Every finding on record at Vancrest of St Mary's

Based on medical record review, resident interview, staff interview and review of facility policy, the facility failed to implement appropriate infection control practices during care of residents on isolation. This affected Resident #2. Additionally, the facility failed to ensure proper signage was posted for type of isolation and usage of personal protective equipment (PPE) for residents who were on isolation. This affected four Residents (#59, #4, #1, #44, and #23). Six residents were reviewed for isolation practices. The facility census was 45.Based on medical record review, resident and staff interview, and policy review, the facility failed to implement appropriate infection control practices during care of residents on isolation. This affected one (#02) out of six reviewed for infection control. Additionally, the facility failed to ensure proper signage was posted for the type of isolation and usage of personal protective equipment (PPE) for residents who were on isolation. This affected six (#02, #59, #04, #01, #44, and #23) of six residents reviewed for isolation practices. The facility census was 45. Findings Include: 1.Review of the medical record for Resident #02 revealed an admission date of 12/04/25. The resident was admitted with diagnosis of pneumonia, hypoxia and pressure induced deep tissue damage of back and sacral area. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The Medicare five days were currently in progress. Review of the Care Plan revised on 12/15/25 revealed altered respiratory status related to pneumonia in hospital, acute respiratory failure with hypoxia, and history of emphysema. Observation on 12/16/25 at 9:50 A.M. revealed Resident #02 did not have a sign for isolation precautions. Interview and observation on 12/16/25 at 9:58 A.M. with License Practical Nurse (LPN) #234 revealed the facility practice was to place a See Nurse Sign on the residents' door and a symbol to represent what type of isolation the resident was in for staff to know. The LPN #234 verified Resident #02 did not have a see nurse sign or a symbol on doorway. LPN #234 placed a sign and a carrot symbolizing contact isolation on Resident #02's doorway. Observation on 12/16/25 at 10:53 A.M. revealed Resident #02 was in the restroom. Certified Nurse Assistant (CNA) #205 entered Resident #02's room, entered the restroom, assisted Resident #2 off the toilet and into a wheelchair, wheeled Resident #02 out of the resident's room, down the hallway and into the dining room without a mask. CNA #205 was not wearing personal protective equipment (PPE) when providing care in Resident #02's room. Interview on 12/16/25 at 11:01 A.M. with CNA #205 verified no PPE was worn when assisting Resident #02 with care. Interview on 12/16/25 at 11:02 A.M. with LPN #234 verified Resident #02 was diagnosed with pneumonia on 12/15/25 and Resident #02 should have a daisy (symbolizing droplet isolation) instead of a carrot. Reviewed isolation symbols with LPN #234 and they were the following: a daisy was for droplet isolation, a carrot was for contact isolation and an elephant was for enhanced barrier precautions. LPN #234 verified Resident #02 should be wearing a mask when ambulated through the halls and in the dining room. 2. Review of the medical record for Resident #59 revealed an admission date of 12/12/25. The resident was admitted with cutaneous abscess of right lower limb and type two diabetes. Review of the MDS assessment dated [DATE] revealed Resident #59 had a Brief Interview Mental Status (BIMS) score of 14, indicating intact cognition. The Medicare five day were currently in progress. Review of the Care Plan dated 12/16/25 revealed Resident #59 was at risk for alterations in nutrition and hydration due to facility placement due to cutaneous abscess right knee, intravenous antibiotic therapy and diabetes. Observation on 12/16/25 at 9:51 A.M. revealed Resident #59 had no sign for isolation precautions. Interview on 12/16/25 at 9:58 A.M. with LPN #234 verified Resident #59 did not have a see nurse sign or a symbol for isolation on doorway. The LPN #234 placed a sign and a carrot symbol indicating contact isolation on Resident #59's doorway. Interview on 12/16/25 at 11:55 A.M. with LPN #234 verified Resident #59 should not be in contact isolation and should be in enhanced barrier precautions. LPN #234 changed the carrot symbol to an elephant indicating enhanced barrier precautions for cutaneous abscess right knee, intravenous antibiotic therapy and diabetes . 3. Review of the medical record for Resident #04 revealed an admission date of 10/06/25. Diagnoses included intertrochanteric fracture of the left femur, diabetes, transient cerebral ischemic attack, stage three kidney disease, and a diabetic foot ulcer to the left heel. Review of the MDS assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated pressure ulcer, falls, pain, and nutritional status. Review of the Care Plan revised on 12/15/25 revealed acute pain related to recent fracture of left femur, risk of alteration in nutrition and hydration due to facility placement due to left hip fracture, diabetic foot ulcer to the left heel, and risk for falls related to a recent fracture of the left femur. Observation on 12/16/25 at 9:50 A.M. revealed Resident #04 had no sign for isolation precautions. Interview on 12/16/25 at 11:33 A.M. with LPN #234 verified Resident #04 did not have a see nurse sign or a symbol for isolation on doorway. LPN #234 placed a sign and an elephant (enhanced barrier precautions) on Resident #04's doorway for diagnosis of diabetic foot ulcer to left heel. 4. Review of Resident #01's medical record revealed an admission date of 09/27/24. Diagnoses included type II diabetes, cellulitis, colostomy complications, peripheral venous insufficiency, lymphedema, chronic gout, and methicillin resistant staphylococcus (MRSA). Review of Resident #01's MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #01 was cognitively intact. Resident #01 required touching assistance or supervision with toilet use, dressing, and personal hygiene. Resident #01 required maximal assistance with bathing. Review of Resident #01's care plan revised 10/30/25 revealed supports and intervention for contact isolation for extended spectrum beta lactamases (ESBL) and MRSA chronic in bilateral lower extremity wounds, self-care deficit, high risk for falls, pain, risk for fluid volume deficit related to diuretic use, and risk for impaired skin integrity. Review of Resident #01's physician orders revealed an order dated 12/04/24 to maintain contact isolation precautions related to ESBL and MRSA. Observation on 12/15/25 at 9:08 A.M. of Resident #01's room found Resident #1 was out of the room. A cart with personal protective equipment (PPE) was observed inside the door along with two lidded receptacles one labeled soiled linens and one labeled trash. A carrot symbol was observed next to Resident #01's name on the name plate outside of the room along with a sign saying to see nurse before entering the room. The carrot symbolized Resident #01 was on contact isolation. There were no postings found indicating what type of PPE was required to be used when providing care to Resident #01. Interview on 12/15/25 at 9:47 A.M. with LPN #242 verified Resident #01 was on contact isolation for ESBL and MRSA in bilateral lower extremity wounds. Observation on 12/15/25 at 11:33 A.M. of Resident #01's PPE cart and posted signage found no postings indicating what PPE was required to be worn, donned or doffed. Coinciding interview with LPN #242 verified there were no postings for PPE use. Interview on 12/15/25 at 11:36 A.M. with Resident #01 revealed he had seeping edema on his legs and the nurses applied wraps for him when they were due. Resident #01 verified there were a PPE cart and trash cans in his room for isolation. Resident #1 reported he was not sure he was still on isolation because he thought the staff were not using the supplies in the cart anymore. Observation on 12/16/25 at 9:12 A.M. and 12/17/25 at 8:05 A.M. of Resident #01's room found there continued to be no signage indicating what PPE was to be worn when providing care to Resident #01 who was on contact isolation. 5. Review of Resident #44's medical record revealed an admission date of 12/03/24. Diagnoses included cervical fusion of spine, spinal stenosis, type II diabetes, protein calorie malnutrition, conjunctivitis, anxiety disorder, and pruritus (itchy skin). Review of Resident #44's MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #44 was cognitively intact. Resident #44 was dependent on staff for toilet use, personal hygiene, bed mobility, and transfer. Resident #44 required maximal assistance with bathing, dressing. Resident #44 displayed no behaviors during the review period. Review of Resident #44's care plan revised 10/30/25 revealed supports and interventions for contact isolation related to extended spectrum beta lactamases (ESBL) in the urine, self-care deficit, pain, risk for alteration in skin integrity, and risk for falls. Review of Resident #44's physician orders revealed an order dated 01/20/25 to maintain contact isolation related to ESBL. Observation on 12/15/25 at 9:43 A.M. Resident #44 was in bed in her room. Resident #44 had a PPE cart and trash cans inside her room with a sign posted on her door frame to see nurse before entering. Additionally, Resident #44 had a carrot symbol next to her name on the room name plate. The carrot symbol indicated Resident #44 was on contact isolation. There was no signage posted indicating what PPE was to be used when providing care to Resident #44. Coinciding interview with Resident #44 verified staff wore PPE when providing her care. Interview on 12/15/25 at 9:47 A.M. LPN #242 verified Resident #44 was on contact isolation for ESBL in her urine. Observation on 12/15/25 at 11:32 A.M. of Resident #44's room and PPE cart found there continued to be no signage posted for what type of PPE was to be used when providing care to Resident #44 who was on contact isolation. Coinciding interview with LPN #242 verified there were no postings for PPE use when providing care to Resident #44 who was on contact isolation. Further observation on 12/16/25 at 9:10 A.M. and 12/17/25 at 8:28 A.M. of Resident #44 ' s room found there continued to be no signage indicating what PPE was to be worn when providing care to Resident #44 who was on contact isolation. 6. Review of the medical record review revealed Resident #23 was admitted on [DATE]. Diagnoses included pneumonia due to methicillin resistant staphylococcus aureus, methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere, type two diabetes mellitus without complications, hypotension, chronic kidney disease stage four, and major depressive disorder. Review of the MDS assessment dated [DATE] revealed Resident #23 was cognitively intact. Observation on 12/15/25 at 12:50 P.M. revealed the outside of Resident #23 ' s door a magnetic notice to see nurse prior to entering and a picture of a carrot symbol on the name plate. Inside of the room was a PPE cart with no signage. Interview on 12/16/25 at 3:29 P.M. LPN #242 verified Resident #23 ' s room had no PPE instructions. Review of the facility policy titled Isolation-Categories of Transmission-Based Precautions revised September 2022, revealed transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Droplet precautions requires a mask is placed on the resident during transport from his or her room. The resident is encouraged to follow respiratory hygiene/cough etiquette to minimize dispersal of droplets. Review of the facility policy titled Personal Protective Equipment revised October 2018, revealed training on the proper donning, use and disposal of PPE is provided upon orientation and at regular intervals.

Based on record review, staff interview and policy review, the facility failed to ensure residents had accurate comprehensive, person centered and individualized care plans that reflected the residents' current orders, diagnoses and treatment decisions. This affected two (#5, #23) of two residents reviewed for care planning. The facility census was 45.Based on medical record review, staff interview and policy review, the facility failed to ensure residents had accurate comprehensive, person centered and individualized care plans. This affected two (#5 and #23) of two residents reviewed for care planning. The facility census was 45. Findings include: 1. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included aphasia (inability to talk) following intracranial hemorrhage (brain bleed), cerebral infarction (stroke), Sjogren syndrome (autoimmune disease where the body attacks moisture producing glands such as tear glands), depression, dementia, quadriplegia (decreased or lack of ability to move legs and arms), seizures, bipolar disorder, and anxiety. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had impaired cognition, as evidenced by a Brief Interview for Mental Status (BIMS) score of nine. Further review of the MDS revealed diagnoses of dementia, anxiety, depression, and bipolar disorder. The resident was receiving an antipsychotic medication. Review of the physician orders for Resident #5 revealed an order dated 07/04/25 for Abilify (an antipsychotic medication) 10 milligrams (mg) by mouth one time daily. Review of Resident #5's comprehensive care plan dated 09/15/25 revealed there was no care plan problem, goal, or interventions addressing the diagnosis of bipolar disorder. Further review revealed there was no care planning related to the use of an antipsychotic medication, including monitoring for effectiveness or potential adverse side effects. Interview on 12/17/25 at 1:33 P.M. with the Director of Nursing (DON) and the MDS Nurse #224 verified Resident #5 was prescribed Abilify, verified Abilify was an antipsychotic medication, and verified the resident had a diagnosis of bipolar disorder. Further interview verified there was no specific, individualized care plan addressing the use of an antipsychotic medication or the diagnosis of bipolar disorder. The MDS Nurse #224 further stated the facility was monitoring for side effects of the antipsychotic medication and the resident's bipolar disorder; however, this monitoring was documented under other care-planned areas and was not reflected in a clearly identified, individualized care plan addressing bipolar disorder or antipsychotic medication use. Review of the policy titled Behavioral Health Services, dated February 2019, revealed the facility will provide and residents will receive behavioral health services as needed to meet mental and psychosocial well-being in accordance with the plan of care and staff training include implementing care plan interventions that are relevant to the resident's diagnosis. 2. Review of the medical record review revealed Resident #23 was admitted on [DATE]. Diagnoses included pneumonia due to methicillin resistant staphylococcus aureus, methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere, type two diabetes mellitus without complications, hypotension, chronic kidney disease stage four, and major depressive disorder. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of the physician orders dated 04/14/25 revealed an order for Resident #23's advance directive as DNRCC-arrest (Do Not Resuscitate Comfort Care Arrest). Review of the DNR Comfort Care documentation dated 04/14/25, revealed a signed advanced directive verifying Resident #23's advance directive was DNRCC-arrest. Review of the care plan dated 07/31/23 revealed Resident #23's plan of care was the resident was a full code. Interview on 12/17/25 at 2:01 P.M. with the DON verified Resident #23's care plan for advanced directives were not accurate. Review of the policy titled Interdisciplinary Team Care Planning, dated March 2022, verified comprehensive, person-centered care plans are based on the resident assessments and developed by an interdisciplinary team.

Based on observation, staff interview, and review of policy, the facility failed to maintain hand hygiene while delivering meal trays on the 200 hall. This had the potential to affect 12 (#24, #35, #37, #95, #96, #97, #98, #99, #100, #101, #102, and #103) of 12 residents residing in the 200 hall. The facility census was 47. Findings include: Observation, on 11/20/23 beginning at 11:20 A.M., during the lunchroom tray delivery on the 200 hall, revealed the Director of Nursing (DON) was observed to enter the room of Resident #98 and touch the resident's glasses and cell phone. DON placed the tray onto the over bed table and proceeded out of the room and began reaching for another resident tray. Interview at this time with the DON, verified she had reached for another resident's tray and stated, I should have washed my hands after touching the personal items. Observation 11/20/23 at 11:40 A.M., revealed a State tested Nursing Assistant (STNA) #257 was observed to assist a therapist with repositioning Resident #100. STNA #257 exited the room and began reaching for a resident tray from the insulated cart. Interview at the time of the observation, with STNA #257 verified she was proceeding to grab a resident food tray and stated I did not wash my hands after repositioning him. Review of the policy titled Handwashing/Hand Hygiene dated August 2015, revealed an alcohol-based hand rub containing at least 62% alcohol, or alternatively soap and water should be used before and after direct contact with residents and assisting residents with meals.

Based on medical record review, hospital paperwork review, staff interview, and resident interview, the facility failed to obtain admission physician orders for the treatment of a surgical wound present on admission. This affected one (#97) of one residents reviewed for admission. The facility census was 47. Findings include: Review of the medical record of Resident #97 revealed an admitted [DATE]. Diagnoses include non-ST elevation myocardial infarction, atherosclerosis of autologous artery coronary artery bypass graft with angina pectoris with documented spasm and combined systolic (congestive) and diastolic (congestive) heart failure. Review of the hospital discharge paperwork dated 11/15/23 revealed Resident #97 was status post left heart catheterization. A second document titled Cardiac Cath Discharge Instructions undated revealed you can shower after 24 hours, remove the dressing in the shower. Review of the Nursing Admission assessment dated [DATE] revealed Resident #97 was cognitively intact. Review of the progress note dated 11/17/23 at 6:32 P.M., revealed the presence of a pressure dressing to the left groin. A note, written by Registered Nurse (RN) #211, revealed a note stating, Will follow-up on orders when to be removed. Interview on 11/20/23 at 9:02 A.M., with Resident #97 revealed the resident was curious as to why the dressing was still on his groin after his heart catheterization. Resident #97 stated he was reluctant to allow the surveyor to view the dressing. Interview on 11/20/23 at 2:19 P.M., with Director of Nursing (DON) provided verification related to the progress note dated 11/17/23 at 6:32 P.M., which revealed Resident #97 had a pressure dressing to the left groin upon admission. The note indicated a follow-up of when to remove the dressing will occur. She further verified no additional notes or physician orders were documented related to the pressure dressing at the left groin. Review of the progress note dated 11/20/23 at 3:03 P.M., revealed the DON received clarification orders for the left groin pressure dressing. Resident #97 had a cardiac catheterization completed on 11/15/23 and according to the Cardiac Cath Discharge instructions from the Catheterization Laboratory the dressing could have been removed 24 hours post procedure. Review of a progress note dated 11/20/23 at 8:26 P.M., revealed the pressure dressing was removed from the left groin and no signs or symptoms of infection was noted. No drainage was noted at the time and Resident #97 tolerated the procedure well. Interview on 11/21/23 at 11:00 A.M., with the DON verified the dressing was not removed at the hospital and the facility had no orders to address the wound. The DON also verified once clarification orders were obtained the facility did not remove the dressing until five hours later.

Based on record review and staff interview, the facility failed to accurately assess residents' medications for quarterly Minimum Data Set (MDS) assessments. This affected two (#23 and #36) of 16 residents reviewed for accurate assessments. The current census is 47. Findings include: 1. Record review for Resident #23 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #23 included: fracture of femur, aftercare post-surgery, muscle weakness, chronic obstructive pulmonary disease, and anxiety. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Per the assessment the resident was assessed as having received an antipsychotic medication on a routine basis with no gradual dose reduction attempted. Review of Resident #23's care plans dated 08/08/23 revealed no focus for antipsychotic medication noted in the care plans. Review of Resident #23's prescribed medications dating from August 2023 to September 2023 revealed the resident had not received any anti-psychotic medications. Interview on 11/21/23 at 2:45 P.M., with MDS Licensed Practical Nurse (LPN) #310 verified when she completed the assessment, she coded the resident for antipsychotic use on routine basis even though the resident had not received an antipsychotic during the review period. 2. Record review of Resident #36 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #26 included: depression, subarachnoid hemorrhage, hypertension, aphasia, lupus, and anxiety. Review of the quarterly MDS assessment dated [DATE] revealed the resident had been coded for receiving an antipsychotic medication on a routine bases and a gradual dose reduction was attempted. Review of Resident #23's care plans dated 06/12/23 revealed no focus for antipsychotic medication noted in the care plans. Review of Resident #23's prescribed medications dating from September 2023 to October 2023 revealed the resident had not received any anti-psychotic medications. Review of Resident #23's Medication Administration Record (MAR) dated October 2023 revealed the resident had not been prescribed or received any antipsychotic medications. Interview on 11/21/23 at 2:45 P.M., with the MDS LPN #310 verified when she completed the assessment, she coded the resident for antipsychotic use on routine basis even though the resident had not received an antipsychotic during the review period.

Based on medical record review, hospital paperwork review, staff interview, resident interview, and policy review, the facility failed to assess a surgical wound and obtain physician orders for the treatment of a surgical wound. This affected one (#97) of one residents reviewed for admission. The facility census was 47. Findings include: Review of the medical record of Resident #97 revealed an admitted [DATE]. Diagnoses include non-ST elevation myocardial infarction, atherosclerosis of autologous artery coronary artery bypass graft with angina pectoris with documented spasm and combined systolic (congestive) and diastolic (congestive) heart failure. Review of the hospital discharge paperwork dated 11/15/23 revealed Resident #97 was status post left heart catheterization. A second document titled Cardiac Cath Discharge Instructions undated revealed you can shower after 24 hours, remove the dressing in the shower. Review of the Nursing Admission assessment dated [DATE] revealed Resident #97 was cognitively intact. Review of the progress note dated 11/17/23 at 6:32 P.M., revealed the presence of a pressure dressing to the left groin. A note, written by Registered Nurse (RN) #211, revealed a note stating, Will follow-up on orders when to be removed. Interview on 11/20/23 at 9:02 A.M., with Resident #97 revealed the resident was curious as to why the dressing was still on his groin after his heart catheterization. Resident #97 stated he was reluctant to allow the surveyor to view the dressing. Interview on 11/20/23 at 2:19 P.M., with Director of Nursing (DON) provided verification related to the progress note dated 11/17/23 at 6:32 P.M., which revealed Resident #97 had a pressure dressing to the left groin upon admission. The note indicated a follow-up of when to remove the dressing will occur. She further verified no additional notes or physician orders were documented related to the pressure dressing at the left groin. Review of the progress note dated 11/20/23 at 3:03 P.M., revealed the DON received clarification orders for the left groin pressure dressing. Resident #97 had a cardiac catheterization completed on 11/15/23 and according to the Cardiac Cath Discharge instructions from the Catheterization Laboratory the dressing could have been removed 24 hours post procedure. Review of a progress note dated 11/20/23 at 8:26 P.M., revealed the pressure dressing was removed from the left groin and no signs or symptoms of infection was noted. No drainage was noted at the time and Resident #97 tolerated the procedure well. Interview on 11/21/23 at 11:00 A.M., with the DON verified the dressing was not removed at the hospital and the facility had no orders to address the wound. The DON also verified once clarification orders were obtained the facility did not remove the dressing until five hours later. Interview on 11/21/23 at 11:15 A.M. with Administrator, with review of the facility policy titled Admission Assessment and Follow-Up: Role of the Nurse revealed the skin should be assessed and the expectation would be to remove any dressings, unless a specific order not to, to completely assess the skin. Review of the policy titled Admission Assessment and Follow Up: Role of the Nurse dated September 2012 revealed the purpose of the procedure was to gather information about the resident's physical condition upon admission for the purpose of managing the resident. One step included to conduct a physical assessment to include the skin.

Based on medical record review, observation, staff interview, and review of the policy, the facility failed to ensure a resident was free from significant medication error. This affected one (#97) of two residents reviewed for insulin administration. The facility census was 47. Findings include: Review of the medical record of Resident #97 revealed an admitted [DATE]. Diagnosis includes diabetes mellitus type one without complications. Review of the Nursing Admission assessment dated [DATE] revealed Resident #97 was cognitively intact. Review of the physician order dated 11/21/23 revealed an order for Lispro insulin to be administered seven units and per sliding scale with meals. An added instruction read Resident may self-regulate insulin sliding scale. Review of the medication administration record (MAR) and insulin administration records for November 2023 revealed the Lispro insulin ordered for 11/21/23 at 5:00 P.M., was not documented as having been administered. Interview on 11/22/23 at 8:03 A.M., with Director of Nursing (DON) while reviewing the MAR for Resident #97 provided verification the 5:00 P.M. dose of Lispro insulin was not documented as having been administered on 11/21/23 at 5:00 P.M. Telephone interview on 11/22/23 at 8:10 A.M., along with DON, with Licensed Practical Nurse (LPN) #218 provided verification the Lispro insulin was not administered on 11/21/23 at 5:00 P.M. Observation on 11/22/23 at 8:15 A.M., with LPN #219 revealed LPN #219 was observed to place a needle onto the Lispro inulin pen and dialed the knob to 3 (three) and did not prime the needle. LPN #219 administered the insulin to Resident #97. LPN #219 had failed to prime the inulin pen. Interview on 11/22/23 at 8:20 A.M., with LPN #219 provided verification she had not primed the insulin pen prior to administering the 3 (three) units of Lispro insulin to Resident #97. Review of the undated policy titled Insulin Administration Level III revealed a new pen needle will be attached and primed to remove air bubbles. It must be primed before each injection. Turn the dosage knob to the 2 (two) unit indicator with the pen pointing upward, push the knob all the way to release the air. One drop of insulin should appear, repeat the step as needed until you see a drop of insulin to ensure all of the air is out.

Based on medical record review, staff interview and review of facility policy, the facility failed to complete a residents discharge summary. This one (#41) of one resident reviewed for closed medical discharge records. The facility census was 47. Findings include: Review of the closed medical record for Resident #41 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the five day admission Minimum Data Set (MDS) dated [DATE] revealed a Resident #41 had a Brief Interview for Mental Status (BIMS) of 04 indicating severe cognitive impairment. Review of Resident #41's progress note dated 06/14/21, revealed Resident #41 was discharged from the facility to another facility. Further review of Resident #41's medical record revealed no evidence or documentation of a discharge summary being completed. Interview with the Administrator on 07/21/21 at 4:00 P.M., confirmed a discharge summary for Resident #41 was not completed. Review of facility policy, Discharge Summary and Plan with a revision date of 12/2016 revealed when the facility anticipates a resident's discharge to a private residence, another nursing care facility (i.e., skilled, intermediate care, ICF/ICD, etc.), a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment.

Based on medical record review, observations, staff interview and review of facility policy, the facility failed to assist a resident with changing his clothes. This affected one (#7) out of four residents reviewed for Activities of Daily Living (ADL's). The facility's census was 47. Findings included: Medical record review for Resident #7 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's Minimum Data Set 3.0 Assessment (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident #7 had moderate cognitive impairment. Resident #7 required limited assistance from one staff person with dressing. There were no behaviors documented, including no indication Resident #7 refused care or assistance from staff. Review of Resident #7's care plan with a date initiated of 10/16/19 revealed Resident #7 had an ADL deficit related to dementia and required limited assistance from one staff person with dressing. Further review revealed Resident #7 had a knowledge deficit related to dementia and was to be encouraged to participate in ADL's and staff were to assist as needed. Observations on 07/19/21 at 11:14 A.M., 1:34 P.M., and 3:51 P.M. revealed Resident #7 was wearing khaki pants with a red long-sleeved shirt. Observations on 07/20/21 at 9:43 A.M. and 2:44 P.M. Resident #7 was observed wearing the same khaki pants and red long-sleeved shirt observed on 07/19/21. At 2:44 P.M. the shirt and pants were soiled with stains. The shirt had white stains and the pants had a few dark wet spots and a neon orange spot. Observations on 07/21/21 at 9:14 A.M. and 1:33 P.M. Resident #7 was observed wearing the same khaki pants and red-long sleeved shirt observed on 07/19/21 and 07/20/21. The pants and shirt continued to be soiled with the same stains observed on 07/20/21 at 2:44 P.M. Interview on 07/21/21 at 1:33 P.M. State tested Nurse Aide (STNA) #270 reported Resident #7 was compliant with care and accepting of assistance from staff. STNA #270 verified Resident #7 was wearing the same clothes two days in a row (07/20/21 and 07/21/21). STNA #270 was observed offering Resident #7 assistance with picking out new clothes to wear and offered assistance with dressing. Resident #7 actively engaged in picking out his clothes and was agreeable to changing his clothing. Interview on 07/21/21 at 1:35 P.M. Licensed Practical Nurse (LPN) #181 verified Resident #7 was compliant with care and allowed staff to assist with care. LPN #181 verified Resident #7 would need assistance and/or prompting from staff for dressing/changing clothes. Interview on 07/21/21 at 1:50 P.M. LPN #181 verified Resident #7's care plan stated Resident #7 required limited assistance from one staff person with dressing. Observation on 07/21/21 at 2:09 P.M. Resident #7 was observed wearing a different outfit of black pants and a gray long-sleeved shirt. Review of facility undated policy titled, Activities of Daily Living (ADL's)/Maintain Abilities, revealed the facility would ensure residents were given the appropriate treatment and services, including dressing.

Based on medical record review, observation, resident and staff interviews and review of facility policy, the facility failed to ensure a resident had access to her call light to potentially prevent an accident or fall. This affected one (#13) out of three residents reviewed for fall management. The facility's census was 47. Findings included: Medical record review for Resident #13 revealed an admitted [DATE]. Diagnoses included, nontraumatic subacute subdural hemorrhage, unspecified fall, [CONDITION(S)], contusion of front wall of thorax, other seizures, transient cerebral ischemic attack, muscle weakness, chronic obstructive pulmonary disease, heart failure, [CONDITION(S)], scoliosis, [CONDITION(S)], stage IV kidney disease, and high blood pressure. Review of Resident #13's Minimum Data Set 3.0 Assessment (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #13 was cognitively intact. Resident #13 required limited assistance with bed mobility, transfers, walking, eating, toileting, and maintaining hygiene and extensive assistance with dressing. Resident #13 had suffered from a fall since admission. Review of Resident #13's care plan with a date initiated of 01/19/21, revealed Resident #13 was at risk for falls with interventions in place to encourage use of call light for assistance and to keep the call light within reach. Observation on 07/21/21 at 1:25 P.M. Resident #13 was observed seated in her recliner chair covered with a blanket. Her call light was observed clipped onto her bed, in-between the side rails. Resident #13 attempted to reach her call light and was unable to do so. Resident #13 verified she was unable to reach her call light. Staff interviews on 07/21/21/ at 1:26 P.M. Licensed Practical Nurse (LPN) #181 and State-tested Nurse Aide (STNA) #270 verified Resident #13 did not have access to her call light. STNA #270 added she felt therapy staff forgot to provide her call light to her. LPN #181 removed the call light from the bed and clipped it within reach of Resident #13. Review of facility policy titled, Falls- Clinical Protocol, revealed interventions to prevent palls would be identified and utilized.

Based on observations, staff interview, review of the facility policy, and review of the Center for Disease Control (CDC) guidance, the facility failed to implement infection control practices to prevent the potential spread of the Coronavirus Disease 2019 (COVID-19). This had the potential to affect 36 of 36 residents who currently have a negative COVID status. Residents #10, #12, and #14 were positive for COVID-19. The facility census was 39. Findings include: 1. Observations on 12/02/20 at 8:54 A.M. of Registered Nurse (RN) #200, revealed RN #200 was wearing an N95 respirator. The N95 respirator had two straps attached at the base of RN #200's head leaving a gap below and on either side of her chin. Interview on 12/02/20 at 8:57 A.M. with RN #200, verified she was wearing her N95 respirator straps down on her neck and there was a gap around her chin. RN #200 reported she was aware she was supposed to wear one strap on the top of her head and the other down on her neck, but reported it was more comfortable for her to have both straps down. Observation on 12/02/20 at 9:01 A.M. of RN #200, revealed she entered room [ROOM NUMBER] to provide assistance to the resident and continued to wear her N95 respirator with both straps on her neck and a gap visible around her chin. No fit check was observed being completed prior to RN #200 entering the resident room. Review of the undated facility policy titled, N95 Respirator Reuse-Instructions for Donning and Doffing, revealed before entering the room staff were to perform a negative/positive seal check. No air was to be felt around the perimeter while blowing out. If air was coming out it was not a tight seal. When taking a small breath in the mask, it should pucker in slightly. If it did not, it was not a tight seal. When breathing out, the respirator should expand slightly. If it did not, it was not a tight seal. If a tight seal was not able to be maintained, the respirator could not be used. Review of the CDC Guidance titled, Using Personal Protective Equipment (PPE), revised 08/19/20, revealed respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap). A user seal check was to be performed each time the respirator was put on. 2. Observations on 12/02/20 at 9:53 A.M. of the 14-day monitoring area, revealed Licensed Practical Nurse (LPN) #202 wearing a KN 95 mask. LPN #202 was observed entering and exiting room [ROOM NUMBER] on quarantine in the 14-day monitoring area. A sign was posted on the door indicating the resident in room [ROOM NUMBER] was on quarantine until 12/04/20. Interview on 12/02/20 at 9:56 A.M. with LPN #202, verified she was wearing a KN 95 mask and was working with residents in the 14-day monitoring area. LPN #202 reported her KN 95 mask was changed out every other day and were hung each night in a paper bag for storage. Review of the facility policy titled, COVID-19 Procedure: Resident Surveillance, dated March 2020, revealed new admissions and readmissions whose COVID-19 status was unknown would be placed in a single person room and all recommended PPE will be worn during care of residents under observation. This included use of an N95 or higher-level respirator, eye protection, gloves and gown. Review of the CDC Guidance titled, Preparing for COVID-19 in Nursing Homes, revised 11/20/20, revealed a healthcare provider (HCP) should wear an N95 or higher-level respirator, eye protection, gloves, and gown when caring for new admission and readmission for residents whose COVID-19 status was unknown. 3. Interview on 12/02/20 at 8:54 A.M. with Licensed Practical Nurse (LPN) #201, revealed staff were issued one N95 respirator which was worn for up to 72 hours and then replaced. LPN #201 reported each night the respirators were hung in paper bags for storage. The respirators were then reapplied the next day when the staff came on shift. The respirators were also able to be replaced if they became soiled or damaged. Interview on 12/02/20 at 9:24 A.M. with the Administrator, verified each staff was issued one paper bag for their mask storage and one mask. The Administrator reported each mask was worn for no more than three days consecutively. Masks were also replaced if they were soiled or damaged. Observation on 12/02/20 at 9:25 A.M. of the mask storage area, revealed a string of twine attached to the wall with clips suspending paper bags from the string. Each bag was labeled with a staff name and the bags were dated. It was noted there was only one bag per staff hanging. Review of the CDC Guidance titled, Strategies for Optimizing the Supply of N95 Respirators, revised 11/23/20, revealed N95 respirators use should be limited to no more than five uses (five donnings) per device by the same healthcare provider (HCP) to ensure adequate respirator performance. One potentially effective strategy to mitigate the contact transfer of pathogens from the respirator to the wearer could be to issue each HCP who may be exposed to patients with [DIAGNOSES REDACTED]-CoV-2 infection a minimum of five respirators. Each respirator will be used on a particular day and stored in a breathable paper bag until the next week. This will result in each worker requiring a minimum of five N95 respirators if they put on, take off, care for them, and store them properly each day. This amount of time in between uses should exceed the 72-hour expected survival time for [DIAGNOSES REDACTED]-CoV-2 ([MEDICAL CONDITION] that causes COVID-19). If this strategy is used, the total number of donnings should still not exceed five times before discarding the respirator, when no manufacturer instructions are provided to indicate otherwise.

Based on observations, medical record review, staff interview and policy review, the facility failed to implement their policy regarding isolation precautions for one (#28) of one reviewed for transmission based precautions. The facility failed to maintain separation of clean and soiled laundry which had the potential to affect all 37 residents residing in the facility. The facility failed to perform proper hand hygiene prior to performing peritoneal [MEDICAL TREATMENT] for one (#25) of one observed during peritoneal [MEDICAL TREATMENT] procedures. The total facility census was 37. Findings include: 1. Review of Resident #28 medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the modification of the Admission minimum (MDS) data set [DATE] revealed the resident has a brief interview of mental status score of three indicating the resident is severely cognitively impaired, the resident had no hallucinations, delusions,or behaviors coded for the review period. The resident is coded as dependent on staff for all daily cares. Resident has an indwelling urinary catheter, and is always in continent of bowel. Resident is coded as having non Alzheimer's dementia, and [MEDICAL CONDITION] are coded as current diagnosis. The resident received four days of anti-psychotic medication. Review of Resident #28's physician orders [REDACTED]. Review of resident care plan revealed the resident had care plan [MEDICAL CONDITION] in Stage IV coccyx wound with an intervention to follow isolation precautions as needed for active infections. Review of the (MONTH) Treatment Administration Record it was revealed Resident #28 has staff signing off every shift that staff are [MEDICAL CONDITION] contact precautions with care every shift [MEDICAL CONDITION]. During an observation of Resident #28 on 04/15/19 at 10:48 A.M. two staff were observed entering the resident room without personal protective equipment in place (gown and gloves). There is an isolation cart outside the room beside the door. At 10:50 A.M. the resident's room mate is observed to be removed from the room and neither staff had continue to have on gown or gloves. Resident #28's room was entered on 04/15/19 at 10:53 A.M. and the staff were starting to provide care to the resident The staff identified themselves as State tested Nursing Assistant (STNA) #100 and #200. Neither staff were noted to have on a gown to protect their clothing but both staff did have on gloves. The staff were observed to provide incontinent care to Resident #28 who had a bowel movement. The resident has a [DEVICE] dressing to her coccyx, that was not sealed at the base of the coccyx when the resident was noted to be turned on her side, and the machine would alarm. The staff were noted to have their clothing touch the bed linen during the procedure. When the [DEVICE] machine would alarm the staff could touch the base of the dressing and the dressing would seal and the alarm would stop sounding. During an interview with STNA #100 at 10:55 A.M. it was revealed the resident is in isolation [MEDICAL CONDITION] in the wound and it is under the [DEVICE]. The STNA stated staff only have to use personal protective equipment on dressing changes due to the wound being contained by the dressing. During an interview with the Director of Nursing (DON) on 04/18/19 at 10:5 A.M. it was verified the expectation is the staff will wear personal protective equipment when providing personal care to Resident #28 who is in isolation contact precautions. Review of policy titled Isolation - Categories of Transmission Based Precautions dated 2001 with a revision date of (MONTH) 2012 revealed a section specific to Contact Precautions. The policy indicated Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident - care items in the resident's environment. The decision on whether precautions are necessary will be evaluated on a case by case basis. Examples of infections requiring Contact Precautions include but are not limited to: Infections with multi-drug resistant organisms determined on a case by case basis). Staff should wear a disposable gown upon entering he Contact Precautions room or cubicle. 2. During an observation of the laundry with Environmental Services Director (ESD) #700 on 04/18/19 at 11:30 A.M. a laundry rack was observed that was three shelves. The shelves held blankets, hoyer lift pads, wheel chair cushions, and bath blankets on the soiled side of the laundry. ESD #700 stated the items are not used on the residents but were used for spills and then the area where the spilled occurred would be cleaned. ESD #700 confirmed the items should be stored in the dirty side of the laundry. The facility confirmed this had the potential to affect all 37 residents residing in the facility. Review of facility policy titled Departmental (Environmental Services) - Laundry and Linen dated 2001 with a revision date of (MONTH) 2014 it was revealed separate soiled and clean linen at all times. 3. Review of the medical record for Resident #25 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set 3.0 dated 03/26/19, revealed Resident #25 was cognitively intact with a Brief Mental Interview Status score of 14 and PHQ-9 score was 11. Resident #25 was on peritoneal [MEDICAL TREATMENT]. Review of Resident #25's current physician orders [REDACTED]. Continue with yellow/yellow on cycler at night. Unhook [MEDICAL TREATMENT] cycler upon completion, chart numbers, obtain blood pressure and weight. Review of the care plan dated 03/04/18 revealed Resident #25 had potential for fluid volume excess, infection at [MEDICAL TREATMENT] site, fluid retention related to end stage [MEDICAL CONDITION] and [MEDICAL TREATMENT]. Appropriate goal and interventions were in place. Observation on 04/15/19 at 1:21 P.M. revealed Licensed Practical Nurse (LPN) #150 perform exit site care to Resident #25's peritoneal catheter. LPN #150 first opened a pack of sterile four by four (4 x 4) gauze, washed her hands with soap and water, put on gloves, removed old dressing, cleaned around catheter exit site with sterile water and gauze, applied [MEDICATION NAME] cream to gauze and applied gauze over catheter exit site and secured the gauze with tape. Interview on 04/15/19 at 1:27 P.M. with LPN #150 verified she opened sterile gauze package before washing her hands and did not remove her gloves and wash her hands prior to applying the new dressing. Observation on 04/18/19 at 8:27 A.M. revealed LPN #150 was going to perform the peritoneal disconnection for Resident #25. LPN #150 put a treatment in progress sign on the door, washed hands with soap and water for washed five seconds and shut off the water with her hand, then dried her hands with paper towels, put on gloves, pressed buttons on the peritoneal cycler machine, moved a trash can, then removed her gloves, then washed her hands with soap and water for eight seconds, turned off the water and dried hands with paper towels. LPN #150 then clamped the peritoneal line and disconnected the tubing from the catheter port, and capped the catheter port with a cap that had [MEDICATION NAME] in it. LPN #150 then removed her gloves and cleansed her hands with hand sanitizer. LPN #150 took Resident #25's vital signs and weight. LPN #150 said she looks at the waste bag for color, clarity, [MEDICATION NAME], amount and then she documents the findings. LPN #25 said she disposes of the waste into the toilet and the waste bags and tubing gets bagged and gets disposed of in the trash. Interview on 4/18/19 at 8:35 A.M. with LPN #150 verified when washing her hands, she turned off the water and then dried her hands with paper towels and washed her hands for eight seconds. Review of the policy titled Handwashing/Hand Hygiene, revised 08/2015, revealed the procedure to washing hands includes to vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature. Hot water is unnecessarily rough on hands. Rinse hands thoroughly under running water. Hold hands lower than wrists. Don not touch fingertips to inside of sink. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. Discard towels into trash. Use lotions throughout the day to protect the integrity of the skin.

Based on observation, policy review and staff interview, the facility failed to maintain effective pest control for 19 residents who reside on the 400 hallway. The total Facility Census was 37. Findings include: Observation on 04/15/19 at 2:10 P.M., during tour of the attic space with Maintenance Director (MD) #250, noted raccoon feces laying on top of the attic insulation and wood trusses, located above Resident room [ROOM NUMBER]. Further examination revealed a live raccoon laying between the roof trusses, above Resident room [ROOM NUMBER]. Observation of the attic space revealed there was an access door opened on the 400 hall attic space which allowed the Raccoon access to the entire 400 hallway, to include the small kitchenette and dining room to the smoke wall. During an interview with MD #250 on 04/15/19 at 2:11 P.M. it was confirmed there was a live Raccoon in the attic space in the 400 hallway. During an interview with the MD #250 on 04/17/19 at 8:00 A.M. it was revealed there was a live trap in the ceiling to catch the raccoon, however the trap was empty at this time. The facility confirmed this had the potential to affect all 37 residents residing in the facility. Review of the facility policy titled Pest Control dated 2001 with a revision date of 2008 it was revealed the facility shall maintain an effective pest control policy. The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on medical record review and staff interview, the facility failed to have an accurate Pre-Admission Screening and Record Review (PASARR) for one of one (#28) reviewed for PASARR. The total facility census was 37. Findings include: Review of Resident #28 medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the modification of the admission minimum (MDS) data set [DATE] revealed the resident has a brief interview of mental status score of three indicating the resident is severely cognitively impaired, the resident had no hallucinations, delusions, or behaviors coded for the review period. The resident is coded as dependent on staff for all daily cares. Resident #28 has an indwelling urinary catheter, and is always in continent of bowel. Resident #28 is coded as having non Alzheimer's dementia, and [MEDICAL CONDITION] as current diagnosis. The resident received four days of anti-psychotic medication, seven days of anticoagulant, antibiotic and diuretic medication. Review of Resident #28 PASARR completed prior to admission to the facility revealed the resident was coded as not having a [DIAGNOSES REDACTED]. During an interview with the Administrator on 04/17/19 at 10:30 A.M. it was confirmed the PASARR did not accurately reflect Resident #28 as the dementia [DIAGNOSES REDACTED].

Based on medical record review, staff interview and policy review, the facility failed to have care plans that accurately reflected the resident nutritional needs. This affected one (#28) out of 15 care plans reviewed. The total facility census was 37. Findings include: Review of Resident #28 medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the modification of the admission minimum data set ((MDS) dated [DATE] revealed the resident has a brief interview of mental status score of three indicating the resident is severely cognitively impaired, the resident had no hallucinations, delusions,or behaviors coded for the review period. The resident is coded as dependent on staff for all daily cares. Resident has an indwelling urinary catheter catheter, and is always in continent of bowel. The resident is coded as receiving [MEDICATION NAME] feeding that supplies 51% or more of total calories. not being on a therapeutic mechanically altered diet. Review of the resident physician orders revealed the resident has a diet order of pureed diet with honey thick liquids via one half teaspoons, recommended 90 degree positioning during and post meals with an order date of 03/19/19. The resident additionally has enteral feed orders of every four hours of free water, and [MEDICATION NAME] 1.2 cal via peg tube at 90 milliliter (ml) per hour times 12 hours (7:00 P.M.-7:00 A.M.) for 1080 ml and 1296 calories. Review of the resident progress notes revealed the resident had a progress note on 04/01/19 that indicated the resident peripherally inserted central catheter (PICC) line was discontinued. Review of care plans revealed the care plan for activities of daily living of self care performance deficit related to current level of capability listed the resident ability with bed mobility, eating, toileting and transfers as extensive assist and not dependent as listed on the MDS, the interventions are dated 03/01/19 with revision dates of 03/27/19. Resident #28's care plan for risk of dehydration or potential fluid deficit stated related to NPO (nothing by mouth) and the resident had diet orders started on 03/19/19. Lastly Resident #28 had a care plan to reflect the resident having a PICC line, and the Picc line was discontinued on 04/01/19. During an interview with the director of nursing on 04/17/19 at 3:30 P.M. confirmed Resident #28's care plans were not updated to reflect the current status of the resident. Review of the facility policy titled Care Plans-Comprehensive dated 2001 with a revision date of (MONTH) 2010 it was revealed an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs is developed for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.

Based on observation, medical record review, and staff interview, the facility failed to maintain the call light in reach for a resident identified as being at risk for falls. This affected one (#1) of 16 observed during the annual survey. The total facility census was 37. Findings Include: Review of Resident #1 medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of most recent quarterly minimum (MDS) data set [DATE] revealed the resident has a brief interview of mental status score of eight indicating the resident has some cognitive impairment, the resident had no delusions, hallucinations or behaviors during the review period. The resident is coded as requiring supervision assist from staff for bed mobility transfers, walking in the room, eating and toileting. The resident does require extensive assist for one person for dressing and personal hygiene. The resident is occasionally incontinent of bladder. The resident reported shortness of breath with exertion, and has had a fall since admission to the facility. Review of resident care plan revealed the resident has potential for injury fall care plan related to falls in the community with an intervention to encourage to ask/use the call light for assistance and call light within reach. Observation of Resident #1 on 04/15/19 at 9:48 A.M. revealed the call light was on night stand not in reach of the resident who was lying in bed. Observation of Resident #1 on 04/15/19 at 2:00 P.M. revealed the resident was lying in bed and the call light was on the over bed table that was pushed perpendicular to the bed against the wall out of reach of the resident. During an interview with State tested Nursing Assistant Assistant (STNA) #300 on 04/15/19 at 2:22 P.M. it was confirmed Resident #1's call light was not in reach and it should be. STNA #300 confirmed the call light was not available to the resident. STNA #300 stated the resident does not like it clipped to his person or blanket so the staff keep it clipped to the pillow. The staff moved the call light to the pillow so the resident had access to the call light.

Based on medical record review, observation, staff interview and policy review, the facility failed to perform urinary catheter care according to the facility policy. This affected one (#13) of one resident sampled for urinary catheters. The facility census was 37. Findings include: Review of the medical record for Resident #13 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #13 had moderate cognitive impairment with a brief interview for mental status score of 10 out of 15. PHQ-9 was four. Resident #13 had an indwelling catheter and was always continent of bowel. Resident #13 had shortness of breath or trouble breathing with exertion and used oxygen. Review of the care plan dated 01/18/19 revealed Resident #13 had an indwelling Foley catheter due to [MEDICAL CONDITION] and has potential for complications related to indwelling Foley catheter. Resident #13 will remain free of signs/symptoms of urinary tract infection. Appropriate interventions were in place. Review of the current physician orders [REDACTED]. Order dated 03/15/19 may change Foley as needed for leaking or clogged tubing. Review of the labs results dated 03/19/19 revealed urine culture result with [MEDICATION NAME] gram negative bacilli (bacteria) greater than 100,000 and(NAME)pneumoniae (bacteria) greater than 100,000. An order dated 03/20/19 [MEDICATION NAME](antibiotic) 750 milligrams twice a day for three days for urinary tract infection. Observation on 04/18/19 at 10:15 A.M. revealed State tested Nurse Aide (STNA) #100 perform catheter care on Resident #13. STNA #100 gathered supplies, washed his/her hands, put on gloves, uncovered the resident, pulled down resident's adult brief, took a soapy washcloth and folded the washcloth around his hand and cleaned the creases on each side of the vaginal area and wiped downward with his washcloth, but went back over the other areas he had already cleaned with the same washcloth. STNA #100 then got a clean washcloth and repeated cleaning the residents pelvic creases and then vaginal area in a downward motion, a brownish color was on the washcloth after cleaning Resident #13. STNA #100 then took a clean wet washcloth with no soap to rinse the resident using the same washcloth wiping the creases then down the vaginal area in a downward motion. STNA #100 used a clean washcloth with soap and water to clean the catheter from insertion site downward away from the resident approximately four inches. STNA #100 used a towel to dry the resident and then pulled her brief back up and covered her. STNA #100 removed the gloves and washed his hands. Interview on 04/18/19 at 10:24 A.M. with STNA #100 verified he had used the same washcloth to clean Resident #13 and went back over with the same part of the washcloth to clean the vaginal area. Review of the policy titled Catheter Care, Urinary, revised 09/2014, revealed for a female resident, use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth for each downward cleansing stroke. Change the position of the washcloth with each downward stroke. Next change the positron of the washcloth and cleanse around the urethral meatus. Do not allow the washcloth to drag on the resident's skin or bed linen. With a clean washcloth, rinse with warm water using the above technique. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward.

Based on review of medical records and staff interview, the failed to administer eye drops as ordered to a resident. This affected one (#16) of six residents reviewed for unnecessary medications. The census was 37. Findings include: Review of Resident #16's closed medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. hypertension, major [MEDICAL CONDITIONS], dementia, [MEDICATION NAME] degeneration, [MEDICAL CONDITIONS], and corneal abscess of right eye. Resident #16 was discharged to the emergency room (ER) on 04/13/19 for evaluation of right eye infection. As of completion of the annual survey on 04/18/19 Resident #16 had not yet returned to the facility. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was assessed as being cognitively intact. Resident #16 required required extensive assistance with activities of daily living (ADLs). Review of Resident #16's physician orders [REDACTED]. Another order dated 04/06/19 was for [MEDICATION NAME] (antibiotic) 0.3% one drop every two hours while awake. Review of Resident 16's medication administration records (MAR's) for (MONTH) 2019 revealed no documentation of PredForte and [MEDICATION NAME] being administered on 04/08/19 at 8:00 P.M. and on 04/09/19 at 4:00 P.M., 6:00 P.M. and 8:00 P.M. During an interview on 04/17/19 at 4:18 P.M. the Director of Nursing (DON) confirmed that Resident #16 had not been given PredForte and [MEDICATION NAME] on 04/08/19 at 8:00 P.M. and on 04/09/19 at 4:00 P.M., 6:00 P.M. and 8:00 P.M. as ordered. This deficiency substantiates Complaint Number OH 824.

Based on medical record review and staff interview, the facility failed to ensure a resident was free from unnecessary medication when the facility failed to limit as needed [MEDICAL CONDITION] medication orders to 14 days. This affected one (#29) of five residents sampled for unnecessary medications. The facility census was 37. Findings include: Review of the medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 dated 03/29/19 revealed Resident #29 was cognitively intact with a brief interview for mental status score of 15 out of 15. Resident #29's PHQ-9 score was nine and the resident had verbal behaviors directed toward others one to three days and rejected care one to three days during the assessment period. Resident #29 received anti-anxiety, anti-depressant, anti-coagulant, opioids and diuretics seven days during the assessment period. Review of the care plan dated 02/16/19 revealed Resident #29 had the potential for anxiety related to anxiety disorder, resident becomes short of breath and with anxiety episodes and uses oxygen. Resident #29 had potential for at risk for altered behavior patterns related to disruptive interactions, disruptive verbally, resistive to care, anxiety, inappropriate verbal behaviors, physical behaviors directed toward staff, non-compliance with staff using proper lift equipment for transfers. Resident #29 had potential for altered mood pattern related to anxiety, depression, dependent on others for daily care due to [MEDICAL CONDITION]. Resident #29 received [MEDICAL CONDITION] medications related to anxiety and depression. Review of the current orders revealed Resident #29 had orders for the following [MEDICAL CONDITION] medications: [REDACTED] Review of the PRN (as needed) [MEDICAL CONDITION] Medication Order Review form dated 04/16/19 for Resident #29 revealed a current order for [MEDICATION NAME] 0.5 mg one tablet every 24 hours as needed for anxiety. Order was started on 04/02/19. Order was reviewed by physician and marked the medication as effective toward the indication for use as above for anxiety, but did not mark an end date or mark the order to continue another 14 days and then review. Interview on 04/18/19 at 3:52 P.M. with the Administrator verified that Resident #29 did not have an end date for the [MEDICATION NAME] 0.5 mg every 24 hours as needed.

Based on medical record reviews, observation, staff interviews, review of infection control logs, and review of facility policy, the facility failed to follow the infection control surveillance program to monitor causes of infection. The facility further failed to maintain infection control when providing catheter care. This affected one (#10) of one resident reviewed for catheter care. The facility census was 32. Findings included: 1. Review of facility infection control logs for (MONTH) (YEAR) through (MONTH) (YEAR) revealed specific organisms were not tracked after cultures for infections were obtained. Further review of the logs identified nine cultures were collected. Interview on 03/21/18 at 1:00 P.M. with Registered Nurse (RN) #70 revealed the facility had not been tracking specific organisms obtained from cultures in order to identify trends. Review of the undated facility policy titled Surveillance for Infections revealed the purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-Associated Infections, to guide appropriate interventions, and to prevent future infections. Further review revealed when infection or colonization with epidemiologically important organisms is suspected, cultures may be sent, if appropriate, to a contracted laboratory for identification or confirmation. Cultures will be further screened for sensitivity to antimicrobial medications to help determine treatment measures. 2. Review of Resident #10's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Observation on 03/21/18 at 5:50 P.M., revealed State tested Nurses Aide (STNA) #100 completed catheter care for Resident #10. After completing the procedure Resident #10 was assisted into his wheelchair. STNA #100 drug Resident #10's catheter bag and tubing across the floor underneath of his wheelchair in order to hang in the back. Interview immediately following the observation with STNA #100, confirmed Resident #10's catheter bag and tubing was placed on the floor underneath of his wheelchair. Review of the facility policy titled Catheter Care, Urinary, revised (MONTH) 2014, revealed the purpose is to prevent catheter-associated urinary tract infections. Further review revealed the catheter tubing and drainage bag are to be kept off the floor.

Based on medical record review, observations, staff, resident, and family interview, review of facility policy and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), it was determined the facility failed to implement interventions to prevent pressure ulcer development for a resident who was at high risk for pressure ulcers. This resulted in actual harm when Resident #42 developed an avoidable suspected deep tissue injury/pressure ulcer on her bilateral heels and an avoidable Stage II pressure ulcer on her coccyx. This affected one (#42) of three residents reviewed for pressure ulcers. The facility identified a total of four residents with pressure ulcers. Findings include: Review of Resident #42's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #42's quarterly minimum data set (MDS) assessment dated [DATE] documented Resident #42 required supervision of one person for bed mobility and transfers; always continent of urine and bowel; had no pressure ulcers and was not at risk for pressure ulcer development. Further review of the medical record revealed Resident #42's clinical health status for quarterly review dated 09/30/11 documented there were no concerns with any pressure ulcers being present. The resident scored a "22" on the "Braden Scale for Predicting Pressure Sore Risk" which indicated she was not at risk at that time due to no impairment with sensory perception, rarely moist, walks frequently, no limitations in mobility, nutrition was adequate and no problems with friction and shear. Review of the nursing progress notes revealed Resident #42 began having complaints of left hip pain on 10/19/11 and two x-rays of the left hip were negative. On 10/26/11, a computed tomography (CT) scan of the left lower extremity was taken and this showed an extensive [MEDICAL CONDITION] sacrum. Review of physician orders [REDACTED]. Resident #42's Activity of Daily Living (ADL) flow sheet log for October and November 2011 were reviewed. From 10/01/11 to 10/19/11, the resident was independent to supervision with bed mobility and transfers. After 10/19/11, the review revealed the resident began requiring assistance with ADL's and on 11/23/11 and 11/24/11, it was documented that Resident #42 required extensive assist of one person for bed mobility and transfers. Review of Resident #42's nursing progress note entitled "SBAR-Change of Condition" dated 11/24/11 documented the resident was found to have 3.0 cm by 3.0 cm dark mushy areas to the bilateral heels. The resident was recently bedfast due to a [MEDICAL CONDITION], currently ambulating per one assist and walker, has a [DIAGNOSES REDACTED]. Review of the wound evaluation flow sheet dated 11/24/11 documented the presence of a 3.0 centimeter (cm) by 3.0 cm area to the bilateral heels that were mushy and dark in color. The staging of these areas was not noted on the flow sheet. Review of the physician orders [REDACTED]. The wound evaluation flow sheet indicated the left heel measured 4.3 cm by 3.3 cm and was pulling on the back of the heel and the right heel was intact and measured 3.5 cm by 3.2 cm. There was no staging of the areas on documented. On 12/12/11, a new area was noted on the coccyx measuring 0.5 cm by 0.25 cm with no depth or staging noted. Review of physician orders [REDACTED]. Review of the quarterly MDS assessment dated [DATE] indicated Resident #42 required extensive assist of two person for bed mobility and transfers; was frequently incontinent of urine and bowel; was at risk for pressure ulcer development and had one Stage II pressure ulcer that developed on 12/12/11 and two unstageable deep tissue pressure areas. The "SBAR- Change of Condition" dated 12/12/11 at 4:27 A.M. noted the "heels starting to hurt", continent and incontinent of bladder and later in the day at 10:25 P.M., it was documented that an open area to the coccyx was found. The nurse documented the resident has spent more time in bed and prefers to lay on back. The area measured 0.5 cm by 0.25 cm (no depth measurements). A treatment was initiated, the family and doctor were notified, the resident was encouraged to turn side to side while in bed and a pressure relieving cushion was to placed in the wheelchair. On 12/14/11, the physician ordered a dressing to the left heel due to the area being opened. Review of Resident #42's physician progress notes [REDACTED]. The progress note did not document any assessment of the pressure ulcers. A physician progress notes [REDACTED]. In addition, there was no documentation that Resident #42 had been seen at the wound clinic or by a specialist related to the pressure ulcer development or that it had been offered to the family. Further review of the wound evaluation flow sheet dated 12/15/11 noted a small slit to the coccyx that measured 0.5 cm by 0.25 cm with no depth measurements. On 12/15/11, the right heel measured 3.5 cm by 3.2 cm with the discolored area intact and the left heel area measured 4.3 cm by 3.3 cm with an open area but no staging documented. On 12/15/11, the physician ordered a therapy boot to the left heel and on 12/18/11, an alternating air mattress was added to the bed. On 12/20/11, therapy boot order changed to multipodus splint to the left heel while in bed. Further review of the wound evaluation flow sheet dated 12/29/11 noted the coccyx area was open and measured 1.5 cm by 0.5 cm by 0.1 cm. The area was no staged. On 12/29/11, the right heel discolored area measured 3.0 cm by 2.8 cm and the left heel area measured 4.0 cm by 3.8 cm with a 1.0 cm by 1.0 cm open area. There was no staging noted. Resident #42's care plan dated 04/15/11 entitled pressure ulcer actual or at risk due to impaired cognition and limitations in mobility was reviewed. The care plan documented that interventions implemented on 04/15/11 consisted of; do not massage over bony prominence's; conduct weekly skin inspections; provide pressure reduction/relieving mattress; provide pressure reducing chair cushion and therapy as needed. Further review of the care plan revealed that interventions were not specific to prevent pressure ulcer development to the heels prior to 11/24/11 and to the coccyx prior to 12/12/11. The care plan was revised on the following dates with the following interventions: on 11/28/11, encourage heel protectors to heels while in bed and apply skin prep to bilateral heels; on 12/12/11, encourage resident to turn side to side while in bed and assure pressure relieving cushion to wheelchair; on 12/15/11, multipodus splint was added to the left heel and on 12/18/11, an alternating air bolster mattress to the bed. On 01/03/12 at 6:56 P.M., observations of Resident #42 revealed she was seated in a wheelchair in her room. The resident was sitting on a cushion, her bilateral feet were on the floor with shoes on; the bed was also noted to have an air mattress in place. On 01/04/12 at 1:30 P.M. to 1:50 P.M., observations of Resident #42's pressure ulcer care with Registered Nurse (RN) #5 were made. During the observation, RN #5 removed an old dressing to the left heel and coccyx. RN #5 measured the coccyx wound which was 1.5 cm in length by 2.8 cm in width by 0.3 cm in depth. RN #5 stated the wound was a Stage II pressure ulcer; however, verified the presence of slough in the wound bed. The wound was cleansed with soap and water, patted dry, skin prep was applied to the peri-wound and a foam dressing was applied and secured. The area on the entire left heel was measured as 4.3 cm in length by 3.5 cm in width with the entire area being "scaley" and being able to see approximately three layers of skin with an underlying open area that measured 0.8 cm in length by 0.5 cm in width by 0.1 cm in depth. The wound was red/granulated with a small amount of yellowish drainage. The area was cleansed; skin prep was applied; a non adhesive dressing was also applied and wrapped with kerlix then the heel was placed in a multipodus boot. The right heel measured 3.0 cm in length by 2.0 cm in width with a brown eschar covered (unstageable) area. The right heel received a skin prep treatment and was placed in a cloth heel protector. During the observations, Resident #42 was noted to have one multipodus boot in her room that was ordered to the left heel that would fully suspend the heel when applied and two cloth style heel protectors. The cloth heel protector was ordered to the right foot; however, during the observation the cloth heel protector was noted with yellow drainage in the area where the heel would rest and the right heel had no active drainage. During the observations, RN #5 verified the cloth heel protector that is ordered to the right foot must have been applied to the left foot. On 01/03/12 at 10:31 A.M., interview with RN #5 during Stage 1 of the survey revealed Resident #42 currently has one or more pressure ulcers. RN #5 was asked to provide the highest stage of the pressure ulcers and she stated the most advanced is a Stage II on Resident #42's coccyx and a Stage II on her left heel. On 01/03/12 at 6:50 P.M., an interview with Resident #42 revealed she was currently comfortable. She stated her right heel doesn't bother her but her left heel does hurt at times (she was unable to rate or describe the pain). During the interview, Resident #42 was able to answer simple questions and was unable to answer detailed questions. During interview on 01/03/12 at 7:00 P.M., State tested Nurse Aide (STNA) #22 indicated she would think Resident #42 was at high risk for pressure ulcer development. STNA #22 stated she does not think the resident has any pressure ulcers on her heels. On 01/04/12 at 3:39 P.M., interview with the Director of Nursing (DON) revealed she has been working on wound care with the nurses. The DON verified the lack of documentation regarding prior heel ulcer preventative measure in place prior to 11/24/11 and the lack of specific interventions to prevent coccyx pressure ulcers prior to 12/12/11. The DON also verified that interventions would be documented on the care plan and TAR. During interview on 01/04/12 at 6:15 P.M., Licensed Practical Nurse (LPN) #7 stated that approximately the month before Resident #42 developed the deep tissue injuries on the heels, she was found to have a fractured sacrum. He stated she was spending more time in bed and there was an order for [REDACTED]. LPN #7 stated he has not seen the heel areas in a few days but did state he has seen the coccyx area the night before and he would consider it a Stage III pressure ulcer at it's current state. On 01/05/12 at 10:30 A.M., additional interview with the DON, Corporate Nurse #8 and the Administrator confirmed Resident #42 developed deep tissue injuries/pressure ulcers on the bilateral heels on 11/24/11 and a Stage II pressure ulcer on the coccyx on 12/12/11. The interview further verified the resident was experiencing a decline in her condition at and before the time of the pressure ulcer development which was related to the [DIAGNOSES REDACTED]. The interview also verified the lack of specific pressure ulcer preventative measure regarding the decline and that new interventions added to the care plan took place after each pressure ulcer had already developed. The DON verified that prior to the development of the pressure ulcer and during the change of condition the facility did not re-evaluate the resident's "Braden Scale for Predicting Pressure Sores." The DON further verified that Resident #42 developed the deep tissue injuries on her bilateral heels on 11/24/11 and a Stage II pressure ulcer on the coccyx on 12/12/11 and the facility did not re-evaluate the need for a speciality mattress until an alternating air mattress was added on 12/18/11. The DON stated she had a phone interview with the physician which confirmed the physician has been in to see the resident since the pressure ulcer development; however, the physician has not assessed/evaluated Resident #42's pressure ulcers. On 01/05/12 at 11:15 A.M., an interview with Resident #42's family member revealed her aunt is at the facility because she requires more care than the family can provide at home. The family member indicated she was aware of a "sore" on her aunt's tailbone and stated that's the only one she was aware of. The family member stated that her aunt needed more care at the end of October 2011 going into November 2011 and that around Thanksgiving time she required even more care from the staff. Review of the facility's policy entitled "Skin Integrity Guideline" revised January 2011 indicated all residents will be assessed/observed for risk of skin breakdown 24 hours of admission then quarterly and as necessitated by change in condition. If identified risk present the interventions will be documented in the Immediate Plan of Care or Comprehensive Care Plan. If there is a decline in skin integrity, pressure redistribution surfaces will be reviewed for appropriateness. The policy further documented that a change of condition criteria may include bedfast and bowel incontinence. Information from the NPUAP was reviewed. The review revealed that a suspected deep tissue injury is defined as a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear; the area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue; evolution may include a thin blister over a dark wound bed; the wound may further evolve and become covered by thin eschar and evolution may be rapid exposing additional layers of tissue even with optimal treatment. Additionally, the NPUAP guidelines entitled 'Pressure Ulcer Prevention Points' were reviewed. The guidelines documented: to identify all individual risk factors to guide specific preventive treatment; that use devices that eliminate pressure on the heels; for short-term use with cooperative patients, place pillows under the calf to raise the heels off the bed and place heel suspension boots for long-term use. Reposition bed-bound persons at least every two hours and chair-bound persons every hour consistent with overall goals of care; use written repositioning schedule. A Stage III pressure ulcer is defined as full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. A Stage II pressure ulcer is defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister.