when she provided medications and reconnected Resident #1's enteral feed. LPN #801 stated she should have worn gloves as she had gotten the liquid from either the medications or the tube feed on her bare hands. Review of the Medication Administration policy, dated April 2019, revealed staff should follow established facility infection control procedures for the administration of medications. Review of the Infection Control Guidelines for Nursing Procedures policy, dated 12/29/20, revealed standard precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes.

Based on medical record review, staff interview, and review of facility policy, the facility failed to establish parameters for Resident #232's blood pressure medication, resulting in mediction not being administered. This affected one resident (Resident #232) of five residents reviewed for medication administration. The facility census was 73. Findings include: Review of Resident #232's medical record revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, hypotension, gastrostomy, Crohn's disease, Alzheimer's dementia, and history of liver cirrhosis. Review of the physician order dated 09/29/23 timed at 10:00 P.M. for Resident #232, revealed an order for Midodrine hydrochloride (blood pressure medication) tablet 10 milligram given via Percutaneous Endoscopic Gastrostomy (PEF- feeding tube) tube three times a day for diagnosis of hypertension. No parameters were listed when to hold. Further review of the medical record revealed no documentation the physician was consulted on when to hold Resident #232's blood pressure medication. Review of Resident #232's medication administration record (MAR) for October 2023 identified the following days her Midodrine 10 mg tablet was held: 10/01/23 the nursing progress note timed at 5:17 A.M. revealed Midodrine was held due to systolic blood pressure (SBP) of 110 10/01/23 the MAR revealed the 6:00 A.M. dose of Midodrine was held due to SBP of 118 10/01/23 the MAR revealed the 2:00 P.M. dose of Midodrine was held due to SBP of 113 10/01/23 the MAR revealed the 10:00 P.M. dose of Midodrine was held due to SBP of 120 10/01/23 the nursing progress note timed at 10:23 P.M. revealed the Midodrine was held due to SBP of 120 10/02/23 the MAR revealed the 6:00 A.M. dose of Midodrine was held due to SBP of 115. 10/02/23 the MAR revealed the 2:00 P.M. dose of Midodrine was held due to SBP of 146. 10/04/23 the MAR revealed the 6:00 A.M. dose of Midodrine was held due to SBP of 108. 10/04/23 the nursing progress notes timed at 5:50 A.M. revealed the Midodrine was held due to SBP of 111. 10/05/23 the MAR revealed the 2:00 P.M. dose of Midodrine was held due to SBP of 123. 10/08/23 the MAR revealed the 2:00 P.M. dose of Midodrine was held due to SBP of 112. 10/12/23 the MAR revealed the 10:00 P.M. dose of Midodrine was held due to SBP of 131. 10/12/23 the nursing progress note at 11:00 P.M. revealed the Midodrine was held due to SBP of 131. 10/16/23 the MAR revealed the 2:00 P.M. dose of Midodrine was held due to SBP of 138. 10/17/23 the MAR revealed the 10:00 P.M. dose of Midodrine was held due to SBP of 138. Interview on 10/19/23 at 12:56 P.M. with the Director of Nursing (DON) revealed she spoke with the physician and obtained standing orders for parameters for Resident #232's blood pressure medication to be held if systolic blood pressure is above 140. The DON confirmed there were multiple incidents on the October 2023 MAR where staff held Midodrine, and should not have without contacting the physician. Review of the April 2019 revised facility policy titled, Administering Medications, revealed medications are administered in accordance with prescriber orders, including any required time frame. If the drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall complete appropriate documentation on the MAR for that drug and dose.

Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to provide shaving services to two (Residents #1 and #4) and failed to provide showers as scheduled to Resident #4. This affected two (Residents #1 and #4) of three resident reviewed for showers and shaving. The facility census was 73. Findings include: 1. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included cerebral palsy, acute and chronic respiratory failure with hypoxia, and muscle weakness. Resident #1 was observed to have a tracheostomy (a surgically-created airway in the front of the neck, into the trachea, in which a tube is placed to provide a patent airway) and was dependent on a mechanical ventilator for breathing. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was able to make himself understood, which included the ability to express ideas and wants. Resident #1 was also able to understand others. Review of the plan of care dated 06/27/23 and revised 07/18/23, revealed Resident #1 had an activities of daily living (ADL) self-care performance deficit related to disease process, required staff assistance to complete ADL tasks daily, and fluctuations were expected due to diagnosis. Interventions included total dependence of one staff member was required for personal hygiene and grooming tasks. Review of the shower schedule and corresponding shower sheets for 10/01/23 through 10/17/23, revealed Resident #1 was scheduled to receive showers on Tuesday and Friday nights. Shower sheets dated 10/07/23, 10/10/23, 10/13/23 and 10/17/23 indicated Resident #1 received a bed bath on each shower day. The shower sheets contained a section to identify if the resident was shaved, with a corresponding section to identify if a resident refused. The shower sheets did not contain evidence Resident #1 was offered, received or refused assistance with shaving on 10/07/23, 10/10/23, 10/13/23 and 10/17/23. Review of the electronic medical record revealed no additional documentation the resident was offered, received, or refused assistance with shaving from 10/01/13 through 10/17/23. Observation on 10/16/23 at 11:29 AM. revealed Resident #1 with facial hair approximately one half inch in length. The facial hair appeared patchy and uneven. Resident #1 communicated he preferred to be clean shaven. Observations on 10/17/23 at 8:25 A.M. and on 10/18/23 at 7:26 A.M. revealed Resident #1 was still unshaven. Interview on 10/17/23 at 1:29 PM with State tested Nurse Aide (STNA) #316 revealed residents were supposed to be shaved on shower days at a minimum, more often if requested by the resident. STNA #316 stated shower documentation was completed in the electronic record, and also on a paper shower sheets which are stored in a monthly binder at the nurse's station. Tasks such as as shaving and nail care, would be documented on the paper shower sheets and are co-signed by the nurse on duty. Interview on 10/18/23 11:46 A.M. with the Director of Nursing (DON) verified when a resident received assistance with bathing, it was documented on the shower sheets and also in the electronic medical record. Observation and interview on 10/19/23 at 8:20 A.M. with Registered Respiratory Therapist (RRT) #603 revealed Resident #1 to be clean shaven. RRT #603 stated she was very familiar with Resident #1 and he is usually clean shaven. RRT #603 stated STNA #320 just shaved Resident #1 yesterday. RRT #603 told Resident #1 he looked nice, to which Resident #1 smiled. When asked if Resident #1 preferred to be clean shaven, he nodded his head to indicate yes, witnessed by RRT #603. Interview on 10/19/23 at 8:43 A.M. with STNA #320 verified he shaved Resident #1 on the afternoon of 10/18/23. STNA #320 stated he asked Resident #1 if he wanted to be shaved, and he stated that he did. STNA #320 further stated that Resident #1 mainly communicated by a head nod or shake, or by hand movements, but was able to speak, it is just quiet due to his tracheostomy limiting his voice. 44454 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included muscle weakness, lack of coordination, other problems related to care provider dependency, depression and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was with mild cognitive impairment and required extensive assistance of one staff for personal hygiene including shaving. The resident required physical assistance of one staff for bathing. The resident did not exhibit any behaviors such as refusal of care. Review of the plan of care dated 04/21/23 and revised 05/17/23, revealed Resident #4 had an activities of daily living (ADL) self-care performance deficit related to disease process, required staff assistance to complete ADL tasks daily, and fluctuations were expected due to diagnosis. Interventions included limited assistance of one staff for hygiene/grooming, and resident required extensive assistance of two staff for showering. Review of the shower schedule and corresponding shower sheets for 10/01/23 through 10/17/23, revealed Resident #4 was scheduled to receive showers on Sunday and Thursday nights. The resident refused showers on 10/03/23 and 10/05/23. There was no documentation the resident was offered, received, or refused showers as scheduled on 10/08/23, 10/12/23, or 10/15/23. There was also no documentation the resident was offered, received, or refused assistance with shaving on these dates. Further review of the electronic medical record revealed Resident #4 received a bath/shower on 10/02/23. There was no additional documentation within the medical record to indicate Resident #4 received assistance bathing as scheduled on 10/08/23, 10/12/23, or 10/15/23. There was also no documentation the resident was offered, received, or refused assistance shaving for 10/01/13 through 10/17/23. Observation on 10/16/23 at 2:03 P.M. revealed Resident #4 was unshaven with multiple weeks of facial hair growth on his face. Resident #4 stated he preferred to be clean-shaven. Observations on 10/17/23 at 11:40 A.M. and on 10/17/23 at 12:30 P.M., revealed Resident #4 was still unshaven. Interviews on 10/17/23 beginning at 3:04 P.M. with State tested Nurse Aide (STNA) #316 and STNA #333, revealed residents were supposed to be shaved on shower days. Both staff members reported if a resident was shaved, it would be indicated on their shower sheet which was located in a binder at the nursing station. Staff also reported if a resident refused, the refusal would be documented on the shower sheet and signed by the nurse on duty. Interview on 10/18/23 at approximately 8:30 A.M. with the Director of Nursing (DON) verified when a resident received assistance with bathing, it was documented on the shower sheets and also in the electronic medical record. Interview on 10/18/23 at 8:51 A.M. with STNA #322 verified Resident #4 had quite a bit of facial hair. STNA #322 also verified shaving assistance would typically be provided during showers. Interview on 10/18/23 at 1:03 P.M. with the DON, verified there was no additional documentation to verify Resident #4 was offered or received assistance with bathing or shaving on 10/08/23, 10/12/23, or 10/15/23. Review of the facility policy titled, Shower/Tub Bath, revised October 2010, revealed the date and time a shower/tub bath was performed should be recorded on the resident's activities of daily living record and/or in the resident's medical record. The policy also stated if the resident refused the shower/tub bath, the reason(s) why and the intervention taken would be documented. Review of the facility policy titled, Shaving the Resident, revised October 2010, revealed if a resident was shaved the date and time the procedure was performed would be documented in the resident's medical record. The policy also stated if the resident refused the treatment, the reason(s) why and the intervention taken would be documented.

Based on record review, staff interview, and review of facility policy, the facility failed to ensure the physician provided rationale for the continuation of a medication after a pharmaceutical recommendation. This affected one (Resident #5) of five residents reviewed for unnecessary medications. The facility census was 73. Findings include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included but were not limited to COVID-19, type II diabetes mellitus, dysphagia, depression, muscle weakness, history of falling, mild intellectual disabilities, cognitive communication deficit, restlessness and agitation, and insomnia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 was severely cognitively impaired and required limited assistance of one staff for bed mobility and transfers. Review of Resident #5's prescribed medications list for 06/01/23 through 10/18/23 identified a current order for insulin lispro solution 100 units per milliliter, inject as per sliding scale subcutaneously before meals and at bedtime related to type II diabetes mellitus without complications. Review of Resident #5's medication administration record for October 2023, revealed the resident's blood glucose level was normally checked four times per day. Review of the pharmaceutical recommendation made to the attending physician for Resident #5 on 08/08/23, revealed the recommendation stated the average sliding scale over the past seven days was 5.4 units per day, sliding scale insulin could lead to hypoglycemia and frequent finger sticks decreased the residents quality of life as well as increased costs and nursing time. The recommendation stated please consider basal insulin adjustment and/or adding scheduled mealtime insulin with a goal to discontinue use of sliding scale. A line was marked through disagree and indicated please offer clinical rationale below. There was no rationale documented. Review of Resident #5's medical record revealed no rationale was documented by the physician. Interview on 10/19/23 at approximately 10:00 A.M. the Director of Nursing (DON) stated she spoke with the physician and the medical record as a whole showed why the physician disagreed with the recommendation. The DON verified there was no rationale documented specifically pertaining to the pharmaceutical recommendation. Review of the facility policy titled, Medication Regiment Reviews, revised April 2007, revealed the consultant pharmacist would review the medication regimen of each resident at least monthly and provide a written report to physicians for each resident with an identified irregularity. Copies of drug/medication regimen review reports, including physician responses would be maintained as a part of the permanent medical record.

Based on observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure medications were administered with an error rate of less than five percent. A total of two errors were observed during 34 opportunities, for a medication error rate of 5.88%. This affected two (Residents #55 and #41) of four residents reviewed during medication administration. The facility census was 73. Findings include: 1. Review of Resident #55's medical record revealed an original admitted [DATE]. Medical diagnoses included metabolic encephalopathy, sepsis, urinary tract infection, acute urinary retention, and type II diabetes mellitus. Resident #55 was hospitalized from 10/11/23 to 10/14/23. Review of Resident #55's physician's orders revealed an order dated 10/14/23 for Meropenem (an antibiotic) 1000 mg twice daily by intravenous (IV) route, to treat a urinary tract infection (UTI). The medication was scheduled to be administered at 8:00 A.M. and 8:00 P.M. Observation on 10/18/23 at 10:57 A.M. revealed Agency Registered Nurse (RN) #805 prepared the dose of intravenous Meropenem to be administered to Resident #55. Resident #55's intravenous site was cleansed, flushed with 10 milliliters of normal saline, and connected to new tubing. Agency RN #805 programmed the intravenous pump to the ordered infusion rate and confirmed this was Resident #55's morning dose of intravenous antibiotics that was scheduled for 8:00 A.M. Agency RN #805 verified that the dose of medication was not administered at the ordered time and was overdue by nearly three hours at the time of administration. 16453 2. Review of Resident #41's medical record revealed an admitted [DATE] with medical diagnoses including Diabetes mellitus, hepatic failure, cirrhosis of the liver and major depression. Review of Resident #41's physician orders revealed an order dated 02/18/23 for Basaglar KwikPen, inject 35 units subcutaneously one time a day. Observation on 10/17/23 at 7:15 A.M. of Licensed Practical Nurse (LPN #306) completing medications for Resident #41 revealed LPN #306 obtained Resident #41's Basaglar Kwikpen and turned the dial to 36 units. LPN #306 administered the insulin to Resident #41. Upon returning to the medication cart, LPN #306 confirmed the dial was set to 36 units instead of the ordered 35 units of insulin. The pen was observed to have numbers for even and dashes for the odd numbers. Review of the facilities Medication Administration policy dated April 2019 revealed medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (I) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

Based on medical record review, observation, and resident and staff interviews, the facility failed to allow a resident to make an informed medical decision regarding his diet. This affected one (Resident #35) of three residents reviewed for resident rights. The facility census was 70. Findings include: Review of Resident #35's medical record revealed an admission to the facility occurred on 03/20/19. with medical Diagnoses included dysphagia (trouble swallowing), morbid obesity, Diabetes, chronic respiratory failure and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact and able to make all his needs known. Resident #35 used to have a tube feeding for all his nutritional needs and took nothing by mouth. Review of the Choice Not to Receive Nursing/Medical Services, Care, and or Treatment form dated 01/31/23 revealed Resident #35 was choosing not to consume thickened liquids or pureed foods. The top section of the form identified staff have identified the risks and possible consequences of choosing to not receive the medical treatment initialed below. The form identified having been given all the possible negative outcomes of the choice to not receive the treatment. The resident initialed and signed the form dated 01/31/23. Review of the physician order dated 02/15/23 revealed Resident #35 was ordered a pureed diet with nectar thickened liquids. Review of Resident #35's progress notes dated 06/03/23 at 1:45 P.M. revealed a nurse was called into the room and Resident #35 asked for ice. The nurse told Resident #35 he could not have ice due to safety concerns and his physician order for thickened liquids. Resident #35 became very upset and yelled at the nurse and stated This is expletive. I signed a paper. Resident #35's sister then called the facility asking why Resident #35 cannot have ice. The nurse noted educating the sister on the concerns for aspiration. The nurse said she will give him a can of pop as requested but will not open it for him. The nurse documented when entering the room, the resident stated yelling, you are taking my rights away. Observations and interview with Resident #35 occurred on 11:49 A.M. and 2:45 P.M. Resident #35 confirmed the facility provided him with the risk of consuming regular foods and liquids, however he can make the informed decision himself. Resident #35 confirmed he understands the risks of potential aspiration and still wants the regular food and liquids. Resident #35 was observed drinking a can of soda and eating pizza. Resident #35 confirmed he has been ordering regular food outside the facility that was delivered because the facility will not give it to him. Resident #35 stated he was not getting ice and thin liquids (water) when asking was ridiculous, and the staff wonder why I get upset. Interview with Dietary Manager #40 on 06/14/23 at 12:07 P.M. confirmed the kitchen staff follow the physician orders for Resident #35 and send him a pureed diet with thickened liquids. Dietary Manager #40 stated Resident #35 refuses to eat the purred food. Dietary Manger #40 confirmed she was not permitted to send him a regular diet with regular liquids. Interview with the Director of Nursing (DON), Administrator and Regional Nurse #50 on 06/14/23 at 12:18 P.M. confirmed the facility was not allowing Resident #35 to have a regular diet provided by the facility. The facility was following the physician diet order of pureed food with thick liquids), instead of Resident #35's informed decision to have regular food and liquids. They have instructed their staff that Resident #35 was only to have pureed and thickened liquids and were not assisting him to get ice, thin liquids like water, regular food as he wishes. The facility was following the guidance that was provided from their corporation as they were concerned with getting sued if something happened to Resident #35. This deficiency represents non-compliance investigated under Complaint Number OH00143219.

Based on record review, observations, staff interview, resident interviews, policy review, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to wear appropriate personal protective equipment (PPE) when the Community Transmission levels were high and two COVID-19 positive residents (#24 and #66) resided in the facility. This had the ability to affect the additional 71 residents residing in the facility. The facility census was 73. Findings include: Review of Resident #66's medical record revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #66's hospital discharge instructions dated 11/08/22 revealed the resident admitted to the facility positive for COVID-19. Review of Resident #66's care plan revealed she was to be under strict isolation precautions with room quarantine related to COVID-19 diagnosis. Review of Resident #24's medical record revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #24's hospital discharge summary dated 11/04/22 revealed the resident was diagnosed with COVID-19 on 11/01/22. Review of Resident #24's progress note dated 11/9/22 revealed the resident had been placed in quarantine/isolation with an obtained order by the physician due to testing positive for the COVID-19 virus. Review of the Centers for Disease Control and Prevention (CDC) website the [NAME] County community transmission rate was high for 10/27/22 through 11/02/22. Observation upon entrance on 11/09/22 at 4:56 A.M. revealed Licensed Practical Nurse (LPN) #200 met the surveyor at the front door with no control source in place. The nurse was absent of a face mask and eye protection. LPN #200 then walked into the south hall where residents resided. Interview with LPN #200 on 11/09/22 at 5:04 A.M. verified the nurses failed to wear any PPE while in close contact with residents. On initial tour on 11/09/22 at 4:47 A.M. LPN #210 was observed in the south hall standing at the nurses cart outside of Rooms 211, 212, 213, and 214 absent of any PPE including any sort of mask. Observation on 11/09/22 at 5:15 A.M. revealed Resident #24 and Resident #66 resided on the North Hall and were under transmission based precautions. Observation of the North Hall revealed LPN #220, State tested Nurse Aide (STNA) #400 and STNA #410 had on surgical masks with the coverings lowered onto their partial mouths, but not covering their noses. The staff failed to wear any eye protection. Observation of isolation equipment on 11/09/22 at 5:24 A.M. revealed sufficient amounts of PPE were available for staff use outside of Resident #24 and Resident #66's rooms. Interviews with STNA #400, STNA #410, STNA #420, and STNA #430 on 11/09/22 between 5:14 A.M. and 7:37 A.M. verified the night shift failed to wear source control while COVID-19 positive residents resided in the facility and the county transmission rate was high. Interviews on 11/09/22 from 5:42 A.M. through 11:20 A.M. with Resident #16, Resident #33, and Resident #36 revealed the nursing staff failed to wear face masks on the night shift. Review of the facility policy titled Coronavirus Disease (COVID-19) - Using Personal Protective Equipment/Source Control. dated 10/03/22, revealed when community levels are high, source control is recommended for everyone. If County Transmission is high, facility shall consider having healthcare personnel (HCP) use PPE as described: To simplify implementation, when County Transmission rate is high, consideration for implementing universal use of National Institute for Occupational Safety and Health (NIOSH)-approved particulate respirators with N95 filters or higher for HCP during all resident care encounters or in specific units or areas of facility at higher risk for COVID-10 transmission, and eye protections worn during all resident care encounters. Interview with the Director of Nursing (DON) on 11/09/22 at 9:52 A.M. verified the facility policy stated if the Community Transmission rate was high but there was no COVID-19 in the facility the staff were to wear surgical masks and eye protection. If the Community Transmission level was high and there was an outbreak in the facility the staff must wear an N95 mask and eye protection. Interview with the Infection Control Preventions on 11/09/22 at 10:11 A.M. verified the staff should have been wearing appropriate source control in the facility due to the COVID-19 status of two residents and the County Community Transmission level being high. Review of the CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 09/23/22, revealed when [CONDITION(S)]-CoV-2 Community Transmission levels are high, source control is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients. This citation is non-compliance associated with Master Complaint Number OH 167.

Based on medical record review, observation, and staff interview the facility failed to ensure residents had access to their call light. This affected one resident (#05) of three residents reviewed. The facility census was 62. Findings include: Review of the medical record revealed Resident #05 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the modification of the five day Minimum Data Set, dated dated dated [DATE] revealed Resident #05 had both short and long term memory problems, had no hallucinations, delusions but did have physical and other behaviors coded one to three days of the review period. The resident required extensive assistance for all daily care except eating which the resident was dependent on staff to eat. During the initial tour of the facility completed on 05/11/22 from 8:00 A.M. to 8:30 A.M. it was observed Resident #05 was sitting in a Geri-chair with floor mats on both sides of the chair. The resident's call light was on the floor behind the resident between the two beds in the room. During an interview with Respiratory Therapist #300 on 05/11/22 at 8:12 A.M., verified Resident #05's call light was on the floor out of the resident's reach. During an interview and observation with Licensed Practical Nurse (LPN) #310 on 05/11/22 at 11:09 A.M., revealed Resident #05 was able to converse some and was able to purposefully use his call light. he can. The resident's room was visible at this time and once the LPN turned towards the room and verified his call light was on the floor out of Resident #05's reach. This deficiency substantiates Complaint Number OH 305.

Based on medical record review, observation, review of the pressure injury log, and staff and resident interview the facility failed to ensure preventative skin interventions were implemented. This affected one resident (#10) of three residents reviewed for alteration in skin conditions. The facility census was 62. Findings Include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with most recent readmitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #10 was cognitively intact, had no hallucinations delusions or behaviors during the review period, required extensive assistance for bed mobility transfers, dressing and toilet use and was independent for eating. The resident was coded as having a Foley catheter and always incontinent of bowel. The resident was coded as having a pressure ulcer, being at risk for a pressure ulcer and having interventions in place. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress notes revealed Resident #10 was placed in quarantine for covid positive on 01/29/22. The resident was on advanced droplet precautions through 2/12/22 due to the covid positive results on 01/29/22. Review of the wound care notes revealed the resident wound to the left ankle was center acquired and was found on 02/06/22. Review of the wound care note dated 04/20/22 revealed Resident #10 had a chronic in-house acquired malleolus left lateral unstageable ulcer which measures 4.0 cm by 3.0 cm by 0.1 cm with interventions to offload the heel. The note dated 04/27/22 revealed the individual has a chronic in-house malleolus left lateral unstageable ulcer the note revealed the wound needs to be improved, and the intervention was to offload heels and a low air loss (LAL) mattress. The note documented the wound plan of care was discussed with resident and the nurse to order a new offloading boot for the left lower extremity (LLE). The wound measured 3.5 cm by 3.0 cm by 0.1. Review of the weekly skin rounds dated 05/04/22 revealed Resident #10's left ankle wound measured 3.0 centimeter (cm) by 3.0 cm by 0.1 cm. Review of the weekly pressure injury log revealed Resident #10 should have heel protectors/boots and a grade two mattress (air mattress). During an observation and interview on 05/11/22 at 10:10 A.M., Resident #10 was observed with her foot on a folded-up pillow resting on the lateral surface of the foot and ankle, the resident was lying on a mattress that was not an air mattress. Resident #10 said the staff had mentioned something about a boot for her foot however no one had brought one into her to use. During an observation on 05/11/22 at 11:55 A.M. revealed Resident #10 had no air mattress on the bed and no heel boot was on her left foot at this time. During an interview on 05/11/22 at 11:56 A.M., State tested Nursing Assistant (STNA) #360 verified Resident #10 was not on an air mattress and had no boot on her foot. This deficiency substantiates Complaint Number OH 305. This is an example of continued noncompliance from the survey dated 04/07/22.

Based on observations, storage of medication policies, resident and staff interviews, the facility failed to ensure all medications were maintained locked and not left at residents bedsides unattended. This had the potential to affect 13 residents whom are mobile and reside on Unit #1 (Resident #01, #02, #06, #07, #09, #10 #12, #35, #38, #39, #40, #41 and #42). The facility census was 64. Findings include: Observation of Unit #1 occurred on 04/27/22 at 7:51 A.M. Resident #12 was observed in bed with her eyes closed. The observation identified a pills cup that contained two pills sitting on her bedside stand, near the bed. The observation identified the day Nurse Licensed Practical Nurse (LPN #203) was down the hallway and no in sight of Resident #12's room. Observation of Resident #12 occurred on 04/27/22 at 8:20 A.M., with State tested Nursing Assistant (STNA #308). The observation identified Resident #12's two pills remained at the bedside stand. STNA #308 confirmed the medications were sitting on the stand. Interview with Resident #12 on 04/27/22 at 8:20 A.M. identified the night shift nurse left the medications at the bedside, with a cup of pudding beside the medications. Resident #12 confirmed she does not like to take her medications until she is up for the day. Review of Resident #12's medication administration records (MAR) and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . that identified two pills, [MEDICATION(S)] 30 mg (blood pressure medication) and [MEDICATION(S)] 2.5 mg (medication to treat reflux). The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility storage of medications policy, revised April 2019, identified drugs and biological's used in the facility are stored in locked compartments. This deficiency substantiated Complaint OH 673.

Based on medical record review and staff interviews, the facility failed to provide one resident (Resident #35) of four sampled residents, the risks and benefits of care and the choice to decline the care, in regards to a pureed diet. The facility also failed to place grab bars/side rails for one of four sampled residents (Resident #08), when requested. The facility census was 64. Findings include: 1. Review of Resident #35's medical record identified admission to the facility occurred on 01/29/22. Resident #35 has medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical records identified the hospital had recommended palliative care, however Resident #35 remains a full code. Resident #35's medical record identified an admission assessment dated [DATE] which evidenced Resident #35 had intact cognition. The record also identified Resident #35's refusals of [CONDITION(S)] treatments at times, with risks of the decline of treatment. Interview with Resident #35 occurred on 04/27/22 at 9:12 A.M.,in the presence of [CONDITION(S)] Licensed Practical Nurse (LPN) #700. Resident #35 was asked about his care and treatments at the facility and identified his biggest concerns was over the food he was getting. Resident #35 confirmed I dont want that[OBSCENITY] Resident #35 confirmed he is not a baby and does not want that baby food. Resident #35 identified he is going through some major changes with his health and that food issues just aggravates the situation. Interview with Speech Therapist (ST) #110 occurred on 04/27/22 at 9:48 A.M. ST #110 identified she has worked with Resident #35 since his admission and is very familiar with him. The interview confirmed upon his original admission he was receiving regular diet. The interview identified ST #110 recommended soft food, because Resident #35 was coughing a lot, he has lung cancer. ST #110 confirmed Resident #35 declined the soft food. The interview confirmed Resident #35 was in the hospital from 04/13/22 through 04/23/22 and she placed Resident #35 on a pureed diet as of 04/25/22, because this is the safest for him. ST #110 confirmed Resident #35 really is not eating it at all and just wants coffee and to smoke. ST #110 confirmed she is aware Resident #35 is not eating and does not want the pureed diet; however no informational conference has been completed with Resident #35 and his daughter to allow Resident #35 to be in charge of his medical decisions, including the type of food he receives. Review of the Speech Therapy evaluations dated 04/25/22 identified Resident #35 goal is I want to eat regular foods and coffee. The evaluation identified patient is easily agitated by not getting what he wants. Patient is confused and has poor recall of medical information. The assessment additionally identified patient is not receptive to being told how to feed himself in a safer manner. Patient dose not agree with modification of diet texture. Patient is not happy with pureed texture. 2. Review of Resident #08's medical record identified admission to the facility occurred on 03/31/22 with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A fall risk assessment dated [DATE] identified Resident #08 was at moderate risk for falls. A side rail assessment dated [DATE] identified Resident #08 requested grab bars for positioning. Review of the physicians orders identified no evidence of grab bars or side rails as the resident requested. Observation and interview with Resident #08 occurred on 04/27/22 at 1:55 P.M. The observation identified a grab bar was located on the left side of the bed however none on the right side. Resident #08 identified the biggest concern at the facility is they tell you what you going to do instead asking the patient what we want to do. The resident is observed in a big boy bed with a half rail on the left side of the bed however none on the right side. Resident #08 confirmed she requested this upon admission. State tested Nursing Assistant (STNA) #308 confirmed Resident #08 only had one rail on 04/27/22 at 2:08 P.M. This deficiency substantiated Complaint OH 233.

Based on medical record review, review of hospital records, staff interview and policy review, the facility failed to timely assess, monitor and/or implement treatments for a resident's skin breakdown. This resulted in Actual Harm on [DATE] when Resident #70 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, this resulted in Actual Harm on [DATE] when Resident #70 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (#70) of three residents reviewed for pressure ulcers. Facility census was 67. Findings include: Review of the medical record for Resident #70 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of hospital documentation dated [DATE] revealed Resident #70 had no apparent skin injuries. Resident #70 had an abrasion to the left anterior leg and a resolved pressure injury to the back of the head. Review of Resident #70's admission assessment dated [DATE] revealed no skin assessment was completed. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed Resident #70 had intact short-term memory and intact long-term memory. Resident #70 was dependent on two staff for bed mobility, toilet use, and personal hygiene. Resident #70 had an indwelling urinary catheter and was always incontinent of bowel. The assessment indicated Resident #70 was at risk for developing pressure ulcers/injuries and had one unstageable deep tissue injury present on admission. Further review of the comprehensive assessment revealed Resident #70 had a pressure reducing device for her bed. Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #70 was at high risk for the development of pressure ulcers. Review of Resident #70's nursing notes dated [DATE] through [DATE] revealed no documentation of skin breakdown, wound assessments, or physician notification of any skin breakdown. Review of Resident #70's treatment administration record (TAR) dated [DATE] through [DATE] revealed no wound treatments were administered. Review of Resident #70's physician orders dated [DATE] through [DATE] revealed no orders for wound care. Upon admission, Resident #70 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a skilled nurses notes for [DATE] at 11:48 A.M. revealed Resident #70 had no new changes to skin integrity noted. Resident #70's sacrum area was red in color with a small amount of bleeding noted. The area was cleaned with normal saline, triple antibiotic ointment and a foam dressing was applied. There was no comprehensive wound assessment including assessment of the wound bed and wound measurements. There was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a physician order dated [DATE] revealed to apply a foam border dressing every day and as needed to the sacrum for preventative. Review of nurses note dated [DATE] at 11:18 A.M. revealed Resident #70 had excoriated buttocks due to incontinence briefs as resident's family member stated the resident was allergic to the briefs and requested the resident not wear briefs while in bed. Further review revealed, dressing changed as per treatment orders. A foam border dressing was applied to sacrum for protection. Review of the Wound Nurse Practitioner's (WNP) consultation note dated [DATE] at 1:54 P.M. revealed nursing reported Resident #70 had a coccyx wound present on admission and worsened following malfunction of the air mattress. The WNP noted Resident #70 had a suspected deep tissue injury to the coccyx measuring 10 centimeters (cm) in length by 15 cm in width by 0.1 cm in depth. There was a small amount of serosanguinous drainage. The wound was described as 100% granulation tissue with no odor or redness. The wound was described as partially intact and deep purple. The WNP recommended to cleanse the wound with normal saline, cover with bordered foam daily and as needed. The WNP further recommended for house barrier cream to be applied to the buttocks every shift and reposition every two hours per facility policy and monitor nutrition intake. Further review of the WNP's note revealed nursing reported the wound was present since admission on [DATE]. Review of a physician order dated [DATE] revealed to cleanse the coccyx with normal saline (NS), apply bordered foam dressing every dayshift for wound care. Review of a weekly skin assessment dated [DATE] at 2:03 P.M. revealed Resident #70 was noted with bruising to the left rear shoulder, left scapula and right scapula. Resident #70 was noted with pressure to sacrum with no comprehensive wound assessments. Review of an incident report dated [DATE] at 2:08 P.M. revealed when repositioning Resident #70, three bruised areas were noted of the right and left upper back shoulder and mid upper back. The prominent bony areas were covered with foam pad for protection. There was no description of the wounds and no wound measurements. There was no documentation the physician was notified. Review of Resident #70's physician orders and TAR dated [DATE] through [DATE] revealed no physician orders for treatments were obtained or documented for the right and left upper back shoulders and mid upper back. Further review of the TAR revealed the wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nurses note dated [DATE] at 10:30 A.M. revealed Resident #70 was unresponsive, cardiopulmonary resuscitation (CPR) was administered until the resident was transferred to the emergency room . Review of an emergency department (ED) note dated [DATE] revealed Resident #70 was found to be febrile and septic secondary to bilateral lower lobe pneumonia. Resident #70 was noted with a stage three sacral decubitus ulcer. Resident #70 was transferred to another hospital. Review of hospital documentation dated [DATE] revealed Resident #70 had an unstageable pressure ulcer to the coccyx on arrival to hospital measuring 14.5 cm in length by 15 cm in width by 0.2 cm in depth. The edges of the wound were pink/red and moist, however more than half was obscured by a patch of adherent eschar. Resident #70 was noted with three distinct wounds to her upper back and shoulder but had been charted together with the right shoulder wound. Resident #70 was noted with an unstageable pressure injury to right upper scapula measuring 2.3 cm in length by 3.1 cm in width by 0.1 in depth. The wound bed was dry, yellow with eschar with no drainage. The wound on the left upper scapula was noted as a stage three pressure ulcer measuring 3.2 cm in length by three cm in width and 0.1 cm in depth. The wound bed was described as moist, pink, scab/crust, yellow and eschar with scant drainage and dried exudate. Resident #70 was also noted with an unstageable pressure injury to the mid upper back measuring 3.5 cm in length by three cm in width and 0.1 cm in depth. The wound bed was dry, burgundy/maroon with eschar. The surrounding tissue was red. Resident #70 had an unstageable pressure ulcer to the right ear measuring one cm in length by 0.5 cm in depth by zero cm in depth. The wound bed was noted as scab/crust with surrounding dry flaking skin. Review of Resident #70's readmission assessment dated [DATE] revealed no skin assessment was completed upon readmission. Review of a weekly skin assessment dated [DATE] revealed Resident #70 was noted with previously identified skin areas/abnormalities including pressure injuries to the right scapula, left scapula and upper-mid vertebra suspected as deep tissue injuries. Resident #70 was also noted with a pressure injury to the sacrum. There were no comprehensive wound assessments completed and no wound measurements were completed. Review of Resident #70's physician orders dated [DATE] through [DATE] revealed no orders for wound treatments for the wounds on the resident's coccyx, right scapula, left scapula and mid upper back. Review of Resident #70's TAR dated [DATE] through [DATE] revealed no wound treatments were completed for the wounds on the resident's coccyx, right scapula, left scapula and mid upper back for three days after readmission. Review of the WNP's consultation note dated [DATE] revealed Resident #70 had an unstageable pressure ulcer to the coccyx measuring 13 cm in length by 17 cm in width by 2.5 cm in depth. There was moderate serosanguinous drainage with no odor and no redness of the surrounding tissue. The wound bed was 40 percent (%) slough and 60% granulation tissue. The wound was described as worsening. Further review of the WNP note revealed nursing reported Resident #70 had three new wounds to the upper back prior to hospitalization on [DATE]. Resident #70 had an unstageable pressure ulcer to the upper mid back measuring 3.5 cm in length by three cm in width by 0.1 cm in depth. The wound had moderate serosanguinous drainage. The wound was 80% slough/eschar and 20% granulation tissue with no odor. Resident #70 also had a stage three pressure ulcer to the left scapula measuring 1.5 cm in length by two cm in width by 0.1 cm in depth. The wound had moderate serosanguinous drainage with 100% granulation tissue with no odor. Additionally, Resident #70 had an unstageable pressure ulcer to the right scapula measuring one cm in length by three cm in width by 0.1 cm in depth. The wound was 80% slough/eschar and 20% granulation tissue with moderate serosanguinous drainage with no odor. Review of Resident #70's physician orders dated [DATE] revealed to cleanse the sacrum with wound wash, apply honey to wound bed, loose pack with alginate and cover with bordered dressing every dayshift and as needed. Further review of the physician orders for the left and right shoulders and upper back revealed to cleanse with wound wash, apply honey to wound bed, cover with alginate and ordered dressing every dayshift and as needed. Review of Resident #70's TAR revealed the wound treatments to the sacrum, right and left shoulders and upper back were completed from [DATE] through [DATE]. Review of nursing note dated [DATE] at 7:19 A.M. revealed Resident #70 was sent to the ED due to unresponsiveness. Resident #70 returned to the facility on [DATE]. Review of Resident #70's readmission skin assessment dated [DATE] revealed the resident had a stage three pressure ulcer to the sacrum and three back wounds. There was no further assessment of the wounds including wound measurements. Review of Resident #70's physician orders dated [DATE] through [DATE] revealed there were no ordered wound care treatments for the resident's wounds. Review of Resident #70's TAR dated [DATE] through [DATE] revealed no wound treatments were completed. Review of Resident #70's nursing progress note dated [DATE] at 6:00 P.M. revealed the resident was sent to the ED after being found unresponsive. Review of an ED note dated [DATE] revealed the resident had a stage four sacral pressure ulcer. Interview on [DATE] at 1:01 P.M. and 4:54 P.M., the Director of Nursing (DON) verified no admission skin assessment was completed for Resident #70 on [DATE]. The DON also verified readmission skin and wound assessments were not completed on [DATE] and [DATE]. The DON verified there were no physician orders obtained for the skin breakdown on the coccyx wound until [DATE]. The DON verified there were no physician orders or wound treatments initiated for the resident's four pressure ulcers upon return from the hospital on [DATE] until [DATE]. The DON verified there were no physician orders or wound treatments completed when the resident returned from the hospital on [DATE] through time of discharge on [DATE]. Interview on [DATE] at 5:29 P.M., the Assistant Director of Nursing (ADON) #204 verified Resident #70 had a small red area to the coccyx upon initial admission. ADON #204 verified Resident #70's wounds to the back of the right shoulder, left shoulder and mid upper back were present before she discharged to the hospital on [DATE]. ADON #204 stated Resident #70's nurse told her there was a treatment in place when asked. Interview on [DATE] at 6:16 P.M., with Licensed Practical Nurse (LPN) #207 revealed Resident #70 had a red spot on the coccyx when she first admitted . LPN #207 stated she thought, we were padding and protecting the area, but was not 100% sure. LPN #207 stated when she first saw the areas on the resident's shoulders, the areas looked like abrasions, like the first layer of skin was off. Review of facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated [DATE], revealed staff would examine the skin of a new admission for ulceration or alteration in skin. The wound assessment would include a description and documentation of the full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue, pain assessment, resident's mobility status, current treatments, including support surfaces and all active diagnoses. The physician would assist staff to determine etiology and characteristics of the skin alteration. Review of the facility policy, Wound Care, dated [DATE] revealed, Verify there is a physician's order for the wound care procedure. Also record in the medical record the type of wound care given, the date and time wound care was given, the position in which the resident was placed, the name and tile of the individual performing the wound care, any change in resident condition, all assessment data (i.e. wound bed color, size, drainage, et.) obtained when inspecting the wound, how the resident tolerated the procedure, if the resident refused the treatment and why, and the signature and tile of the person recording the data. Report other information in accordance with facility policy and professional standards of practice. This deficiency substantiates Master Complaint Number OH 131 and Complaint Number OH 818.

Based on medical record review, review of hospital records, staff interview and review of facility policy, the facility failed to ensure intravenous (IV) antibiotic medications were administered per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (#70) of three residents reviewed for infections. The facility census was 67. Findings include Review of the medical record for Resident #70 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #70's comprehensive Minimum Data Set (MDS) assessment, dated 01/23/22, revealed the resident had intact short-term memory and intact long-term memory. The resident was dependent on two staff for bed mobility, toilet use, and personal hygiene. Review of a nurses note dated 03/02/22 at 7:19 A.M. revealed Resident #70 was transferred to the emergency room due to being unresponsive at 6:00 A.M. Review of the physician emergency department (ED) note dated 03/02/22 revealed Resident #70 presented for decrease responsiveness. A computerized tomography (CT) scan showed bilateral pneumonia with interval improvement. The physician noted Resident #70 had no cough, fever or increased sputum production. Resident #70 was at baseline ventilator settings. Resident #70 previously had a bronchoscopy with the same findings by CT which were not consistent with pneumonia. The physician had not believed Resident #70 had active bacterial pneumonia. The physician noted no indication for antibiotics at this time. Review of the ED radiology diagnostic results dated 03/02/22 at 8:57 A.M. revealed Resident #70 had bilateral basilar infiltrates, right greater than left. Aspiration pneumonia was a concern. However, there had been some apparent interval improvement when compared to the prior study. Review of a nurse's note dated 03/03/22 at 8:32 A.M. revealed the ED transferred Resident #70 to another hospital for unresponsiveness. Review of a hospital documentation dated 03/04/22 revealed Resident #70 was discharged back to the facility on [DATE] with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nurses note dated 03/06/22 at 6:23 P.M. revealed Resident #70 was noted to have missed medication. The pharmacy was notified with request for the medication to be drop shipped. The pharmacist assisted this nurse in pulling from the ekit (emergency) and would get it sent out. The on call physician was notified and the orders restarted. Review of a nurses note dated 03/07/22 at 5:12 A.M. revealed Resident #70 was started on an IV antibiotic by the Registered Nurse on duty. Resident #70 tolerated well and no adverse effects were noted. Review of a nurses note dated 03/07/22 at 6:00 P.M. revealed Resident #70 was found unresponsive at approximately 5:45 P.M. Resident #70 was unresponsive to touch, pain, verbal stimulus or suctioning. Resident #70 was transferred to the emergency room . Review of an ED note dated 03/07/22 revealed Resident #70 had worsening of pulmonary infiltrate and was initiated on [MEDICATION(S)] and [MEDICATION(S)] IV. Review of a health status note dated 03/08/22 at 6:06 A.M. revealed the ED sent Resident #70 to another hospital with aspiration pneumonia. Interview on 03/22/22 at 4:54 P.M., the Director of Nursing (DON) revealed on 03/04/22 the resident returned from the hospital with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON revealed the antibiotics were not administered for Resident #70 until 03/07/22 and the resident developed worsening pulmonary infiltrates. The DON revealed the [MEDICATION(S)] and [MEDICATION(S)] were available in the facility emergency (E) kit. The DON also revealed the physician was not notified at the time of each missed medication administration. Review of facility policy titled, Medication Administration, revised 04/2019, revealed medications would be administered in accordance with prescriber orders, including any required time frame. Medications would be administered within one hour of their prescribed time unless otherwise specified. This deficiency substantiates Master Complaint Number OH 131.