Every finding on record at Twin Towers

Based on medical record review, observation, staff interview, review of facility policy, and review of online guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess a resident's skin and failed to identify pressure ulcers (injuries to skin and underlying tissue caused by prolonged pressure, friction, or shear, usually over bony areas like the hips, heels, or tailbone) until they had reached an advanced stage. This resulted in Actual Harm for Resident #66 on 02/16/26, when the resident was admitted to the facility without pressure ulcers, was assessed to be at high risk for development of pressure ulcers and developed an avoidable unstageable pressure ulcer (a full-thickness wound where damage depth is hidden by slough [a soft, moist, yellow or white devitalized tissue comprised of dead cells, fibrin, and bacteria that forms in the wound bed, acting as a significant barrier to healing by stalling the inflammatory phase] or eschar [a thick, dry, black or brown layer of dead tissue that forms over deep wounds] making an accurate stage assessment impossible and an unstageable pressure area signifies a deep stage III or IV ulcer requiring urgent medical attention) to the right heel. An additional Harm situation occurred for Resident #76 on 02/15/26, when the resident was admitted to the facility without pressure ulcers, was assessed to be at high risk for development of pressure ulcers and developed a stage III pressure ulcer to the right heel. This affected two Residents (#66 and #76) of the two residents reviewed for pressure ulcers. The facility census was 61.Findings include: 1. Review of the medical record for Resident #66 revealed an admission date of 07/23/23. Diagnoses included Alzheimer's disease, pulmonary embolism (PE), difficulty walking, muscle weakness, and fracture around internal prosthetic joint. Review of the plan of care for Resident #66 dated 07/03/24, revealed the resident was at risk for impaired skin integrity related to impaired physical mobility, moisture from incontinence, and thyroid disease with the goal for the resident's skin to remain intact without pressure ulcer development. Interventions included the following: monitor skin at least weekly and prn for any area of concern and notify the physician for treatment, provide measures to decrease pressure/irritation to skin (pressure reducing mattress and pressure reducing cushion), monitor turning and repositioning, if in the same position for greater than two hour period, cue and or assist to turn, and inform the physician of any complications/adverse changes. Review of the physician order dated 07/04/24, revealed Resident #66 was ordered to have bilateral lower extremities, heels and ankles offloaded with pillows every shift. Review of the physician order dated 07/05/24, revealed Resident #66 was ordered to have weekly skin assessments completed on Fridays during the night shift (7:00 P.M. to 7:00 A.M.). Review of the most recent Braden Scale for Predicting Pressure Sore Risk for Resident #66 dated 10/04/25, revealed the resident was at high risk for the development of pressure ulcers. Review of the October, November, and December 2025, and January and February 2026, Treatment Administration Records (TAR) for Resident #66 revealed no documentation the facility off-loaded/floated the bilateral lower extremities, ankles and heels on 01/20/26, 02/01/26, 02/08/26 and 02/17/26. The TAR indicated on 02/13/26, Licensed Practical Nurse (LPN) #610 documented on the weekly skin assessment, that Resident #66 no skin impairments identified. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #66 had moderate cognitive impairment and was always incontinent of bowel and bladder, had no range of motion due to impairment in both upper and lower extremities and required a wheelchair for mobility. The resident was dependent on staff for activities of daily living (ADL). Resident #66 was assessed as being at risk for the development of pressure ulcers and did not have an unhealed pressure ulcer/injury. Review of the nurse's progress notes for Resident #66 from 02/01/26 through 02/16/26, revealed no documentation regarding any wound on resident's right heel. Review of the shower sheets for Resident #66 dated 02/13/26 at 6:15 A.M. and 02/15/26 at 6:45 A.M. revealed no new documented skin issues. Review of a weekly skin assessment for Resident #66 on 02/13/26 authored by LPN #610, revealed no skin impairment was identified. Review of the nurse's progress note for Resident #66 dated 02/16/26 at 4:15 P.M. and authored by Registered Nurse (RN) #350, revealed the resident had a black area on the right heel which appeared to be pressure related. There were no open areas or drainage and the skin surrounding the area was intact. The resident complained of pain when the area was touched. Wound Care Nurse Practitioner (WCNP) #900 was notified and ordered for betadine to be applied daily and as needed and leave area open to air with off-loading boots to be applied while the resident was at rest. Betadine was applied per the order with the area left open to air, and off-loading boots applied. Will continue to monitor and report changes. Review of the physician order dated 02/17/26, revealed Resident #66 was ordered to have bilateral heels floated off the bed with pillows as the resident allowed every shift. Review of the nurse's progress note for Resident #66 dated 02/17/26 at 7:00 P.M., revealed RN #600 rounded with WCNP #900 and there was a discolored DTI (a serious pressure-related injury causing damage to underlying soft tissue, presenting as persistent, non-blanchable, deep red, maroon, or purple discolored intact skin or a blood-filled blister) to the resident's right heel and the treatment consisted of betadine and to leave open to air. The measurements were 1.8 centimeters (cm) in length by 2.3 cm width by 0.1 cm width. The resident was ordered to have off-loading boots while in bed, no shoes and only non-skid socks until healed. Review of Skin Evaluation Form assessment for Resident #66 dated 02/17/26, authored by RN #600, revealed the resident had a pressure injury staged as a DTI to the right heel that measured 1.8 cm length by 2.3 cm width by 0.1 cm depth. The treatment consisted of betadine to wound and leave open to air and off-loading boot while in bed. Review of WCNP #900's progress notes for Resident #66 dated 02/17/26, at 11:10 A.M. revealed the resident had an in-house acquired unstageable pressure ulcer of the right heel on 02/17/25 (incorrectly documented by WCNP #900 and should have been 02/16/26) and was located on the right calcaneus. The wound measured 1.0 cm in length by 3.0 cm width by 0.2 cm depth. There was no drainage noted, no granulation within the wound bed, and no necrotic tissue (dead or devitalized cells that cannot be salvaged, appearing as discolored [black, brown, yellow], foul-smelling, or leathery [eschar] tissue) within the wound bed. The peri-wound skin was dry, scaly and discolored DTI. The ordered treatment was to apply betadine and leave open to air and offload heels with off-loading boots, no shoes, and only non-skid socks. Review of the physician order dated 02/18/26, revealed Resident #66 was ordered to have off-loading boots daily while at rest and have betadine applied to left heel and leave open to air. Review of a Skin Evaluation Form for Resident #66 dated 02/24/26 authored by RN #175, who rounded with WCNP #900, revealed Resident #66 had a skin impairment categorized as an unstageable full thickness pressure injury to the right heel that measured 3.0 cm in length by 3.0 cm width by 0.1 cm depth. The tissue was epithelial with no drainage. Review of WCNP #900's progress notes for Resident #66 dated 02/24/26, revealed the resident's wound was classified as unstageable with etiology of pressure ulcer and was located on the right calcaneus. The wound measured 3.0 cm in length by 3.0 cm width by 0.1 cm depth. There was no drainage, no granulation tissue within the wound bed, and a large amount 67 percent (%) to 100% of necrotic tissue within the wound bed, including eschar. The peri-wound was dry/scaly. The treatment was to apply betadine and leave open to air daily and off-load heels with off-loading boots, no shoes, only non-skid socks. The goal and anticipation were that the wound would heal and will be followed weekly. Review of the plan of care for Resident #66 revised on 02/24/26, revealed the resident had an unstageable pressure ulcer to the right heel with the goal to heal the right heel pressure ulcer. Interventions included: treatment to ulcer as ordered, wound care consultation as necessary, weekly skin checks by nurse, pressure reducing mattress to bed, pressure reducing cushion to wheelchair, dietary consultation as needed, and nutritional supplements as ordered. Observation of Resident #66's heels on 02/25/26 at 3:24 P.M. with Certified Nursing Assistant (CNA) #505, revealed Resident #66's right foot had a padded boot in place, the left heel did not, and neither of the resident's heels were being floated to off-load pressure. The resident's right heel had an area the approximate size of a golf ball on the central, right heel and was black in color. During the observation, Resident #66 revealed she experienced pain associated with the area on her right heel, especially during the time when the staff put her socks on and /or removed them. There were soft foam wedges observed sitting on a chair in the resident's room During an interview on 02/25/26 at 3:26 P.M., CNA #505 verified Resident #66's heels were not being floated/off-loaded and should have been. CNA #505 proceeded to place the soft foam wedge in the resident's room under Resident #66's right and left calves to float the heels to off-load pressure. During an interview on 02/26/26 at 11:35 A.M., RN #350 recalled an unknown CNA called her to Resident #66's room on 02/16/26 around 12:00 P.M. because of a skin impairment on the resident's right heel. RN #350 stated the area on Resident #66's right heel was a circular black area, approximately the size of a golf ball, and it was not open or draining. RN #350 revealed she took a picture of Resident #66's right heel wound on 02/16/26 at approximately 12:04 P.M. and sent it to WCNP #900 via the facility phone. RN #350 stated WCNP #900 ordered to have betadine applied to the area and leave open to air. RN #350 verified the wound treatments were not started until 02/18/26. Review of a picture of Resident #66's right heel on 02/26/26 at 11:35 A.M., taken by RN #350 on her dedicated facility phone, revealed the picture was time-stamped on 02/16/26 at 12:04 P.M. The area was round, black and the surrounding skin was red. RN #350 stated she immediately sent the picture to WCNP #900. During an interview on 02/26/26 at 1:45 A.M., CNA #575 stated approximately one month ago, Resident #66, complained of pain in the right foot whenever CNA #575 was putting on her socks. CNA #575 was unable to remember if she shared this information with the nurse. During an interview on 02/26/26 at 2:24 P.M. the Director of Nursing (DON), verified Resident #66's right heel wound was discovered on 02/16/26. The DON verified the treatment regimen of applying to betadine to right heel and leaving open to air was ordered on 02/16/26 but not initiated until 02/18/26. During an interview on 02/26/26 at 4:05 P.M., the DON stated skin assessments for Resident #66 were scheduled to be completed every Friday by the nurse and they were supposed to documented on the TAR, and if a skin impairment was identified, it would be documented in the nurse's progress notes. Review of the February 2026 TAR on 02/26/26 at 4:00 P.M. with the DON, revealed Resident #66 had a skin assessment completed on 02/13/26 and no areas of skin impairment were identified. The DON verified if an area of skin impairment was identified on the weekly skin assessment, a progress note would be completed by the nurse completing the skin assessment. During an interview via phone on 02/27/26 at 8:46 A.M., WCNP #900 verified Resident #66's right heel skin impairment was an avoidable unstageable, DTI discovered on 02/16/26. WCNP #900 verified when Resident #66's right heal area opens; it will be visible as a stage III or IV wound bed. Review of the February 2026 TAR for Resident #66, revealed the order for off-loading boots was initiated on 02/18/26 and the treatment was not completed on 02/21/26 and 02/23/26. 2. Review of the medical record of Resident #76 revealed an admission date of 02/10/26. Diagnoses included congestive heart failure (CHF), history of atrial fibrillation, coronary artery disease, and chronic obstructive pulmonary disease (COPD). Review of the nurse's progress note dated 02/10/26 at 11:57 P.M. authored by Licensed Practical Nurse (LPN) #610, revealed the resident was admitted to the facility with no skin issues besides some redness in the groin area. Review of the baseline plan of care for Resident#76 dated 02/10/26, revealed the resident was at risk for impaired skin integrity. Interventions included turning and repositioning every two hours, elevating the heels off the bed, and apply off-loading boots. The resident was to receive showers twice weekly (Tuesdays and Fridays). Review of the Braden Scale for Predicting Pressure Sore Risk for Resident#76 dated 02/11/26, revealed the resident was at high risk for developing pressure ulcers. Review of the Nursing Screen for Resident #76 dated 02/11/26, revealed the resident was admitted with excoriation/reddened area to the groin. No other skin issues were identified. Review of the comprehensive MDS assessment dated [DATE], revealed Resident #76 had intact cognition. The resident was dependent on staff for bed mobility and putting on/taking off footwear, bathing, and toileting. The resident was at risk for pressure ulcers but did not have any pressure ulcers at the time of the assessment. Review of the nurse's progress note for Resident #76 dated 02/15/26 at 12:27 P.M. authored by RN #615, revealed the resident presented with a ruptured blister to the right lateral heel measuring 1.0 cm in length by 3.0 cm in width, and 0.2 cm in depth. A picture of the wound was taken and sent to WCNP # 900. The resident complained of pain in the area. The area was cleansed with normal saline, patted dry, triple antibiotic ointment (TAO) applied was covered with a dried clean dressing. Awaiting a return call from WCNP #900 for ongoing treatment. Review of the nurse's progress note for Resident #76 dated 02/16/26 at 9:05 A.M., revealed a new order was received to apply betadine to the right lateral heel and leave area open to air daily and as needed and off-loading boots while at rest. Review of a physician order for Resident #76 dated 02/16/26, revealed the resident was ordered to have bilateral off-loading boots applied while at rest as tolerated. A physician order dated 02/16/26 and discontinued 02/24/26, revealed the resident was ordered to have betadine applied to the right lateral heel and leave wound open to air. A physician order dated 02/17/26 and discontinued 02/24/26, revealed the resident was ordered to have the right heel cleansed with normal saline, Medihoney applied, and a dry, clean dressing applied. A physician order dated 02/24/26, revealed the resident was ordered to have her right heel cleansed with normal saline, mupirocin two percent applied and a dry clean dressing applied twice a day and as needed. Review of the February 2026 TAR for Resident #76, revealed an order dated 02/16/26 for betadine to be applied to the right heel daily and leave open to air. The treatment was not completed on 02/16/26, 02/17/26, nor 02/20/26. Further review of the TAR revealed an order dated 02/16/26 for off-loading boots while at rest as tolerated upon rising and at bedtime. The order was not completed on 02/16/26 (at bedtime), 02/17/26 (upon rising), 02/20/26 (upon rising), 02/21/26 (at bedtime), and 02/23/26 (at bedtime). Further review of the TAR revealed an order dated 02/19/26 to cleanse the open area to the right heel with normal saline, apply Medihoney (advanced wound dressing to promote healing in chronic and acute wounds) and dry clean dressing daily. The order was not completed on 02/21/26. Further review of the TAR revealed an order dated 02/24/26 to cleanse the open area to the right heel with normal saline, apply Mupirocin 2 % topical ointment and dry clean dressing twice per day. The treatment was not signed off on the night shifts of 02/24/26 nor 02/25/26. Review of WCNP #900's progress notes for Resident #66 dated 02/17/26 at 11:00 A.M., revealed the resident was seen for wound to the right heel which was reported to WCNP #900 as being present on admission. WNP #900 saw the resident in the facility and the staff noted the right heel appeared to have had a blister to the area; however, the wound was open at the time of this visit. WNP #900 assessed Resident #76's right heel to be a stage III pressure ulcer, measuring 1.0 cm in length by 3.0 cm in width by 0.2 cm depth. There was a medium amount of serous drainage (a thin, watery, clear-to-pale-yellow fluid that is a normal part of the early inflammatory stage of healing) noted, large granulation (the growth of new, healthy, red or pink, moist, and bumpy connective tissue and capillaries that fill the wound base) and no necrotic tissue within the wound bed. Orders were to apply Medihoney, apply a low air loss mattress and turn and reposition. Review of a Skin Evaluation Form for Resident #76 dated 02/17/26 at 6:43 P.M. and authored by RN #600, revealed the resident had a stage III pressure injury to right heel that measured 0.0 cm in length by 3.0 cm width by 0.2 cm depth with moderate amount of exudate. The treatment consisted of Medihoney with a dry dressing and apply off- loading boots. Review of the nurse's progress note for Resident #76 dated 02/17/26 at 6:47 P.M., authored by RN #600, revealed she rounded with WCNP #900. The resident had a busted blister to the right heel busted and under the blister was a stage III pressure ulcer with moderate granulation and measured 1.5 cm in length x 2.0 cm width x 0.2 cm length. Review of shower documentation for Resident #76 revealed the resident refused a shower on 02/17/26 (Tuesday) and received a bed bath on 02/24/26 (Tuesday). There was no documentation about showers being provided to the resident on 02/13/26 and 02/20/26. Review of WCNP #900 progress notes for Resident #66 dated 02/24/26 at 8:20 A.M., revealed WNP #900 saw the resident in the facility and noted the wound was not improving. The area remained classified as a stage III pressure area and measured 2.0 cm in length by 2.5 cm width by 0.2 cm depth. There was a medium amount of serous drainage noted, small amount of granulation, and a large amount of necrotic tissue in the wound bed. The peri-wound was noted with erythema and tender upon palpation and blood-tinged purulent draining. Orders were given to obtain a wound culture, change the treatment regimen to mupirocin ointment twice per day, get a Roho (specialized, air-filled, adjustable pressure-relieving devices designed to prevent skin breakdown, heal pressure ulcers, and improve comfort for individuals with limited mobility) or an air cushion for wheelchair, start the resident on doxycycline (antibiotic) twice daily for seven days and follow-up weekly. Review of a Skin Evaluation Form for Resident #76 dated 02/24/26 at 12:19 P.M. and authored by RN #175, revealed the resident had an unstageable full thickness pressure injury to right heel that measured 2.0 cm in length by 2.5 cm width and 0.2 cm depth. The wound was assessed with eschar, no exudate and treatment consisted of mupirocin ointment and dry dressing twice daily. Observation of Resident #76's right heel on 02/26/26 at 1:00 P.M., revealed a red and beefy area with sloughed skin covering approximately half of the wound. There was a small amount of drainage observed. During an interview on 02/26/26 at 1:17 P.M., RN 305 stated on 02/16/26, she received the order for off-loading boots. RN #305 stated the off-loading boots were ordered on 02/16/26 but not signed off on the TAR until the night of 02/17/26. RN #305 stated offloading boots are readily available in central supply. During an interview on 02/26/26 at 1:46 P.M., LPN #610 verified she completed Resident #76's admission skin assessment on 02/10/26. LPN #610 stated the only concern with Resident #76's skin was some redness to the resident's groin and denied any wounds the resident's heels. During an interview on 02/26/26 at 2:16 P.M., the DON verified the resident only had shower documentation on 02/17/26, which noted the resident refused, and a bed bath on 02/24/26. The DON verified treatments were not signed off as being completed on 02/16/26, 02/17/26, 02/20/26, 02/21/26, 02/23/26, and 02/24/26. The DON verified treatments should have started the same day they were ordered. The DON further verified Resident #76, who was dependent on staff for activities of daily living went from having no pressure ulcer on admission, 02/10/26, to developing a stage III on her right heel on 02/15/26 During an interview on 02/26/26 at 2:24 P.M., RN #615 stated, on 02/15/26, she was the supervisor on duty, and an CNA came to her with a concern about Resident #76's right heel. RN #615 stated she went to look at the resident's heel, and it looked like a ruptured blister. RN #615 stated she measured the area, cleansed it with normal saline, applied triple antibiotic ointment, and covered it with a dry dressing. RN #615 stated she notified WCNP #900 and waited for a response before putting in any new orders. During an interview on 02/27/26 at 11:22 A.M., WCNP #900 stated she documented the blister was present on admission because that is what the facility staff told her. WCNP #900 stated she was contacted on 02/10/26, after the resident was admitted , and the only thing mentioned to her was the redness in the resident's groin and there was no mention of a blister on the resident's heel. WCNP #900 stated her expectation is for treatments to be initiated on admission if areas are present, and for treatments to be initiated as soon as they are ordered. WCNP #900 stated she could not recall if she received a picture of the resident's heel; however, stated she was initially notified the resident had an intact blister but stated it was opened when she saw the resident on 02/17/26. WCNP #900 could not say whether the area was avoidable because she did not know the resident well enough because the resident was new to the facility. WCNP #900 stated it is hard to tell how quickly a blister could form and would depend on whether the area was rubbing against something (like a shoe) or resting on (on a mattress). WCNP #900 stated her expectation is for residents to be bathed twice a week, with the first bathing occurring quickly after admission. WCNP #900 stated the resident's shoes should have been removed right away. Review of facility policy titled, Pressure Ulcer/Injury Prevention and Treatment, dated 11/22/17, revealed the facility would provide care to promote the prevention of pressure ulcer/pressure injury development and promote the healing of existing pressure ulcer/pressure injuries. The definition of an avoidable pressure ulcer/injury revealed avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Review of the National Pressure Injury Advisory Panel (NPIAP) guidelines, dated 2014, pages 70-71, at (https://npiap.com/general/custom.asp?page=2014Guidelines), revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Unstageable pressure ulcer is defined as a depth unknown full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined.

Based on record review, staff interviews and policy review, the facility failed to adequately monitor residents' weights to ensure accuracy of documented weight loss/gain. This affected two Residents (#10 and #12) out of three residents reviewed for nutrition. The facility census was 61. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of Parkinsonism, cognitive communication deficit, and bipolar disorder.Review of the physician order dated 10/04/24, revealed Resident #10 was ordered to receive a regular diet, regular consistency. Review of the weights for Resident #10 revealed the resident had documented weights on 10/08/25 of 195 pounds (lbs.) and on 11/21/25 of 172.8 lbs. This represented an 11.38 percent (%) weight loss in forty-three days. The resident's next documented weight was on 12/19/25 (204.4 lbs.). Review of the nutrition progress note for Resident #10 dated 11/21/25 and authored by Registered Dietician (RD) #605, revealed Resident #10's current body weight of 172.8 lbs. triggered for a significant weight loss of 11.38 % in the past thirty days and 8.47 % weight loss in the past ninety days. Recommendation of discontinuing Ensure Plus 240 milliliters (ml) and providing Two Cal 240 ml two times a day to provide 950 calories and 40 grams (gm) of protein due to significant weight loss. The physician was notified of the weight loss. There was no recommendation for a re-weight.Review of the weights for Resident #10 revealed the resident had documented weights on 11/21/25 of 172.8 lbs. and on 12/19/25 of 204.4 lbs. This represented an 18.29 % weight gain in thirty days. The resident's next documented weight was on 01/05/26 (204 lbs.). Review of the nutrition progress note for Resident #10 dated 12/19/25 and authored by RD #605, revealed Resident #10's current body weight of 204.4 pounds triggered for a significant weight gain of 18.29 % in the past thirty days. The Two Cal 240 ml two times a day to provide 950 calories and 40 gm of protein remained appropriate due to triggered weight loss last month. Will continue to evaluate the need for supplementation. The physician was notified of weight gain. There was no recommendation for a re-weight.Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE]. revealed Resident #10 had intact cognition and was frequently incontinent of bowel and bladder. The resident required set-up assistance for oral and personal hygiene and bed mobility, and moderate assistance for toileting, bathing, dressing and transfers.Review of the weights for Resident #10 revealed the resident had documented weights on 02/01/26 of 210.8 lbs. and on 02/08/26 of 187.2 lbs. This represented an 11.2 % weight loss in seven days.During an interview on 02/24/26 at 9:55 A.M., Resident #10 stated he was not on a weight loss and/or weight gain plan.During an interview on 02/25/26 at 12:16 P.M., RD #605 verified Resident #12 was on a monthly weight schedule and she reviewed the resident's weights monthly. RD #605 stated if a resident experienced a significant weight gain or weight loss, a re-weight was to be obtained with her expectation that the re-weight be obtained within one week and revealed this was communicated with the nursing department via an email. RD #605 verified Resident #10 had a documented significant weight loss and/or gain and re-weights were not obtained to validate the documented weight loss/gain. During an interview on 02/25/26 at 12:18 P.M., the Director of Nursing (DON) stated it was her expectation that any resident who experienced a documented significant weight gain or weight loss should have obtained a re-weight within two days. Review of the active plan of care for Resident #10 revealed Resident #10 was at risk for nutritional problems with a goal to maintain current body weight plus or minus 3 percent (%) and remain free from significant weight changes. Interventions included to obtain food preferences, diet history (has a selective menu in place to make preferred choices during meal periods), provide supplements as ordered, offer substitutes for food/beverage dislikes or refusal of food/beverages, encourage high protein foods, offer milk with meals to increase protein intake, encourage by mouth intake and assist as needed, monitor adequacy of by mouth intake, evaluate weight record, and provide diet as ordered. 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses of Alzheimer's dementia, malignant neoplasm of right breast, diabetes mellitus type II, and hypertension.Review of the admission plan of care dated 01/11/25 for Resident #12, revealed the resident was at risk for alteration in nutrition with a goal to maintain current body weight plus or minus three % and remain free from significant weight changes. Interventions included to obtain food preferences / diet history (loves mac and cheese), provide supplements as ordered, offer substitutes for food/beverage dislikes or refusal of food/beverages, encourage high protein foods, offer milk with meals to increase protein intake, encourage by mouth intake and assist as needed, sipper cup with lid for coffee, monitor adequacy of by mouth intake, evaluate weight record, monitor for signs and symptoms of hypoglycemia or hyperglycemia, monitor skin condition/integrity, evaluate nutrition related labs, and provide diet as ordered.Review of the weights for Resident #12, revealed the resident had documented weights on 10/02/25 of 170 lbs. and on 10/06/25 of 182.8 lbs. This represented a 7.53 % weight gain in four days. The resident's next documented weight was on 11/01/25 (192.2 lbs.).Review of the weights for Resident #12, revealed the resident had documented weights on 10/06/25 of 182.8 lbs. and on 11/01/25 of 192.2 lbs. This represented a 5.14 % weight gain in twenty-five days. The resident's next documented weight was on 12/01/25 (180 lbs.). Review of the nutritional assessment for Resident #66 dated 10/15/25 authored RD #605, revealed the resident's current body weight triggered for significant weight gain of 5.18 % in thirty days. The resident had an order for weights to be obtained monthly. The resident had no edema present. The ordered diet was regular with thin liquids.Review of the weights for Resident #12 revealed the resident had documented weights on 11/01/25 of 192.2 lbs. and on 12/01/25 of 180 lbs. This represented a 6.35 % weight loss in one month. The resident's next documented weight was on 01/01/26 (140.2 lbs.). The resident's weight of 192.2 lbs. on 11/01/25 and 176.2 lbs. on 02/01/26 represented a severe weight loss of 8.32 % in three months. Review of the nutrition progress note for Resident #12 dated 11/21/25 authored by RD #605, revealed the resident's current body weight of 192.2 lbs. triggered a significant weight gain of 13.06 % in thirty days and 12 % weight gain in ninety days. The physician was notified of the weight gain. There was no recommendation for a re-weight.Review of the weights for Resident #12 revealed the resident had documented weights on 12/01/25 of 180 lbs. and on 01/01/26 of 140.2 lbs. This represented a 22.11 % weight loss in one month. The resident's next documented weight was on 01/21/26 (177.1 lbs.).Review of the nutrition progress note for Resident #12 dated 12/19/25 authored by RD #605, revealed the resident's current body weight of 180 lbs. triggered for significant weight loss of 6.35 % in thirty days. The physician was notified of wight loss. There was no recommendation for a re-weight.Review of the weights for Resident #12 revealed the resident had documented weights on 01/01/26 of 140.2 lbs. and on 01/21/26 of 177.1 lbs. This represented a 26.32 % weight gain in twenty days. The resident's next documented weight was on 02/01/26 (176.2 lbs.).Review of the MDS Annual assessment dated [DATE], revealed Resident #12 had severe cognitive impairment and was always incontinent of bowel and bladder. The resident required set-up assistance for eating and oral hygiene, and was dependent for personal hygiene, toileting, bathing, and dressing, and required maximal assistance for bed mobility and transfers.Review of the annual nutritional assessment for Resident #12 dated 01/14/26 authored by RD #605, revealed a current body weight of 140.2 lbs. triggered for significant weight loss of 22.11 % for thirty days, 23.30 % weight loss for ninety days, and 19.61% weight loss for six months. The resident had an order for re-weight due to such significant weight loss. The resident received Ensure Plus 240 milliliters (ml) two times a day by mouth to provide 700 calories and 26 grams (gm) of protein in between meals. The unintended weight loss was related to cognitive decline and poor appetite for greater than three months. There were no recommendations to the physician.Review of the documented weights for Resident #12 revealed the re-weight requested on 01/14/26 for Resident #12 was not obtained until 01/21/26 (177.1 lbs.) Review of the nurse's progress note for Resident #12 dated 01/14/26, revealed a new order was received for Resident #12 to be re-weighed. Review of the nutrition progress note for Resident #12 dated 01/15/26 authored by RD #605, revealed a re-weight was requested (for the 01/01/26 documented weight) but was still pending. The physician was notified of the weight loss. Review of the nutrition progress note for Resident #12 dated 02/20/26 authored by RD #605, revealed a current body weight of 176.2 lbs. triggered for a significant weight gain; however, this was pulling from an outlier weight. During an Interview on 02/25/26 at 12:16 P.M., RD #605 verified Resident #12 was on a monthly weight schedule and she reviewed the resident's weights monthly. RD #605 verified if a resident experienced a significant weight gain or weight loss, a re-weight was to be obtained with her expectation that the re-weight be obtained within one week and revealed this was communicated with the nursing department via email. RD #605 verified Resident #12 had a documented significant weight loss of 22.11 % from 12/01/25 to 01/01/26 and Resident #12 was not re-weighed until 01/21/26.During an interview on 02/25/26 at 12:16 P.M., the Director of Nursing (DON) stated it was her expectation that any resident who experienced a documented significant weight gain or weight loss, then the staff should have obtained a re-weight within two days. Review of policy titled, Weights and Weight Change Management, undated, revealed residents will be weighed at least monthly unless otherwise ordered by the physician or recommended by dietician/designee and weight will be documented in the clinical record or in weight monitoring software. Significant weight changes will be addressed by the dietician/designee and interdisciplinary care team. Residents are reweighed if a significant weight loss is noted or to confirm accuracy of weight. The dietician/designee will reassess the nutritional needs and intake of any resident with a significant weight change and make recommendations related to the results of assessment.

Based on medical record review, family interview, staff interview, and policy review, the facility failed to ensure resident responsible parties were notified of changes in condition. This affected two Residents (#08 and #12) of the five residents reviewed. The facility census was 61. Review of the medical record of Resident #08 revealed an admission date of 12/08/25. Diagnoses included end-stage renal disease (ESRD), dependence on renal dialysis, chronic obstructive pulmonary disease (COPD), and hypothyroidism. Review of the medical record revealed on 12/09/25, Resident #08 weighed 118.6 pounds (lb.). On 12/13/25, the resident weighed 112 lb. On 12/23/25, the resident weighed 113.6 lb. On 12/31/25, the resident weighed 110.8 lb. On 01/10/26, the resident weighed 109.6 lb. On 01/21/26, the resident weighed 105.4 lb. On 01/01/26, the resident weighed 100.4 lb. On 02/05/26, the resident weighed 98.2 lb. On 02/18/26, the resident weighed 96 lb. On 02/22/26, the resident weighed 94.3 lb. On 02/24/26, the resident weighed 93 lb. Review of the comprehensive Minimum Data Set (MDS) assessment for Resident #08 dated 12/11/25, revealed the resident had moderately impaired cognition. The resident required supervision with eating and partial/moderate assistance with activities of daily living. Review of the medical record revealed no documented evidence of Resident #08's responsible party being notified of Resident #08's weight loss. During an interview on 02/24/26 at 12:52 P.M., Resident #08's daughter stated she was aware her mother was not eating; however, nobody mentioned anything about her weight loss. Resident #08's daughter stated the last weight she was aware of was 115 lb. During an interview on 02/25/26 at 12:22 P.M., Registered Dietitian (RD) #600 stated she relied on the nursing to notify the residents' responsible parties when she has new orders; however, she had no process for notifying responsible parties of weight loss. RD #600 verified there was no documentation in the medical record of Resident #08's responsible party being notified of her significant weight loss. During an interview on 02/25/26 at 12:26 P.M., the Director of Nursing (DON) stated all notifications made by the nursing staff would be documented in the medical record if the notification was completed. Review of the facility policy titled, Notification and Reporting of Changes in Health Status, Illness, Injury, and Death of a Resident, undated, revealed the appropriate associates will promptly inform the resident and resident's representative when there is a change in the residents' health status, including situations of illness, injury, or death. The notification shall include a description of the circumstances and cause (if known). A notification of change in the health status and any intervention taken shall be documented in the medical record.

Based on observation, staff interview, and facility policy review, the facility failed to ensure that staff were fit tested for a respirator required for respiratory protection when working with Coronavirus Disease 2019 (COVID-19) positive residents. This had the potential to affect all 72 residents that resided in the facility. The census was 72. Finding included: During an observation on 08/26/24 at 1:48 P.M., State tested Nurse Aide (STNA) #8 was observed coming out of a COVID-19 positive resident's room with a bag of soiled items. STNA #8 had on a surgical mask and gloves. During a concurrent interview STNA #8 stated, when entering the room with a COVID-19 positive resident, she would put an N95 (respirator) mask on top of a surgical mask, gown, face shield, and gloves. STNA #8 stated there was a bin inside the room to discard all the personal protective equipment (PPE). STNA #8 stated she would discard everything and when she would exit the room, she would just have on a surgical mask and would put new gloves on when she came out. STNA #8 stated she had not been fit tested for a respirator. During an interview on 08/26/24 at 2:21 P.M., Licensed Practical Nurse (LPN) #9 stated she worked at the facility for [AGE] years and had not been fit tested for a respirator. During an interview on 08/27/24 at 9:59 A.M., LPN #10 stated she had not been fit tested for a respirator. During an interview on 08/27/24 at 12:02 P.M., the Administrator stated fit testing was done by corporate and they were not able to provide any records. The Administrator stated there had been some changes in staff and they were not sure where the records were. During an interview on 08/28/24 at 11:40 A.M., the Director of Nursing (DON) stated there had been a lot of turnover in the past year in administration and the fit testing was handled by corporate. The DON stated she did not handle the fit testing, so she would not be able to speak on what may have happened to the records. During an interview on 08/30/24 at 11:35 A.M., the DON stated her expectation was for staff to wear PPE that was appropriate for the precautions and that fit testing be performed on staff upon hire and annually thereafter. During an interview on 08/30/24 at 2:38 P.M., the Administrator stated her expectation was for staff to wear the appropriate PPE and for fit testing to be done according to the policy. Review of a facility policy titled, Respiratory Protection Procedure, dated 04/21/2021 revealed, under section Six - Fit Testing, revealed fit testing is conducted to determine how well the seal of a respirator 'fits' on an individual's face and that a good seal can be obtained. Respirators that do not seal do not offer adequate protection. The policy revealed fit testing will be conducted at least annually and prior to any associate being allowed to wear any respirator. A record of fit testing for each associate will be recorded on a fit testing log to serve as record of the individual test. Records of fit testing shall be maintained by the Respiratory Protection Program Administrator, or their designee, for at least six years.

Based on observation, staff interview, and facility policy review, the facility failed to ensure staff properly stored frozen foods and staff with beards wore beard guards during preparation of food to prevent contamination. The failure had the potential to affect 72 residents who received meals from the kitchen. The census was 72. Findings included: 1. During an observation on 08/26/24 at 9:09 A.M., Preparation (Prep) [NAME] #6 was observed preparing food with a full beard and no beard cover. During an interview on 08/26/24 at 9:35 A.M., Prep [NAME] #6 stated he was preparing the ham and putting up buns when the surveyor entered the kitchen. He stated he did not know if he should have been wearing a beard cover. During an interview on 08/26/24 at 9:40 A.M., the Dietary Manager (DM) stated Prep [NAME] #6 should have had a beard cover on while preparing food. During an interview on 08/29/24 at 10:18 A.M., the Administrator stated beard covers should be worn when preparing food. Review of a facility policy titled, Orientation and Education, revised 01/2024, revealed in the section titled, Associates Working with Food, included to restrain all facial hair with a beard net/restraint. 2. During an observation on 08/26/24 at 9:17 A.M., the freezer was observed. There was a hamburger patty observed lying in a box and left open to air. There was one box of chicken tenders which was left open to air. During a concurrent interview the DM stated the food should be sealed and not left open to air. During an interview on 08/29/24 at 10:18 A.M., the Administrator stated the hamburger patty was left open to air, but it was one and they did not realize one was left in the bag. She stated the food stored in the freezer should be sealed. Review of a facility policy titled, Production, Purchasing, Storage, revised 01/2024, revealed in the section titled, Procedures, included to cover, label, and date unused portions and open packages. The section titled, Frozen Storage, included to wrap food tightly to prevent cross contamination.

Based on observation, staff interview, medical record review, and facility policy review, the facility failed to ensure the medication error rate was less than five percent (%). There were five errors out of 31 opportunities, which resulted in a medication error rate of 16.13% for two (Resident #29 and Resident #49) of three residents observed for medication administration. The census was 72. Findings included: 1. Review of a profile face sheet revealed the facility admitted Resident #29 on 09/18/23. According to the profile face sheet, the resident had a medical history that included diagnoses of chronic kidney disease stage three and urinary tract infections. Review of Resident #29's physician's orders included an order dated 08/07/24 for the supplement cranberry concentrate 500 milligram (mg) capsule by mouth daily for recurrent urinary tract infections. During an observation of medication administration on 08/28/24 at 8:36 A.M., Registered Nurse (RN) #14 administered Azo-Cranberry for urinary tract health. During an observation and interview on 08/28/2024 at 3:32 P.M., RN #14 read the cranberry concentrate order and then pulled the box of Azo-Cranberry for urinary tract health and read the ingredients, which were 900 mg of powdered concentrated cranberry in two tablets, vitamin C 60 mg, calcium phosphate 50 mg, phosphorous 38 mg and 100 million colony forming units (CFUs) of probiotic. RN #14 verified it was a medication error and should have been clarified prior to administration, even though it was a supplement. During a telephone interview on 08/30/24 at 1:08 P.M., the Pharmacist stated cranberry concentrate 500 mg and Azo-Cranberry for urinary tract health were not the same medication. The Pharmacist stated Azo had additional additives to help ease the pain of a urinary tract infection, such as vitamin C, phosphorus, and at times probiotics. 2. Review of a profile face sheet revealed the facility admitted Resident #49 on 10/26/22. According to the profile face sheet, the resident had a medical history that included diagnoses of heart failure, hypertension (high blood pressure), and mild cognitive impairment. Review of Resident #49's physician's orders included an order dated 02/07/23 for supplemental calcium 600 with vitamin D3 600 milligrams (mg) (1,500 mg) - 200-unit tablet by mouth daily for calcium deficiency, an order dated 02/07/23 for supplemental ferrous gluconate 324 mg by mouth daily with breakfast for anemia, an order dated 03/23/23 for supplemental vitamin C 500 mg capsule, extended release by mouth daily for wound healing and skin support, and an order dated 03/23/23 for Stress B with Zinc tablet, one tablet by mouth daily for wound healing and skin support. During an observation of medication administration on 08/28/24 at 9:13 A.M., RN #14 administered Resident #49 the following medications including; calcium 600 mg/10 mcg (micrograms) with vitamin D3, one tablet; ferrous sulfate 224 mg, one tablet; vitamin C 500 mg, one tablet; and Stress formula multivitamin with zinc. During an observation and interview on 08/28/24 at 8:32 A.M., RN #14 looked at the electronic medication administration record (EMAR) for the calcium order and stated the order was confusing. However, she thought she had pulled the right medication because it had 600 mg of calcium and vitamin D3 in it. She then looked at the EMAR and pulled out a box of medication from the third drawer of the medication cart for ferrous gluconate. She stated she had given Resident #49 ferrous sulfate 224 mg from the top drawer. RN #14 looked at the EMAR and pulled the vitamin C 500 mg and acknowledged it did not say extended release. She then looked at the EMAR and pulled the Stress formula multivitamin bottle and acknowledged there was no B on the bottle. RN #14 agreed the above four medications passed were medication errors and she should have clarified the medications prior to administration, even if they were supplements. During an interview on 08/30/24 at 11:13 A.M., the Director of Nursing (DON) stated she was upset because the facility had an overabundance of supplements available for the nurses to use during medication pass. She stated she wished RN #14 had looked before giving the medication and not just gave it, If it was close, and if she did not have the right medication or supplement, got the order clarified with the physician or changed to what was available in-house stock. The DON stated her expectation was for nurses to look at the EMAR and give the right medications following the five rights of medication administration as well as the physician's order. She stated that in the event the nurses did not have the medication/supplement they needed, to look for it first in the stock room and then get the orders clarified with the physician and change to a medication/supplement that was available. During an interview on 08/30/24 at 2:53 P.M., the Administrator stated her expectation was for the nurses to give the medications per physician's orders and to follow protocol. During a telephone interview on 08/30/24 at 1:08 P.M., the Pharmacist stated the order for calcium 600 with vitamin D3 600 mg (1,500 mg) - 200-unit tablet was not an accurate medication order, and he was not sure what medication the staff were trying to describe. However, it was not the calcium 600 mg with 10 mcg of D3, that had been given, and it was a medication error. He stated ferrous sulfate 224 mg was not the same medication as ferrous gluconate 324 mg, and it was a medication error. The Pharmacist stated there was a big difference between vitamin C 500 mg and vitamin C 500 mg extended release. He stated the extended release was given to residents to help ease stomach upset, with the full dose coated to release slowly into their digestive system, and it was a medication error. He also stated being given a Stress formula multivitamin with zinc instead of a Stress B with zinc multivitamin would be a medication error as well. The Pharmacist further stated although there were only subtle differences in the medication names, the effects and types of medications were different, and all examples given were medication errors. Review of an undated facility policy titled, Medication Administration, revealed the section titled Purpose included to administer medications in a safe and effective manner. The policy specified nurses will administer medications safely and effectively following the five rights of medication administration and follow the five rights of medication administration to ensure the right patient, right drug, right dose, right route, and right time.

Based on staff interview, medical record review, and facility policy review, the facility failed to ensure pharmacy recommendations were implemented for two (Resident #58 and Resident #72) of five sampled residents reviewed for unnecessary medications. The census was 72. Findings included: 1. Review of a profile face sheet revealed the facility admitted Resident #58 on 09/20/23. According to the profile face sheet, the resident had a medical history that included diagnoses of Alzheimer's disease and dementia with other behavioral disturbance. Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/24/24, revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of three, which indicated the resident had severe cognitive impairment. The MDS assessment revealed the resident received antipsychotic and antidepressant medications during the assessment period. Review of Resident #58's care plan included a category for psychotropic drug use, initiated 10/03/23, that indicated the resident had the potential for drug related complications associated with the use of psychotropic medications related to antipsychotic use. Interventions directed the pharmacy to review medications and make recommendations monthly, as needed. Review of Resident #58's pharmacy medication reconciliation and admission/readmission drug regimen review (DRR) dated 06/14/24, revealed a recommendation by the pharmacist to discontinue the resident's order of hormone supplement melatonin three (3) milligrams (mg) and olanzapine (an antipsychotic) 2.5 mg. The review revealed the physician agreed with the recommendation on 07/23/24. Review of Resident #58's physician's orders contained an order dated 02/10/24 for olanzapine 2.5 mg by mouth at dinner for mood disorder. Further review revealed no stop date for olanzapine 2.5 mg. The physician's orders contained an order dated 02/10/24 for Melatonin 3 mg by mouth at dinner for insomnia. Further review revealed no stop date for melatonin 3 mg. During an interview on 08/30/24 at 4:40 P.M., Physician #2 stated Resident #58 transitioned from assisted living to the skilled nursing facility, and part of the reason for the move was due to increased anxiety and behaviors. Physician #2 stated Resident #58 receive a psychiatric consultation and was put on melatonin and olanzapine based on recommendations from them. Physician #2 stated he would not order residents on an antipsychotic without a recommendation from a psychiatrist. Physician #2 indicated there should be psychiatric notes available for Resident #58's usage of melatonin and olanzapine; however, no notes were provided at the time of the survey. 2. Review of a profile face sheet revealed the facility admitted Resident #72 on 05/06/24. According to the profile face sheet, the resident had a medical history that included diagnoses of Alzheimer's disease, depression, and cognitive communication deficit. Review of an admission MDS assessment, with an ARD of 05/10/24, revealed Resident #72 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. The MDS assessment revealed the resident received antipsychotic and antidepressant medications during the assessment period. Review of Resident #72's care plan included a category for psychotropic drug use, initiated 07/03/24, that indicated the resident had the potential for drug related complications associated with use of psychotropic medications related to antidepressant, antipsychotic use. Interventions directed the pharmacy to review medications and make recommendations monthly, as needed. Review of Resident #72's pharmacy document titled, Note to Attending Physician/Prescriber, dated 08/01/24, revealed the resident was receiving an antipsychotic agent but lacks an allowable diagnosis. The following Diagnostic and Statistical Manual of Mental Disorders (DSM) -[illegible] are considered appropriate diagnoses or conditions: schizophrenia, schizoaffective disorder schizophreniform disorder, delusional disorder, brief psychotic disorder, mania, bipolar disorder, depression with psychotic features refractory major depression, atypical psychosis, related psychosis, mania, psychosis not otherwise specified (NOS), psychosis without dementia, dementing illnesses with associated behavioral symptoms, medical illnesses (delirium with manic, psychotic symptoms and treatment), dementing illnesses with associated behavioral symptoms, medical illnesses, delirium with manic, psychotic symptoms and treatment, hiccups, and nausea and vomiting (N and V) with cancer (CA) or chemotherapy (chemo). Further review revealed documentation of, To note: antipsychotics by themselves are not approved for singular treatment of depression. Review of Resident #72's physician's orders contained an order, dated 05/06/24, for Zyprexa (an antipsychotic) five (5) mg by mouth daily for depression. During an interview on 08/30/24 at 11:35 A.M., the Director of Nursing (DON) stated the pharmacist made recommendations, but it would be up to the physician or nurse practitioner to change the resident's medications. The DON indicated the expectation was for recommendations to be followed. During an interview on 08/30/24 at 11:37 A.M., the Assistant Director of Nursing (ADON) stated once a pharmacy recommendation was received, it was provided to the physician or nurse practitioner. The ADON stated it would then go to nursing staff to make the changes and notify the family. During an interview on 08/30/24 at 12:33 P.M., the Pharmacist stated he performed the DRR and during the reviews, he would look for psychotropic medication reductions, laboratory values, and if doctors were doing what they said they would do. The Pharmacist stated he would generally look at the diagnoses of each resident and if he saw that a medication was being given for a diagnosis that the resident did not have, he would request a diagnosis from the physician. The Pharmacist stated he did an DRR on Resident #72 in July 2024 and asked for another diagnosis for the antipsychotic medication. The Pharmacist stated he did not get a response back from July 2024, so he did another DRR in August and requested the diagnosis again. Review of a policy titled, Medication Regimen Review, dated 01/2019, indicated, the consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The medication regiment review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. The MRR also involves a thorough review of the resident records, and may include collaboration with other members of the interdisciplinary team, collaboration with the resident, family members or other resident representatives. The MRR also involves reporting of findings with recommendations for improvement. All findings and recommendations are reported to the director of nursing and the attending physician/extender. The policy also indicated, recommendations are acted upon and documented by the facility staff and/or the prescriber. The Prescriber accepts and acts upon suggestion, and the Director of Nursing or designated licensed nurse address and document recommendations that do not require a physician intervention, e.g. (exempli gratia, for example), monitor blood pressure.

Based on staff interview, medical record review, and facility policy review, the facility failed to notify the physician related to bleeding during indwelling urinary catheter changes for one (Resident #49) of three sampled residents reviewed for urinary catheters. The census was 72. Findings included: Review of a profile face sheet revealed the facility admitted Resident #49 on 10/26/22. According to the profile face sheet, the resident had a medical history that included diagnoses of benign prostatic hyperplasia with lower urinary tract symptoms and obstructive and reflux uropathy. Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/04/24, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of nine, which indicated the resident had moderate cognitive impairment. The MDS assessment indicated the resident had an indwelling urinary catheter. Review of Resident #49's physician orders contained an order dated 04/23/24 to change F/C (Foley catheter) #18 French size (Fr), a universal gauge system used to measure the diameter of indwelling catheters, with a 10 milliliter (mL) balloon (used to hold the indwelling urinary catheter in the bladder), every month and pro re nata (prn; which means as needed). Review of Resident #49's interdisciplinary notes, documented by Licensed Practical Nurse (LPN) #1 on 04/23/24 at 6:05 A.M., revealed Resident #49's indwelling urinary catheter was changed and had a clear red return. The notes revealed no documentation the physician was notified regarding the clear red return. Review of Resident #49's interdisciplinary notes dated 05/20/24 at 2:52 P.M. revealed Resident #49 was observed with the indwelling urinary catheter in their hand with the bulb deflated, and a small amount of blood was noted at the urethra. The note revealed a Foley catheter #18 Fr with a 10 mL balloon was re-inserted, with blood strands noted in the resident's urine. The notes revealed no documentation that the physician was notified of the blood in Resident #49's urine. Review of Resident #49's interdisciplinary notes, documented by LPN #1 on 06/26/24 at 6:17 A.M., revealed Resident #49's indwelling urinary catheter was changed with a return of clear yellow urine with small blood clots. The notes revealed the resident tolerated the procedure with mild pain rated at four out of 10. The notes revealed no documentation that the physician was notified of the blood clots in Resident #49's urine. Review of Resident #49's interdisciplinary notes, documented by LPN #1 on 07/25/24 at 6:13 A.M., revealed Resident #49's indwelling urinary catheter was changed with an initial visualization of hematuria (blood in urine), yellow urine with a tinge of red and a small clot. The notes revealed no documentation that the physician was notified of the blood in Resident #49's urine. Review of Resident #49's interdisciplinary notes, documented by LPN #1 on 08/27/24 at 7:47 A.M., revealed Resident #49's indwelling urinary catheter was changed with visualized hematuria in the catheter tubing. The notes indicated Resident #49 tolerated the indwelling urinary catheter change with some discomfort during insertion. The notes revealed no documentation that the physician was notified of the blood in Resident #49's urine. During an interview on 08/30/24 at 9:13 A.M., LPN #1 stated she was the nurse who changed out Resident #49's catheter on a regular basis. LPN #1 stated the resident had prostate issues and bled when the catheter was changed. During a follow-up interview on 08/30/24 at 5:09 P.M., LPN #1 stated she did not call the physician about Resident #49 bleeding with the indwelling urinary catheter changes. During an interview on 08/30/24 at 4:37 P.M., Physician #2 stated the staff had not made him aware of Resident #49 bleeding with catheter changes for the last several months. Review of an undated facility policy titled, Notification and Reporting of Changes in Health Status, Illness, Injury and Death of a Resident, revealed, it is the policy of the facility to notify the Resident, the Resident's physician, and Resident Representative as required by state and federal regulation.

Based on observation, staff interview, medical record review, and facility policy review, the facility failed to ensure staff followed physician orders for indwelling urinary catheter care for one (Resident #49) of three sampled residents reviewed for urinary catheters. The census was 72. Findings included: Review of a profile face sheet revealed the facility admitted Resident #49 on 10/26/22. According to the profile face sheet, the resident had a medical history that included diagnoses of benign prostatic hyperplasia with lower urinary tract symptoms and obstructive and reflux uropathy. Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/04/24, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of nine, which indicated the resident had moderate cognitive impairment. The MDS assessment indicated the resident had an indwelling urinary catheter. Review of Resident #49's physician orders contained an order dated 04/23/24 to change F/C (Foley catheter) #18 French size (Fr), a universal gauge system used to measure the diameter of indwelling catheters) with a 10 milliliters (mL) balloon (used to hold the indwelling urinary catheter in the bladder), every month and pro re nata (prn, which meant as needed). Review of Resident #49's interdisciplinary notes, documented by Licensed Practical Nurse (LPN) #1 on 08/27/24 at 7:47 A.M., revealed Resident #49's indwelling urinary catheter was changed, the catheter was removed, and was a #18 Fr with a 30 mL balloon. The note revealed a #18 Fr catheter was inserted with visualized hematuria (blood in the urine), and a 30 mL balloon was inflated with the resident experiencing discomfort. During an observation on 08/29/24 at 4:27 P.M., Registered Nurse (RN) #3 checked the label of Resident #49's indwelling urinary catheter that was currently in place and stated it was a #18 Fr with a 30 mL balloon. During a phone interview on 08/30/24 at 9:13 A.M., LPN #1 stated she was the nurse who normally changed Resident #49's urinary catheter and had changed the resident's catheter on 08/27/24. She stated that as she entered the urethra, the patient said, Oh, oh, and grimaced. She stated the resident usually bled when changing the catheter, and as she advanced the catheter in the urethra, no urine return was noted, only blood in the catheter. LPN #1 stated she continued to advance the catheter until it would not advance anymore and inflated the balloon. She stated she asked the resident if they were doing okay after the procedure, and Resident #49 stated, Oh, I am not sure. LPN #1 stated the resident had dementia and could not always express themselves. She further stated she knew what size catheter to anchor based on the physician's order. When informed by this surveyor the physician's order stated the catheter was to be a #18 Fr 10 mL balloon, she stated she had looked and did not have a #18 Fr 10 mL balloon available, so she used what she had and that was a #18 Fr 30 mL balloon and inflated the balloon to the full 30 mL. LPN #1 then stated, I should have just ordered one instead of using the bigger balloon. During an interview on 08/30/24 at 11:28 A.M., the Director of Nursing (DON) stated she was unsure why the nurse would use a larger size indwelling urinary catheter without a physician's order. She stated there was a difference between a 10 mL balloon and a 30 mL balloon, and there was a stock supply of items on site that should have been used. The DON stated LPN #1 could have called the physician and gotten an order to delay the catheter change until the right size arrived if she did not have what she needed. She stated her expectation was for the nurse to check the order, follow the physician's order exactly as it was written, and insert the catheter per the urinary catheter policy and protocol. During an interview on 08/30/24 at 2:59 P.M., the Administrator stated she expected the nurses to follow the physician's orders for the changing indwelling urinary catheters, use the right size catheter and provide the appropriate care. During an interview on 08/30/24 at 4:37 P.M., Physician #2 stated he had not been made aware of the use of a larger catheter balloon or bleeding from catheter insertion for Resident #49. He stated the catheter size needed to remain a #18 Fr with 10 mL balloon unless the catheter was spontaneously falling out, and he doubted it was. He also stated the catheter size and balloon size should not be changed simply out of convenience to the staff, as that was not how the process should work. Physician #2 stated specific catheter sizes were used for specific reasons and should not be for the convenience of the staff and what was available to them at the time. Review of an undated facility policy titled, Catheter Care, revealed the section titled Purpose included to provide person-centered care for residents to ensure proper hygiene procedures. The policy further indicated residents with indwelling catheters will receive catheter care daily and as needed in order to maintain adequate personal hygiene and reduce or prevent complications such as urinary tract infections.

Based on staff interview and medical record review, the facility failed to ensure nursing staff possessed and demonstrated competencies and skill set necessary to provide indwelling urinary catheter care for one (Resident #49) of the sampled residents reviewed for urinary catheters. The census was 72. Findings included: Review of a profile face sheet revealed the facility admitted Resident #49 on 10/26/22. According to the profile face sheet, the resident had a medical history that included diagnoses of benign prostatic hyperplasia with lower urinary tract symptoms and obstructive and reflux uropathy. Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/04/24, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of nine, which indicated the resident had moderate cognitive impairment. The MDS assessment indicated the resident had an indwelling urinary catheter. Review of Resident #49's physician orders contained an order dated 04/23/24 to change F/C (Foley catheter) #18 French size (Fr), a universal gauge system used to measure the diameter of indwelling catheters) with a 10 milliliter (mL) balloon (used to hold the indwelling urinary catheter in the bladder), every month and pro re nata (prn, meant as needed). During an observation on 08/29/24 at 4:27 P.M., Registered Nurse (RN) #3 checked the label of Resident #49's indwelling urinary catheter that was currently in place and stated it was a #18 Fr with a 30 mL balloon. Review of Resident #49's interdisciplinary notes, documented by Licensed Practical Nurse (LPN) #1 on 08/27/24 at 7:47 A.M., revealed Resident #49's indwelling urinary catheter was changed, the catheter was removed, and was a #18 Fr with a 30 mL balloon. The note revealed a #18 Fr catheter was inserted with visualized hematuria (blood in the urine), and a 30 mL balloon was inflated with the resident experiencing discomfort. During a phone interview on 08/30/24 at 9:13 A.M., LPN #1 stated she was the nurse who normally changed Resident #49's urinary catheter and had changed the resident's catheter on 08/27/24. She stated that as she entered the urethra, the resident said, Oh, oh, and grimaced. She stated the resident usually bled when changing the catheter, and as she advanced the catheter in the urethra, no urine return was noted, only blood in the catheter. LPN #1 stated she continued to advance the catheter until it would not advance anymore and inflated the balloon. She stated she asked the resident if they were doing okay after the procedure, and Resident #49 stated, Oh, I am not sure. LPN #1 stated the resident had dementia and could not always express themselves. She further stated she knew what size catheter to anchor based on the physician's order. When informed by this surveyor the physician's order stated the catheter was to be a #18 Fr 10 mL balloon, she stated she had looked and did not have a #18 Fr 10 mL balloon available, so she used what she had and that was a #18 Fr 30 mL balloon and inflated the balloon to the full 30 mL. LPN #1 then stated, I should have just ordered one instead of using the bigger balloon. During an interview on 08/30/24 at 11:28 A.M., the Director of Nursing (DON) stated she was unsure why the nurse would use a larger size indwelling urinary catheter without a physician's order. She stated there was a difference between a 10 mL balloon and a 30 mL balloon, and there was a stock supply of items on site that should have been used. The DON stated LPN #1 could have called the physician and gotten an order to delay the catheter change until the right size arrived if she did not have what she needed. She stated her expectation was for the nurse to check the order, follow the physician's order exactly as it was written, and insert the catheter per the urinary catheter policy and protocol. During an interview on 08/30/24 at 3:10 P.M., the DON stated she did not have a nursing competency for LPN #1, as the facility did not do them regularly. She also confirmed there had been no recent in-services for nursing staff on indwelling urinary catheter insertion and care. During an interview on 08/30/24 at 5:02 P.M., the DON stated the facility did not do annual competencies with the staff; their education was mostly based on the computer, including orientation. The DON also stated the facility did not have a policy for staff competencies.

Based on observation, interview policy review, the facility failed to label and date foods, accurately test for dishwasher sanitation and use hand gloves in a sanitary manner during food service. This had the potential to affect all the resident's receiving food from the kitchen. The total facility census was 76. Findings Include: 1. During the kitchen tour observation on 10/31/22 at 8:30 A.M. revealed the following sanitation violations in the main kitchen: The ice machine scoop was laying horizontally on a counter and not draining vertically. In the walk in refrigerator there were undated, uncovered yogurt fruit plates, a serving container of gravy, and tub of macaroni and cheese. There were 12 undated and unlabeled pies and four serving containers of egg salad. There were two opened undated bags of bread. In the walk-in freezer there was food and paper debris on the floor. In the walk-in produce refrigerator there were two large bags of unopened vegetables with no label and date. In the dry storage area there was a bag of identified macaroni undated and unlabeled. Interview on 10/31/22 at 8:55 A.M., Chef #510 verified the sanitation violations including undated, unlabeled foods, uncovered foods, and ice machine scoop stored improperly. 2. Observation 10/31/22 during lunch food service on from 12:26 P.M. to 12:40 P.M. in the 200-unit kitchenette revealed Diet Server (DS) #420 wore gloves, touched plates, opened food carts, touched counter tops, opened hamburger buns, touched tomato, and lettuce without changing gloves. The hamburger bun was served to a resident. DS #420 with same gloves, opened the steam table cover, held a sweet potato to cut it open and placed the potato on a resident plate. Interview on 12:40 P.M., DS #420 verified she had open the bun and placed tomato/ lettuce with gloved hands which had not been changed after touching equipment and countertops. She verified she had opened the potato and placed it on a resident plate without changing gloves. 3. Observation on 11/02/22 at 8:25 A.M. at the breakfast meal in the 300 Unit kitchenette, revealed DS #450 touched the bread bag, countertop, and the toaster with gloved hands and without changing gloves, removed the toast and served the toast to a resident with the same gloved hands. Interview on 11/02/22 at 8:50 A.M., DS #450 verified she served the toast with contaminated gloves and had not used a utensil. 4. Observation on 11/02/22 at 11:25 A.M. revealed Chef #500 picked up the sanitized food processor food contact blades with gloved hands. Chef #500 used the same gloved hand to open a refrigerator and pick up a container of food from the refrigerator. Chef #500 re-assembled the food processor, including the food contact blades, without changing gloves. Chef #500 put food into the processor to prepare puree foods. Interview on 11/02/22 at 11:40 A.M., Chef #500 verified he had assembled the food processor, including food contact surfaces, with contaminated gloves. 5. Observation on 11/03/22 at 10:16 A.M. in the 300 unit dish room, DS #410 used a quaternary chemical test strip to test for a chlorine chemical dish machine, as listed on the dish machine log. The quaternary test strip DS #410 used did not register a chemical reading. The dishwasher log dated 11/03/22 was recorded as chlorine 100 part per million, (ppm) for the breakfast meal. Interview on 11.03/22 at 10:20 A.M., DS #410 was unable to explain why the chemical test did not register but was recorded as 100 ppm. DS #410 was unable to state what type of chemical strip should be used on the dishwasher. Interview on 11/03/22 at 10:45 Diet Manager # 400 stated the chlorine test strip was to be used on the dishwasher. He stated the chlorine test strip was not available to DS #410. Review of facility policies titled Food and Supply Storage, dated January 2022, Meal Tray Assembly Procedures, dated January 2021, and Meal Quality and Temperature, dated January 2022 revealed food preparation shall be stored to prevent contamination.

Based on medical record review, observation, staff interview, review of the recipes, review of the menu spreadsheet, and policy review, the facility failed to provide puree foods as planned by a Registered Dietitian. This affected two residents (#27 and #35) out of three residents reviewed for puree food diets. The facility census was 76. Findings Include: 1. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included bone necrosis of the mouth gums, dysphagia and gastro-[CONDITION(S)] reflux disease. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had moderately impaired cognition and received puree thin liquid diet. 2. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE]. Diagnoses included dysphagia, [CONDITION(S)] disease, [CONDITION(S)], and [CONDITION(S)]. Review of the MDS comprehensive assessment dated [DATE] revealed Resident #35 had intact cognition and received pureed foods with nectar thick liquids diet. Review of the puree soup recipe revealed the puree soup should be served using a six ounce ladle. Review of the puree meat recipe revealed the puree meat should be served using a number 12 scoop. Review of the menu spreadsheet dated 11/02/22 revealed the puree lunch meal consisted of one portion of puree meat, puree soup size six ounces, puree starch of a formed mold, puree carrots of a mold form and pudding one half cup. Observation 11/02/22 from 12:25 P.M., to 1:00 P.M. revealed Diet Server (DS) #410 used number eight scoop for the pureed meat portion, and used the number 12 scoop for the puree soup. There was no molded form starch food. Observation on 11/02/22 at 12:25 P.M., Resident #35 had not received the puree pudding. Resident #27's meal plate was covered and ready to serve when the surveyor asked DS #410 of the missing puree vegetable. Interview on 11/02/22 at 12:45 P.M., DS #410 verified he had not used the correct serving utensil for puree meat or puree soup. He said he had no molded formed starch food and was not aware of the correct scoop size to use for the prepared puree starch. He stated the puree recipes were not available to clarify the serving portions. DS #410 verified Resident #35 was not served a puree vegetable until the surveyor inquired of the missing vegetable. Interview on 11/02/22 at 12:50 P.M., Diet Manager #400 verified the puree meat and soup were the incorrect scoop portions and the spreadsheet was not clear for puree serving sizes. DM # 400 verified Resident #35 had not received the puree pudding portion on the meal tray. Review of facility policy titled Meal Tray Assembly Procedures, dated January 2021 and Puree Program, dated January 2019 revealed puree portion amount will be provided in the proper amounts according to menu spreads. The facility supervisor ensures diet spreadsheet is available, followed at each meal period and is accurate.

Based on record review, staff interview, and review of the facility's policy, the facility failed to monitor resident's blood pressure prior to administration of anti-hypertensive medication as ordered by the physician. This affected one (Resident #90) of four residents reviewed for medications. The census was 81. Findings include: Review of the medical record for Resident #90 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 02/17/21, revealed the resident was cognitively intact Review of the physician orders, dated 02/17/21, revealed an order for [REDACTED]. Review of the MAR, dated 02/2021, revealed the resident's blood pressure was not taken prior to the morning dose of [MEDICATION NAME] on 02/22/21 and 02/26/21 and was not taken prior to the evening doses on 02/19/21, 02/22/21 02/24/21, 02/26/21, and 02/28/21. Interview on 03/31/21 at 3:53 P.M. with Registered Nurse (RN) #185 confirmed Resident #90's record did not include documentation of blood pressure being taken prior to administration of the morning dose of [MEDICATION NAME] on 02/22/21 and 02/26/21 and was not taken prior to the evening doses on 02/19/21, 02/22/21 02/24/21, 02/26/21, and 02/28/21. Review of the facility's undated policy titled Medication Administration revealed medications would be administered to residents as prescribed. This deficiency substantiates Complaint Number OH 845.

Based on record review, staff interview and review of the facility's policy, the facility failed to administer medications as ordered by the physician. This affected one (Resident #90) of four residents reviewed for medications. The facility census was 81. Findings include: Review of the medical record for Resident #90 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 02/17/21, revealed the resident was cognitively intact and required limited assistance of one staff with activities of daily living (ADLs). Review of the physician orders, dated 02/18/21, revealed an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the physician orders, dated 02/17/21, revealed an order for [REDACTED]. Review of the MAR, dated February 2021, revealed the evening [MEDICATION NAME] dose was not documented as administered or refused on 02/18/21 or 02/27/21. Interview on 03/31/21 at 3:53 P.M. with Registered Nurse (RN) #185 confirmed Resident #90's record did not include documentation of administration or refusal of the evening doses of [MEDICATION NAME] Sprinkles on 02/18/21, 02/26/21 and 02/28/21 nor of the evening doses of [MEDICATION NAME] on 02/18/21 or 02/27/21 Review of the facility's undated policy titled Medication Administration revealed medications would be administered to residents as prescribed. This deficiency substantiates Complaint Number OH 845.

Based on observations, policy review, and staff interviews the facility failed to maintain transmission-based precautions on two of five units observed for transmission-based precautions. 1.) The facility staff failed to dispose of soiled disposable isolation gowns appropriately and failed to perform hand hygiene after removal of personal protective equipment upon leaving the rooms of five of five residents (Resident) (R) 4, R7, R8, R9, and R11) who were on transmission-based precautions on the rehab (quarantine) unit. This failed practice had the potential to affect all 15 residents who resided on the rehab unit. 2.) The facility failed to ensure proper handling of soiled isolation linens and a trash bag on one of five units observed for transmission-based precautions. The soiled linen bag and the trash bag had been removed from the room of one of four residents (R6) who was on transmission-based precautions. This failed practice had the potential to increase the spread of infection for all four residents residing on the third floor in the Health Center section of the facility. Findings include: During the entrance conference on 02/18/21 at 9:18 AM, the Director of Nursing (DON) stated the facility had a COVID outbreak and the facility's last positive COVID case was a staff member on 02/01/21. The facility had a COVID unit and a quarantine unit and stated the only COVID positive residents right now were residents who had been admitted from the community with COVID; everyone else had recovered. Review of the facility's undated Policy titled, Management of Newly admitted Residents During COVID-19 Pandemic directed, Newly admitted residents will be placed on the quarantine or isolation unit depending on their COVID-19 status .residents on the isolation and quarantine unit will be placed on isolation precautions in accordance with CDC (Centers for Disease Control) guidance. Review of the facility COVID-19 Plan revised 06/05/20 directed, HCP (Health Care Personnel) who enter the room of a patient with known or suspected COVID-19 should adhere to transmission based precautions and use a respirator (or face mask if a respirator is not available), gown, gloves, and eye protection .routine cleaning and disinfection procedures .are appropriate for COVID-19 in healthcare settings .Management of laundry, food service utensils, and medical waste should also be performed in accordance with routine procedures. Observation during a tour of the quarantine unit on 02/18/21 at 10:30 AM revealed each room had Centers for Disease Control and Prevention (CDC) signs posted that directed, STOP CONTACT PRECAUTIONS STOP EVERYONE MUST: Clean hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. 1. Observation on 02/18/21 at 10:38 AM revealed State tested Nursing Assistant (STNA) 2 doffed a yellow disposable isolation gown in the hall after exiting Resident (R) 4's room and discarded the gown in an uncovered hamper that was lined with a red plastic bag; however, the gown was not contained in the receptacle as a sleeve and the ties of the gown were hanging outside the container. STNA2 told the surveyor she had just finished morning care for R4; thus, the gown was contaminated. 2. During an observation on 02/18/21 at 10:51 AM Licensed Practical Nurse (LPN) LPN6 was in R4's room providing hands on care to the resident. When LPN6 was finished, she doffed her gloves in the room, washed her hands in the bathroom, exited the room and doffed the gown in the hall and discarded the gown in a hamper in the hall, without washing her hands or using alcohol-based hand rub (ABHR). LPN6 donned a clean gown in the hall at 10:57 AM and entered the room of R7 to provide hands on care to another resident. When LPN 6 exited the room she again doffed her gloves in the room, washed her hands in the bathroom, doffed her gown in the hall, discarded the gown in hamper in the hall and did not wash her hands or use ABHR. LPN6 then entered the room of R8 and when she exited the room, repeated the same sequence of doffing and did not wash her hands or use ABHR. During an interview on 02/18/21 at 2:43 PM, LPN6 stated the procedure in the quarantine unit for doffing PPE was to remove the contaminated gloves before leaving the room, wash your hands in the bathroom, remove and discard the gown in hall, then use ABHR. LPN6 stated she was an agency nurse and normally she would doff the contaminated gown in the room; however, at this facility they doff PPE as she described. She also stated it would be wrong not to use ABHR after removing the gown and did not recall breaching that policy. 3. During continuous observation on 02/18/21, for 35 minutes, from 11:15 AM to 11:50 AM, Registered Nurse (RN) 1 and Unit Manager (UM) 1 entered R4's to perform a bedside procedure. When UM1 exited the room, she doffed her gloves in the room, washed her hands in the bathroom, doffed her gown in the hall, and discarded the gown in an uncovered hamper in the hall. When RN1 exited the room, she doffed her gloves in room, washed her hands in the bathroom, exited the room, doffed her gown in the hall, and removed shoe covers and did not use ABHR. RN1 then got clean linens and handed them to UM1 who had re-entered the room. During a telephone interview on 02/19/21 at 3:45 PM, RN1stated she should have washed her hands after removing the gown in the hallway. 4. During an observation on 02/18/21 at 2:30 PM, Certified Occupational Therapy Assistant (COTA)1 walked out of the room of R9 on the quarantine unit wearing an isolation gown and walked down to other end of hall to the door of R10 and obtained a therapy balloon that was at the door's threshold. During the observation COTA1 stated that she had already cleaned the balloon after the last resident used it, and she proceeded to walk to the other end of the hall and got a Clorox wipe to wipe the balloon while she was still wearing the contaminated isolation gown. During an interview on 02/19/21 at 3:00 PM, COTA1 stated she should have taken off her isolation gown when she exited R9's room to retrieve the therapy balloon down the hall. COTA1 stated staff had been trained on using full PPE in the quarantine unit; however, it was confusing that they could leave their gowns on between resident encounters on the COVID Unit and had to remove them after each resident encounter on the quarantine unit. 5. During an observation on 02/18/21 at 2:33 PM, Nurse Practitioner (NP) 1 exited the room of R11 on the quarantine unit and doffed the isolation gown in the hall, discarded the gown in the laundry hamper in the hall, left the sleeve dangling outside of the container and did not wash her hands or use ABHR. NP1 walked off the unit, touched the exit bar of the closed doors with her contaminated hands and less than 10 seconds later she was observed walking out of the bathroom. During an interview as she exited the bathroom regarding handwashing and doffing PPE, NP1 stated that she washed her hands in the bathroom and the water was nice and hot; however, she did not state how long she washed her hands. The NP stated that doffing personal protective equipment (PPE) required her to take off her gloves and gown, dispose the articles in the trash can, and wash her hands. NP1 stated that she could wear the same gown for all residents on the quarantine unit to conserve PPE, That's what the sign says on the wall. 6. During an observation on 02/19/21 at 8:22 AM, LPN7 discarded an isolation gown in a hamper in the hall outside room [ROOM NUMBER] on the quarantine unit; however, the gown was not contained in the laundry hamper and was elevated approximately 6-8 inches above the rim and touching an adjacent wooden door in the hall. Continued observation revealed at 8:23 AM, LPN7 exited the room of R8 wearing an isolation gown and holding a syringe, walked 34 feet to the medication cart, discarded the syringe in the sharps container, doffed the gown and gloves at the medication cart with contact and contaminated the medication cart, then walked approximately 10 feet to discard the items in a laundry hamper in the hall, leaving the strings of the isolation gown outside the laundry hamper. During an interview on 02/19/21 at 11:25 AM, LPN7 stated, to doff PPE, take off gloves before exiting the resident's room and doff the gown in room Because it's dirty. She acknowledged the isolation gowns should not be worn outside the room. During the interview, discarded isolation gowns were again noted 4-8 inches above the rim of the laundry hamper outside room [ROOM NUMBER] and at another laundry hamper outside room [ROOM NUMBER]. During an interview on 02/19/21 at 11:30 AM, UM1/RN viewed the overflowing laundry hampers outside rooms [ROOM NUMBERS] and stated that each resident room had trash cans for used PPE and staff could also discard used PPE in the hall; however, she acknowledged that the contaminated PPE was not properly contained inside the laundry hamper. During an interview on 02/19/21 at 3:51 PM, the Director of Nursing (DON), who was also the Infection Control Preventionist (ICP) stated the facility performed PPE competencies and staff were taught and should not be doffing isolation gowns in the hall, they should be doffed and discarded in the room. In addition, she stated she was not aware how or why laundry hampers were placed in the hall on the quarantine unit to discard contaminated PPE. The DON stated contaminated PPE should be properly contained in a trash receptacle and not left overflowing, and staff not performing hand hygiene after doffing a contaminated gown, Is a problem. 7. On 02/18/21 at 2:50 PM two bags were observed on the floor outside of the room of R6 in the Health Center section of the facility. One was a yellow cloth bag used for soiled linens and the other was a clear trash bag with trash inside. R6 was on transmission-based precautions (TBC). At 2:53 PM a care giver exited the room with a laundry hamper. The staff member identified herself as a private caregiver (PCG 1) for the resident and stated she worked for an outside agency. PCG1 was asked if the two bags should have been placed in the hall. She stated she placed the two bags in the hall so R6 would not trip over them in the room and that she Wanted to only make one trip. She further stated, Did I do something wrong? Interview with the Director of Health Services (DHS) on 02/19/21 at 3:49 PM revealed she was unaware of the situation on 02/18/21. She stated her expectation was the bags should have been discarded appropriately in the proper locations. She stated PCG1 was not trained by the facility. On 02/19/21 at 4:30 PM the DHS returned and stated she had contacted the agency PCG1 was employed by and was told there was monthly education provided to all caregivers and competencies were required. Review of the undated facility policy titled, Isolation Linen stated, .Linens shall be handled, stored, processed and transported so as to prevent the spread of infection .

Based on record review, policy review , staff, facility physician and neurologist interviews, the facility failed to ensure a resident was free of any significant medication errors. This affected one (#5) of the five residents reviewed for medications. The facility census was 92. Findings included: Review of the medical record for Resident #5 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 had severely impaired cognition, had behaviors, did not reject care, did not wander, was a two-person physical assist, required extensive and limited assistance with activities of daily livings (ADLs) and was always incontinent to bowel and frequently incontinent of bladder. Review of the plan of care for Resident #5 dated 08/18/20 revealed resident had [MEDICAL CONDITION] disorder. Interventions included administer anticonvulsant medications as ordered. Review of neurology notes dated 07/13/20 revealed resident had not had a [MEDICAL CONDITION], was overall stable but gets agitated and combative. Notes indicated resident was supposed to be titrated up on [MEDICATION NAME] due to concerns other [MEDICAL CONDITION] medications caused mood problems and agitation but the facility never completed this titration so [MEDICATION NAME] 25 milligram (mg) was discontinued and resident was ordered to continue on Brivaracetam (anticonvulsant) 100 mg twice daily and follow up in two months. Review of physician orders for Resident #5 dated 07/30/20 revealed to [MEDICATION NAME] 25 milligrams (mg) by mouth daily for two weeks from 08/03/20 to 08/17/20 for [MEDICAL CONDITION]. Physician orders dated 08/15/20 revealed [MEDICATION NAME] 25 mg twice daily and [MEDICATION NAME] Extended Release (ER) 500 mg two tablets by mouth for two weeks from 8/18/20 to 09/01/20 for [MEDICAL CONDITION]. Physician orders dated 09/02/20 revealed [MEDICATION NAME] 50 mg twice daily and [MEDICATION NAME] ER 500 mg two tabs daily for two weeks from 09/02/20 to 09/17/20 for [MEDICAL CONDITION]. Handwritten physician orders dated 09/15/20 revealed [MEDICATION NAME] 100 mg twice daily and [MEDICATION NAME] ER 500 mg two times daily for two weeks from 09/18/20 to 10/03/20. Handwritten physician orders dated 09/15/20 was created and signed by LPN #31 and reviewed and signed by Physician #100. Review of the nurses note dated 10/31/20 at 3:25 P.M., documented the resident had a grand mal [MEDICAL CONDITION] around 2:15 P.M., the resident was experiencing uncontrolled jerking motions, not alert to place, unable to respond, eyes rolling to right side only. This activity went on for about 5 minutes, the resident was turned on left side. The resident came around to it and was able to speak and answer questions. Vitals signs were Blood pressure 144/95, pulse 118, respiratory 16, oxygen saturation was 97. Medical doctor (MD) notified. On call doctor responded: staff to watch the resident and call Monday to review medication list with MD, family contacted, resident is at baseline and speaking clearly in the lowest position. Review of Medication Administration Record [REDACTED]. Review of MAR for November 2020 revealed [MEDICATION NAME] 100 mg twice daily was started on 11/03/20. Review of MARs verified the resident was without [MEDICAL CONDITION] medication from 10/03/20 through 11/02/20. Review of nurse's progress notes for Resident #5 dated 11/01/20 by LPN #33 indicated the resident's wife called upset and requested to speak with Physician #100 about the discontinuation of [MEDICAL CONDITION] medications. Notes indicated wife was instructed to call back on Monday to follow up with nurses and physician. Nurses notes dated 11/02/20, by LPN #34 indicated the nurse called Physician #100 to follow up on the [MEDICAL CONDITION] from 10/31/20 and [MEDICATION NAME] 100 mg by mouth two times daily was ordered for [MEDICAL CONDITION] and staff was to notify Neurologist #101 with any [MEDICAL CONDITION] activity. Nurses notes dated 11/02/20, by LPN #35 indicated Neurologist #101 called and gave an order for [REDACTED].#101 had concerns over Resident #5's [MEDICAL CONDITION] medications being discontinued, and Neurologist #101 would follow up directly with Physician #100. Nurse notes dated 11/03/20 by LPN #33 indicated her and LPN #34 spoke with Neurologist #101 and verified orders for [MEDICATION NAME] 100 mg twice daily. Nurses notes were silent for indication the [MEDICAL CONDITION] medications should have been discontinued on 10/03/20. Review of the neurology notes dated 11/12/20 indicated resident was supposed to be taking [MEDICATION NAME] 100 mg twice daily but [MEDICATION NAME] was accidentally stopped due to some medication error and possibly related to a hospital admission. Notes indicated resident had a [MEDICAL CONDITION] on 10/31/20 while a sitter was with him in the room. Notes indicated resident was unresponsive but no jerking, had elevated heart rate, with eyes rolled back and was completely back to baseline in ten minutes. Neurology notes indicated the office was notified and they realized he had missed his follow up appointment and the [MEDICATION NAME] medication had been stopped. Neurology notes indicated it would be too long to have [MEDICATION NAME] restarted so resident was ordered [MEDICATION NAME] 100 mg twice daily. Interview with Physician #100 on 01/12/21 at 7:56 A.M., indicated Resident #5's [MEDICAL CONDITION] medications were stopped by a neurologist when Resident #5 went to the hospital on [DATE] for emergency room visit. Physician #100 stated the hospital called the neurology group and the on-call neurologist was not familiar with the resident's medication regimen and inadvertently discontinued the medications. Physician #100 stated he had a long-detailed conversation with Neurologist #101 on 11/02/20 and when they investigated the incident, Neurologist #101 discovered the medication error was a mix up from her neurology practice when a different neurologist discontinued the medication. Physician #100 verified resident's [MEDICAL CONDITION] medications were discontinued on 10/03/20 and resident was not given any [MEDICAL CONDITION] medications from 10/03/20 through 11/03/20. Interview with Licensed Practical Nurse (LPN) #32 on 01/12/21 at 11:51 A.M., indicated she readmitted Resident #5 when he returned from the hospital on [DATE] at 2:20 A.M. LPN #32 stated she received a call/report from the emergency room which indicated there were no new medication or treatment orders (NNO) upon residents return to facility. LPN #32 stated she called the on-call physician but did not reconcile the medications due to no reported changes. Interview with LPN #33 on 01/12/21 at 12:21 P.M., indicated Resident #5's family called on 11/01/20 and demanded to speak to Physician #100 about the discontinuation of [MEDICAL CONDITION] medications. LPN #33 stated she could not give out the physician's number and family member would have to call back on 11/02/20. LPN #33 stated Neurologist #101 called the facility on 11/02/20 and inquired about Resident #5's current [MEDICAL CONDITION] medications and the [MEDICAL CONDITION] activity recorded on 10/31/20. LPN #33 stated she investigated the error and discovered Resident #5's [MEDICATION NAME] (anticonvulsant) and [MEDICATION NAME] (anticonvulsant) were discontinued on 10/03/20 from an order written [REDACTED].#33 stated she could not find any notes why the medications were discontinued. LPN #33 also stated she assisted Resident #5 with a tele-health visit (virtual via video) with Neurologist #101 on 11/12/20 and Neurologist stated the [MEDICATION NAME] should have never been discontinued. LPN #33 verified resident's [MEDICAL CONDITION] medications were discontinued on 10/03/20 and resident did not receive any [MEDICAL CONDITION] medications from 10/03/20 through 11/03/20. Interview with LPN #31 on 01/12/21 at 2:33 P.M., indicated she wrote an order on 09/15/20 to discontinue the [MEDICAL CONDITION] medications on 10/03/20. LPN #31 stated the facility received a letter from the Neurologist to discontinue the medications so she wrote the order and faxed it to the pharmacy. LPN #31 stated she normally cared for Resident #5 and was not aware Resident #5 did not have [MEDICAL CONDITION] medications from 10/03/20 to 11/03/20. Interview with Neurologist #101 on 01/13/21 at 8:04 A.M., indicated she saw Resident #5 via tele health visit on 07/13/20 for follow-up visit and started a different [MEDICAL CONDITION] medication. Neurologist #101 stated Resident #5's insurance company would not approve the alternative, so she ordered the up titration of [MEDICATION NAME] and down titration of [MEDICATION NAME] on 07/30/20 and provided the facility and pharmacy with very thorough and detailed instructions for the titration of medications. Neurologist #101 stated she was called by the facility on 11/02/20 and informed Resident #5's [MEDICATION NAME] and [MEDICATION NAME] were accidentally stopped on 10/03/20. Neurologist #101 stated she had a detailed conversation with Physician #100 on 11/02/20 about the medications error and physician was not able to provide any insight as to why the error occurred. Neurologist #101 stated she was able to verify the electronic prescriptions were received by the pharmacy. Review of the facility policy titled Equipment and Supplies for Administering Medications dated 01/01/19, revealed medications are administered as prescribed in accordance with good nursing principles and practice This deficiency substantiates Complaint Number OH 276

Based on medical record review, staff interviews, and policy review, the facility failed to notify a resident's representative when [MEDICAL CONDITION] medications were discontinued. This affected one (#5) of the four residents reviewed for notification. The facility census was 92. Findings included: Review of the medical record for Resident #5 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 had severely impaired cognition, had behaviors, did not reject care, did not wander, was a two-person physical assist, required extensive and limited assistance with activities of daily livings (ADLs) and was always incontinent to bowel and frequently incontinent of bladder. Review of the plan of care for Resident #5 dated 08/18/20 revealed resident had [MEDICAL CONDITION] disorder. Interventions included administer anticonvulsant medications as ordered. Review of the handwritten physician orders [REDACTED]. Handwritten physician orders [REDACTED].#31 and reviewed and signed by Physician #100. Review of nurses notes for Resident #5 from 09/01/20 through 11/03/20 were silent for any indication resident's representative was notified when an order was written on 09/15/20 to discontinued [MEDICAL CONDITION] medications on 10/03/20. Review of Medication Administration Record [REDACTED]. Review of MAR for November 2020 revealed [MEDICATION NAME] 100 mg twice daily was started on 11/03/20. Review of MARs verified the resident was without [MEDICAL CONDITION] medication from 10/03/20 through 11/02/20. Review of nurse's progress notes for Resident #5 dated 11/01/20 by LPN #33 indicated the resident's wife called upset and requested to speak with Physician #100 about the discontinuation of [MEDICAL CONDITION] medications. Notes indicated wife was instructed to call back on Monday to follow up with nurses and physician. Interview with Licensed Practical Nurse (LPN) #32 on 01/12/21 at 11:51 A.M., indicated she readmitted Resident #5 when he returned from the hospital on [DATE] at 2:20 A.M. LPN #32 stated she received a call/report from the emergency room which indicated there were no new medication or treatment orders (NNO) upon residents return to facility. LPN #32 stated she called the on-call physician but did not reconcile the medications due to no reported changes. Interview with LPN #31 on 01/12/21 at 2:33 P.M., indicated she wrote an order on 09/15/20 to discontinue the [MEDICAL CONDITION] medications on 10/03/20. LPN #31 stated the facility received a letter from the Neurologist to discontinue the medications so she wrote the order and faxed it to the pharmacy. LPN #31 stated she normally cared for Resident #5 and was not aware Resident #5 did not have [MEDICAL CONDITION] medications from 10/03/20 to 11/03/20. Review of the policy titled Change in Residents Condition or Status dated 07/01/14, revealed the facility will promptly notify the resident, his or her attending physician and the residents responsible party of changes in resident's condition and / or status. This deficiency substantiates Complaint Number OH 276.

Based on observation, staff interview, review of facility policy, review of a Centers for Disease Control (CDC) online resources, and review of an Ohio Department of Health (ODH) Director's Order, revealed two randomly observed facility staff (State tested Nursing Assistant (STNA) #100 and Occupational Therapist (OT) #200) failed to appropriately wear face masks while in a common area to potentially prevent the spread of Coronavirus Disease 2019 (COVID 19). The census was 77. Findings include: 1. Observation on 07/13/20 at 11:50 A.M. revealed STNA #100 was sitting on a couch in the central common living room area of the facility. Further observations revealed STNA #100 was wearing a facemask which was pulled down exposing her nose and mouth. Interview on 07/13/20 at 11:51 A.M. with STNA #100 confirmed her facemask was pulled down exposing her nose and mouth. STNA #100 further confirmed she was on a break. Interview on 07/13/20 at 11:55 A.M. with the Director of Nursing (DON) confirmed all staff should always wear facemask's while in the facility. DON further confirmed STNA #100 was permitted to take her break in the common area if she wished but her facemask should have covered her chin, nose, and mouth. 2. Observation on 07/13/20 at 12:05 P.M. revealed OT #200 was sitting in the therapy gym consuming food and was not wearing a facemask. Another employee wearing a facemask was sitting in the therapy gym facing towards OT #200. Two additional employees were observed seated at desks wearing facemask's and facing away from OT #200. Interview on 07/13/20 at 12:06 P.M. with OT #200 confirmed she was not wearing a mask because she was on her lunch break and the therapy staff was getting ready to have a meeting soon. Review of facility policy titled COVID 19 Plan dated 06/05/20 revealed the facility would educate staff regarding appropriate personal protective equipment (PPE) required in the facility and would also take the following steps to ensure the facility plan was current and effective to ensure the community maintained compliance with the following recommendations: monitor local and state public health sources to understand COVID 19 activity in the community, monitor websites of ODH and the CDC and implement changes in guidance as applicable, oversee the ongoing education to associates and residents regarding infection control procedures that include but are not limited to COVID 19 prevention, transmission and symptoms. Review of a CDC online resource at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care-strategies.html revealed the following guidance regarding facemask's: ensure all healthcare care personnel (HCP) wear a facemask for source control while in the facility. Review of ODH Director's Order dated 07/08/20 revealed(NAME)County, the county in which the facility was situated, was experiencing a very high exposure and spread of COVID 19 and facial coverings were required at all times while in(NAME)County in any indoor space that was not a private residence.

Based on observation, menu review and recipe review, the facility failed to serve lunch according to the recipe and menu. This affected all 82 residents. Findings include: Observation of Rehab Unit dining room on 03/02/20 at 12:25 P.M. revealed residents received soft beef tacos with shredded lettuce and chopped tomatoes. No other toppings were offered during the service. Observation of Health Care Four dining room on 03/02/20 at 12:25 P.M. revealed residents were served taco meat on soft tortilla with shredded cheese. No other toppings offered or available. Observation of Health Care Three dining room on 03/02/20 at 1:19 P.M. revealed residents were served soft tacos with meat only. No toppings were available. Review of Monday's lunch menu revealed the main entree was listed as Soft Beef Taco. Review of recipe entitled beef taco, soft revealed the following ingredients listed onions, yellow, fresh, minced, tomatoes, fresh, chopped, olives, black, pitted, sliced, and sauce, salsa, picante, mild. The recipe stated to place shredded lettuce, chopped tomato, and black olives on taco or on the side, and salsa in a souffle dish for service. Interview on 03/03/20 at 03:11 P.M. Dining Director #300 reviewed taco menu item and verified it does not have a descriptor on the menu of included items, but he would expect additional items to the taco meat. Dining Director #300 verified he did saw two resident with just taco meat, but they were on limited diet. He did not recall seeing any residents with condiments, shredded lettuce, chopped tomato, black olives, or salsa on their plates, which were listed in the beef taco, soft recipe.

Based on review of personnel records, staff interview, and review of facility policy, the facility failed to ensure all staff were checked against the Nurse Aide Registry prior to employment to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of [REDACTED]. This had the potential to affect all 93 residents residing in the facility. Findings include: Review of personnel records revealed no evidence of employees being checked against the State Nurse Aide Registry prior to employment for the following employees: the Licensed Practical Nurse Admissions Manager (LPN AM) #155 hired on 04/25/19; Registered Nurse (RN) #166 hired on 08/16/04; Registered Nurse (RN) #177 hired on 06/10/19; and Registered Nurse (RN) #188 hired on 05/28/19. During interview on 03/03/20 at 3:00 P.M., Human Resource Manager (HRM) #70 verified the above-mentioned employees were not checked on the State Nurse Aide Registry. She stated she was not aware everyone in the facility was to be checked on the State Nurse Aide Registry. She stated she thought the LPN's and RN's were in good standing because of the check for the license with the nursing board. HRM #70 revealed the facility contracts all maintenance, housekeeping and dietary employees. Interview on 03/03/20 at 3:45 P.M. with the Administrator reviewed the hiring process documentation and confirmed the facility had not completed the State Nurse Aide Registry on the above-mentioned employees. The Administrator advised she was aware of the required State Nurse Aide Registry and thought the Human Resource department was completing the required background checks. Review of the facility policy titled Abuse, Neglect, Exploitation, and Mistreatment of [REDACTED].

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on observation, medical record review, staff and resident interview, and review of hospital records, the facility failed to ensure adequate supervision was provided to each resident per their written plan of care during transfers using a stand-up lift device. This resulted in Actual Harm when Resident #23 fell from the stand-up lift device and subsequently sustained a laceration to the back of her head requiring 15 sutures to close to laceration. This affected one (#23) of four residents sampled for transfers. Facility census was 89. Findings include: Review of Resident #23's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The facility completed a significant change Minimum Data Set (MDS) 3.0 assessment of Resident #23's cognitive and physical functional status dated 04/15/19. The 04/15/19 assessment identified the resident as having good memory recall and requiring the physical assistance of two staff for bed mobility, transferring from surface to surface, and toilet use. Resident #23 was also assessed as having functional limitations in range of motion to one upper extremity and both lower extremities and having shortness of breath. The resident weighed 301 pounds. Review of Resident #23's physician's orders [REDACTED]. In addition, there was a physician's orders [REDACTED]. Review of Resident #23's current care plan located in the resident's room, utilized by nursing staff, included the following information regarding lifting/transferring the resident: on 09/27/18 an intervention for mechanical lift (Hoyer) with three staff to get in and out of bed; and on 02/23/18 an intervention for stand-up lift with the assistance of two staff for toileting, make sure to strap legs. The resident's comprehensive plan of care located in the electronic health record contained none of the aforementioned information including the physician's orders [REDACTED].#23. Review of Resident #23's nursing progress notes revealed a note by Licensed Practical Nurse (LPN) #18 on 05/28/19. LPN #18 documented on 05/28/19 a late entry for 05/26/19. LPN #18 documented on 05/26/19 he was sitting at his desk when a State tested Nurse Aide (STNA) (unnamed) approached him and told him that Resident #23 was on the floor, and that she fell out of the stand-up lift. LPN #18 noted he immediately grabbed a vital sign machine and ran back to the room. The resident was laying on her back and appeared to be in respiratory distress. He documented a large amount of blood was coming from the back of the resident's head. Oxygen was provided per nasal cannula and pressure was applied to the back of the resident's head. LPN #18 noted he yelled out for someone to call nine-one-one (911). Emergency medical technicians arrived, and the resident was sent to the emergency department. LPN #18 documented the new intervention, for the resident falling, was staff member education and in-servicing. Emergency department (ED) notes for Resident #23 dated 05/26/19 were reviewed. Review of the ED notes revealed the resident sustained [REDACTED]. The laceration was closed with 15 sutures at the subcutaneous layer, and the skin was closed with staples. The resident returned to the facility after treatment at the ED on 05/26/19. Resident #23 was observed and interviewed on 07/10/19 at 10:50 A.M. The resident was alert and oriented with periods of recall difficulties. The resident denied any mistreatment by staff. When asked if she had any recent falls or injures, she reported that she fell from a Hoyer lift but could not say when it happened other than it was a while back and she could not recall the specifics surrounding the fall. The resident was obese, on continuous oxygen, and appeared to have extreme difficulty breathing at times. She reported she did not get out of bed very often any longer. An interview was conducted with the Director of Nursing (DON) and Administrator on 07/10/19 at 1:42 P.M. regarding Resident #23's fall with injury on 05/26/19. The DON reported on Sunday, 05/26/19, she got a call from the on-call unit manager, Registered Nurse (RN) #102 regarding the incident. RN #102 reported to her that Resident #23 fell in the bathroom and there was a lift involved. The DON stated she directed RN #102 to send the nurse aide involved, STNA #62, home until the incident was investigated by her. The DON stated Resident #23 had fallen from the stand-up lift. STNA #62 had transferred the resident using the stand-up lift by herself, and the resident was supposed to have at least two staff persons to transfer when using a stand-up lift. The DON reported as a result the resident lacerated her head which required 15 sutures to close. The DON stated STNA #62 and Resident #23 were the only persons who directly witnessed the incident. The DON stated during the investigation she asked STNA #62 why she transferred the resident by herself and was told by the aide she thought she could just do it herself. The DON stated STNA #62 was still employed by the facility and was not permitted to return to work until she received in-service education on use of the lift devices which specified that all lift devices require two people for proper technique, and STNA #62 was able to demonstrate proper use of the stand-up lift for resident transfers. The Administrator further reported as a result of the incident, the facility conducted an investigation, disciplined and educated STNA #62, conducted in-service education for all nursing staff, did competency training/observations of all nursing staff on the use of the stand-up lift for resident transfers, and completed performance monitoring. On 07/10/19 at 5:15 P.M., Resident #23's care plan located in her closet was reviewed with the DON and LPN #87 who was familiar with the resident. The DON and LPN #87 affirmed the care plan specified the resident required two staff for toileting using the stand-up lift, and three staff to use the mechanical (Hoyer) lift to get in and out of bed. On 07/10/19 at 5:29 P.M., an interview was conducted with STNA #05 who was assigned to care for Resident #23 during the 3:00 P.M. through 11:00 P.M. shift. She stated she was routinely assigned to care for Resident #23. STNA #05 was questioned regarding what the resident's care plan was for transferring with the stand-up lift prior to the fall on 05/26/19. STNA #05 stated the resident has always required the assistance of two staff to transfer using the stand-up lift. She affirmed she had recently received education and training regarding transferring residents per their written plan of care, that all mechanical lifts required two staff to complete, and that nurses had watched her performing resident transfers with the use of the stand-up lift. On 07/10/19 at 5:34 P.M., an interview was conducted with STNA #62 regarding the fall incident with Resident #23. STNA #62 affirmed she transferred Resident #23 herself on 05/26/19 at about 10:30 A.M. and was aware the resident required the assistance of two staff to safely transfer. STNA #62 explained the resident was sliding out of her wheelchair and appeared uncomfortable so she got her up in the stand-up lift by herself, and then provided incontinence care in the bathroom while the resident was in the lift. She stated she then moved the resident on the stand-up lift out of the bathroom and the resident let go of the handles, collapsed and slid out of the sling with the leg straps still in place. STNA #62 reported the resident half slid/half fell out of the lift backwards but was unsure if the resident hit her head on the bed or the floor, but the fall was outside the bathroom. STNA #62 reiterated she knew the resident was a two person transfer and that she did the transfer herself as other staff were busy with residents finishing up breakfast. STNA #62 stated she was educated on proper transfer technique using the stand-up lift and following each resident's care plan regarding transfers. STNA #62 also reported that she had been observed by administrative nursing staff performing resident transfers using the stand-up lift. Review of the facility's corrective action revealed the following actions were implemented and the deficiency corrected as of 06/27/19: · On 05/26/19, RN #102 reported to the DON that Resident #23 had fallen from the stand-up lift while being transferred by STNA #62 and the resident was sent out 911 to the hospital. The DON directed RN #102 to send STNA #62 home and remove her from the schedule until an investigation was completed. · On 05/26/19, the DON initiated an investigation into the incident and STNA #62 was interviewed and confirmed she had transferred Resident #23 by herself. · A corrective action plan was developed, and implementation initiated on 05/26/19. The investigation was completed by 06/06/19. · On 06/06/19, STNA #62 was disciplined and educated on following resident care plans, always using two staff to transfer a resident, and was observed demonstrating competency transferring a resident using a stand-up lift. RN #75 and the Administrator signed off on STNA #62's competency training. STNA #62 was then permitted to return to work. · All nursing staff were educated beginning 05/26/19 and ending 06/27/19 regarding following resident care plans and proper transfer techniques. The content directed staff to make sure to read and follow each resident's plan of care, and that any resident that requires the use of assistive devices such as a mechanical lift or stand-up lift always required the assistance of two staff. Competency evaluation and training regarding staff demonstration of proper use of the stand-up lift for resident transfers was completed for all licensed nurses and STNA's. · Performance monitoring was initiated on 05/28/19 and completed on 06/27/19. Performance monitoring was initiated on 05/28/19 and conducted three times a week for three weeks, then weekly for three weeks. · On 07/10/19, Resident #66, #87, and #45 were observed being properly transferred using a stand-up lift by two STNAs. · On 07/10/19, STNA's #01, #03, #05, #15, #17, #57, and #62 were interviewed to determine if they had been recently educated regarding the proper use of mechanical lifts and stand-up lifts. All seven STNA's reported they had been educated on the proper use of stand-up lifts, and all reported that they are to always have two nursing staff when transferring residents using a stand-up lift or any mechanical lift. This deficiency substantiates Complaint Number OH 251.

Based on surveyor observation, review of self reported incident, interview with management staff, review of personnel files and in-service training records, the facility failed to ensure that the resident environment remained as accident free as is possible. This affected one (#17) in three sampled residents. This resulted in harm for Resident # 17 when she suffered a fracture of her left distal femur and her superior ramus. The census was 95 residents. Findings include: Review of the medical record revealed Resident #17 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. The resident was noted to be 40 1/2 inches tall and only weighed 56 pounds. The resident was [AGE] years old. Additional review of the medical record revealed that on 08/22/12 the Occupational Therapist noted that the staff should not perform the cradle lift, but only recommend use of hoyer lift with a small pad to prevent injuries. The most recent MDS (minimum data set) dated 01/22/13 revealed the resident was dependant on staff for all activity of daily living (ADL's). The dependence on staff for ADL's did not changed recently or as a result of the injury. Review of the facility medical record revealed that on 12/27/12 at 9:45 P.M. the floor nurse heard resident # 17 yelling out while lying in bed. When found by the nurse, the resident was lying prone in bed. She stated according to the nursing notes "I'm not going to walk again, my left leg is broken. I'm so depressed. The girl who put me to bed got my leg caught between the bed." She stated that her leg was hurting. The initial nursing assessment after the accident revealed her left knee was larger than her right knee due to swelling. She was offered pain medication and accepted 1/2 a tablet of hydrocodone. She was subsequently transported to the hospital and returned on 12/30/13 with a [DIAGNOSES REDACTED]. The nurse aide # 1 was interviewed on 12/28/12 the day after the injury. She admitted the transfer was wrong and that she had made a poor decision. She was terminated from employment due to causing the fracture from an improper transfer. The facility conducted in-service education to other staff to prevent additional problems with transfers on 12/28/12. A care plan was initiated for pain on 12/28/12 at which time staff were to monitor for pain, assess location, offer alternatives and administer medications as ordered. Prior to the injury the resident did not have a care plan for pain. She was given hydocodone 1/2 tablet for mild pain and a full tablet for moderate pain. This was the same amount of pain medication prior to the injury. The facility added morphine 0.25 mg as needed for pain every four hours for moderate pain. She was also started on Vicodin 5/500 mg 1/2 tablet by mouth every four hours for pain. Per review of her December 2012 Medication Administration Record (MAR) pain medication was used after the injury on the evening of the injury on 12/27/12. The MAR for December 2012 also shows Vicodin 5/500 mg 1/2 tab was given four times on December 31, 2012 after the injury. Her pain was rated as a 10 or the highest possible rating for December 28 th prior to leaving for the hospital and after she returned on 12/31/12. In January 2013 she used morphine solution 0.25 ml sub lingual on 01/01/13 four times through 01/05/13 and on 01/09/13 two times. She received .50 ml for severe pain on 1/20/13 one time and 01/24/12 one time. She also received hydrocodone 5/325 1/2 tab for pain on four different days, and one tab for moderate pain 17 times in January 2013. She was also given Vicodin in January 2013 ten straight days, six times a day from January 1, 2013 through January 10, 2013. Moreover, prior to the injury no pain medication was used. Interview with the resident on 01/29/13 and on 02/08/13 at 3:15 P.M. revealed the resident indicated she was in pain. She stated the aide had picked her up under her arms and hit her leg on the bed. She indicated she was in pain at the time of the interview. Further interview with the DON (director of nursing) at the time of the interview on 02/08/13 at 3:15 P.M. indicated the resident does not recall that she injured her left leg on the left foot rest of her wheelchair. A Prevalon boot was ordered to her left heel at all times on 01/21/13. The boot was observed on and in place at the time of the second interview noted above with a small wedge to maintain position of the leg and foot. This deficiency substantiates Complaint Number OH 623.