Every finding on record at Willow Brook Christian Home

Based on review of the Legionella plan, policy review and staff interview, the facility failed to ensure the Legionella plan parameters for temperature readings were followed and failed to ensure new interventions were initiated for documented temperatures readings below the control measure. This had the potential to affect all facility residents. The facility census was 49. Findings include: Review of the Legionella plan dated 07/2025 revealed the facility shall check the outflow and return temperatures of the domestic water heaters. The domestic water heaters had control temperatures of 118 degrees Fahrenheit (F) for the county water and 140 degrees F for the city water. Review of the 2026 monthly temperature logs revealed the county water heater temperature readings were below the control measure. For January the temperatures were 110 degrees F and 112 degrees F; February's were 113 degrees F and 115 degrees F; March's were 110 degrees F and 111 degrees F; and April's were 116 degrees F and 118 degrees F. The city water temperature readings below the control measures for January were 111 degrees F and 113 degrees F; February were 109 degrees F and 111 degrees F; March were 110 degrees F and 110 degrees F; and April were 111 degrees F and 112 degrees F. Interview on 04/29/26 at 9:50 A.M. with Maintenance Director #305 confirmed the documentation showed the temperature readings were below the control measures and there was no documentation regarding what the facility did to correct it. Review of facility policy titled Legionella Surveillance dated 10/01/25 revealed hot water shall be stored at a range of 138 to 142 degrees F and circulated at a minimum return temperature of 124 degrees F.

Based on medical record review, interview, and review of facility policy, the facility failed to ensure the comprehensive care plan was updated for a fall intervention for Resident #45. This affected one resident (#45) of three residents reviewed for falls. The facility census was 49.Findings Include: Review of Resident #45's medical record revealed she was admitted on [DATE] with diagnoses that included but were not limited to hypertension, insomnia and dementia.Review of facility investigation report dated 01/16/26 revealed Resident #45 was found on the floor mat directly beside her bed and a silent bed alarm was implemented as the immediate action taken for fall. Review of Resident #45's progress notes dated 01/20/26, revealed an interdisciplinary team (IDT) note for the fall on 01/16/26 stating a silent alarm was to be applied when Resident #45's was in bed and the plan of care (POC) was reviewed and updated. Review of Resident #45's physicians orders dated revealed an order dated 01/16/26 for a silent alarm to bed every shift. Review of Resident #45's Minimum Data Set (MDS) assessment dated [DATE], revealed she was rarely or never understood. She was alert and unable to make her needs known. She was dependent upon staff with transfers, toileting and personal hygiene.Review of Resident #45's care plans dated 02/23/26 revealed an at risk for falls care plan. Further review of the care plan revealed there was no updated intervention to include the silent bed alarm for the implemented fall intervention on 01/16/26.Interview on 04/30/26 at 12:15 P.M. with Regional Nurse #300 confirmed the comprehensive care plan was not updated to include the fall intervention for a silent bed alarm for Resident #45's fall on 01/16/26. Review of facility policy titled Comprehensive Care Plan dated 08/01/25, revealed the facility is to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Further review revealed the comprehensive care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on staff interview, review of the medical record, and review of facility policy, the facility failed to ensure baseline weight measurements were obtained and verified in a timely manner after admission. This affected one resident (#7) of one resident reviewed for nutrition and weight loss. The facility census was 49.Findings include:Review of the medical record for Resident #7 revealed the resident was admitted to the facility on [DATE] with diagnoses that included unspecified dementia and hypertension amongst other diagnoses, with the diagnosis unspecified protein-calorie malnutrition added to the medical record on 01/29/26. Further review of the resident's medical record revealed the resident's cognition could not be assessed using a standardized cognition assessment tool due to the resident being rarely or never understood, though the resident's cognitive skills for daily decision making were noted to be impaired.Review of weight measurements found in Resident #7's medical record revealed an initial weight of 146 pounds (lbs.) documented in the medical record as measured on 12/26/25. Further review of resident weights revealed the next weight measurement was not recorded until two weeks after admission to the facility on [DATE] when Resident #7 was noted to weigh 130 lbs.Interview on 04/30/26 at 10:18 A.M. with Registered Dietitian (RD) #302 revealed the initial weight of 146 lbs. that was documented for 12/26/25 was a weight that they were told by Resident #7's family that was reported to have been measured in an outside facility. Further interview with RD #302 revealed the facility's policy is to measure a new resident's weight upon admission, and then weekly thereafter for the next three weeks unless there are physician orders specifying a different frequency that weights should be measured. Additional interview with RD #302 at this time revealed they were unsure why an initial weight was not obtained for Resident #7 upon admission, and that it would be difficult to tell if or how rapidly the resident was losing weight after arriving to the facility without measuring their weight in a timely manner upon admission.Interview on 04/30/26 at 11:12 A.M. with the facility Administrator revealed they believed there may have been a potential process error that could have resulted in Resident #7 not having a weight recorded upon admission. Further interview with the Administrator at this time revealed the typical process in the facility was that nursing aides measured resident weights, recorded the weight measurements on paper, and then nurses added the measurements into the electronic health record.Interview on 04/30/26 at 11:55 A.M. with RD #302 further verified no weights were obtained for Resident #7 at the facility until 01/30/26. Additional interview at this time with RD #302 revealed the resident was having respiratory complications around the time of admission, thus no initial weight was recorded upon arrival to the facility, but there was no explanation for why weights were not measured for the next two weeks as indicated by facility weight monitoring policy.Review of the facility policy titled Policy for Monitoring Weights-WBCH effective 06/01/24 revealed residents will be weighed on admission if the resident's condition allows for this procedure. Further review of the policy revealed residents will be weighed every week for 3 weeks following admission if the resident's condition allows for this procedure.

Based on review of the medical record, interviews, review of Food and Drug Administration (FDA) guidance, and policy review, the facility failed to ensure residents drug regimen was free from unnecessary drugs when pain medication parameters were not in place. This affected two residents (#12 and #24) out of three residents reviewed for pain. The facility census was 49. Findings include:1. Review of the medical record for Resident #12 revealed an admission date of 04/10/26. Diagnoses included absence of right leg below the knee, encephalopathy, dysphagia, kidney disease, atrial fibrillation, heart failure, hypertension, edema, and Parkinson's disease.Review of physician orders dated 04/10/26 revealed orders for acetaminophen oral tablet 325 milligrams (mg) with instructions to give three tablets every eight hours for pain.Review of physician orders dated 04/10/26 revealed orders for acetaminophen oral tablet 325 mg with instructions to give one tablet every six hours as needed for mild pain.Review of the plan of care dated 04/11/26 revealed the resident had acute and chronic pain with interventions to educate the resident about phantom pain and evaluate the effectiveness of pain medications.Review of physician orders dated 04/13/26 revealed orders for oxycodone 10 mg with instructions to give one tablet every eight hours for pain.Review of physician orders dated 04/13/26 revealed orders for oxycodone 10 mg with instructions to give one tablet every four hours as needed for severe pain.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition. The MDS assessment also stated Resident #12 had received opioid medications.Review of the Medication Administration Review (MAR) dated 04/2026 revealed oxycodone was given for pain levels of two out of 10, four times; pain levels of three, four, and five out of 10, six times; pain level of six out of 10, 10 times; pain level of seven out of 10, 10 times; and a pain level of eight out of 10, nine times. Acetaminophen was administered for a pain level of eight out of 10. Further review of the MAR found no evidence of parameters of when staff should administer the oxycodone verses the acetaminophen and also did not include any language about maximum daily doses. The full ordered amount of acetaminophen would be a dose of 4,225 mg daily. Interview on 04/20/26 at 11:20 A.M. with Registered Nurse #206 revealed resident pain would be considered mild/moderate for pain levels one to five out of 10 and moderate/severe for five to 10 out of 10. She confirmed, per basic nursing judgement, acetaminophen should not be administered more than 3,000 mg each day. Interview on 04/20/26 at 11:40 A.M. with Regional Nurse #300 confirmed the orders for Resident #12 were not clear, gave no parameters or instructions and confirmed staff gave acetaminophen for higher pain levels (eight out of 10) and oxycodone for lower levels of pain (two, three and four out of 10). Regional Nurse #300 confirmed there was no guidance or instructions provided to nursing staff regarding pain scales for Resident #12 and also confirmed it should be clear about the maximum amount of acetaminophen which should be given. She confirmed 4,000 mg was high and acute liver failure could occur if she was administered over 4,000 mg. Interview on 04/29/26 at 4:23 P.M. with Nurse Practitioner #301 revealed she did not like following parameters for pain medication and putting instructions in the orders, as she wanted the nursing staff to be able to use nursing judgement and for residents to be able to request whatever pain medication they wanted as long as it had been ordered. She was unable to provide a number parameter related pain but stated Tylenol/acetaminophen would be given for lower level of pain (mild or moderate) and a narcotic like oxycodone or tramadol would be for more severe pain. She acknowledged numbers such as a two and three [out of 10] would be more mild pain and an eight to 10 out of 10 would be more severe. She also verified a resident should not go over 3,000 mg of acetaminophen. Resident #12 was brought up specifically and NP #301 verified Resident #12 could go up to 4,000 mg but definitely not over that amount. After confirming Resident #12 had orders for acetaminophen that could put her over 4,000 mg per day, NP #301 stated only by about 1/2 a pill. Review of FDA Guidance titled Acetaminophen - What you should know about using acetaminophen safely current as of 08/14/25, revealed the maximum total amount of acetaminophen taken in 24 hours should not be more than 4,000 mg for adults. It also noted that taking too much acetaminophen can cause liver failure and death. 2. Review of the medical record for Resident #24 revealed an admission date of 05/22/25. Diagnoses included atrial fibrillation, heart failure, hypertension, edema, and Parkinson's disease. Review of physician orders dated 05/21/25 revealed orders for tramadol 50 mg with instructions to give every eight hours as needed for pain.Review of physician orders dated 06/09/25 revealed orders for Tylenol 325 mg with instructions to give every eight hours as needed for severe pain and administer with tramadol for severe pain. Review of the plan of care dated 06/11/25 revealed the resident had pain related to Parkinson's and took opioid medication with interventions to anticipate resident needs for pain relief, evaluate the effectiveness of pain medications, and to monitor requests for pain medications. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 14 indicating intact cognition. The MDS assessment also stated Resident #24 had received opioid medications.Review of the Medication Administration Review (MAR) dated 03/2026 revealed tramadol was given for pain levels of two out of 10, two times; pain level of three out of 10, four times; pain level of four out of 10, two times; pain level of five out of 10, two times; pain level of six out of 10, four times; pain level of seven out of 10, two times; and pain levels of eight out of 10 and 10 out of 10, two times. Tylenol was administered for a pain level of two and three out of 10 and was administered one of two times along with the tramadol. Review of the MAR revealed no evidence of parameters for when pain medication should be administered and which as needed pain medication to administer. Review of the Medication Administration Review (MAR) dated 04/2026 revealed tramadol was given for pain levels of three, four, and five out of 10, three times and a pain level of six out of 10, three times. Tylenol was not administered during this month. Review of the MAR revealed no evidence of parameters for when pain medication should be administered and which as needed pain medication to administer. Interview on 04/20/26 at 11:20 A.M. with Registered Nurse #206 revealed resident pain would be considered mild/moderate for pain levels one to five out of 10 and moderate/severe for five to 10 out of 10.Interview on 04/20/26 at 11:40 A.M. with Regional Nurse #300 confirmed the orders for Resident #24 were not clear whether staff should only administer Tylenol or administer the Tylenol along with the ordered tramadol. Interview on 04/29/26 at 4:23 P.M. with Nurse Practitioner #301 revealed she did not like following parameters for pain medication and putting instructions in the orders, as she wanted the nursing staff to be able to use nursing judgement and for residents to be able to request whatever pain medication they wanted as long as it had been ordered. She was unable to provide a number parameter related pain but stated Tylenol/acetaminophen would be given for lower level of pain (mild or moderate) and a narcotic like oxycodone or tramadol would be for more severe pain. She acknowledged numbers such as a two and three [out of 10] would be more mild pain and an eight to 10 out of 10 would be more severe. NP #301 verified the order for Resident #24 was confusing and stated she would expect staff to be giving the Tylenol for lower levels of pain and tramadol for the higher levels of pain. She confirmed the order was not clearly written. Review of facility policy titled Pain Management dated 08/15/25 revealed the facility shall ensure pain management was provided to residents who required such services. The facilities pharmacological interventions shall follow a systemic approach for selecting medications and doses to treat pain. The interdisciplinary team was responsible for developing a pain management regimen specific to each resident. The following principles shall be utilized for prescribing analgesics including consider evidence based practice tools, consider scheduled medications in place of as needed medications for breakthrough pain, utilize the most effective and least invasive route for administration, use lower doses of medication initially and titrate slowly upward, and opioid treatments shall be prescribed and dosed in accordance with professional standards to optimize effects and minimize adverse reactions.

Based on medical record review, staff interview, review of the self-reported incidents and policy review, the facility failed to ensure an injury of unknown origin was timely reported to the state agency. This affected one (#44) of three residents reviewed who had injuries. The facility census was 40. Findings include Based on medical record review, staff interview, review of the self-reported incidents and policy review, the facility failed to ensure an injury of unknown origin was timely reported to the state agency. This affected one (#44) of three residents reviewed who had injuries. The facility census was 40. Findings Include:Review of the medical record for Resident #44 revealed an admission date of 02/01/22 and death/discharge date of 09/11/25. Diagnoses included vitamin D and B12 deficiencies, dementia with behavioral disturbance, malnutrition and Alzheimer's disease late onset.Review of the care plan dated 02/01/22 revealed Resident #44 had the potential for skin impairment related to fragile skin and decreased mobility with interventions to wear geri-sleeves for bilateral arms. Review of the physician orders dated 10/17/23 revealed Resident #44 should be transferred using the Hoyer lift (mechanical lift). On 11/20/24 revealed an order for geri-sleeves or long sleeves for bilateral hands every shift. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) assessment was not completed as resident was rarely/never understood indicating impaired cognition and Resident #44 was dependent for all activities of daily living and mobility. Review of the progress note dated 09/03/25 revealed a skin tear was noted on Resident #44 in the morning measuring five and a half centimeters by one centimeter (cm). The skin tear was cleansed with normal saline and a foam dressing was applied. Hospice was notified and would be in the facility on 09/04/25 to assess. Review of the incident report dated 09/03/25 revealed a Registered Nurse (RN) #200 was alerted of a skin tear (5.5 cm by 1.0 cm). Preview of the progress note dated 09/04/25 revealed staff spoke with Resident #44's daughter about the skin tear found on 09/03/25. The note stated their was an ongoing investigation to ascertain the cause of it. Review of the skin assessment dated [DATE] revealed a laceration to the right upper extremity measuring 5.5 cm by 0.6 cm by 0.1 cm. Review of the self reported incident dated 09/11/25 revealed Residents daughter alleged Resident #44 received a skin tear due to mistreatment. The investigation summary reported the skin tear was identified on 09/03/25 by the aide during the morning shift and the nurse obtained treatment orders. According to the investigation, the resident had a history of striking out at others during care and had an order for geri-sleeves. Resident #44 also used a Broda chair and the investigation found no evidence of abuse or mistreatment. Interview on 12/23/25 at 8:42 A.M. with RN #200 revealed she was informed of Resident #44 having a skin tear. She revealed at the time of the aide report, she was not aware how it occurred and had not asked the staff present if they knew how she obtained the injury. RN #200 stated she assumed it occurred during the Hoyer transfer but acknowledged she had not asked staff. Interview on 12/23/25 at 9:42 A.M. with Certified Nursing Aide (CNA) #99 revealed she observed some blood on Resident #44's arm after a Hoyer transfer and revealed she informed the other CNA also participating in the Hoyer transfer. They lifted the resident's sleeve and found a large skin tear and they informed the nurse. CNA #99 reported no issues during the transfer and no reason to believe it occurred during the Hoyer transfer. She reported she was unsure how the skin tear occurred. Interview on 12/23/25 at 10:34 A.M. with the Director of Nursing (DON) verified RN #200 was given a written disciplinary action due to a delay in reporting an injury of unknown origin. The DON first revealed she was informed of the injury of unknown origin the next day at the care conference with Residents daughter (09/04/25). The DON verified after review of the self reported incident documentation and staff statements Resident #44's family reported concerns to facility during the care conference on 09/11/25. The DON stated it was believed the resident was cut by a buckle on the Broda chair and after doing the investigation that was the cause determined by the facility. The DON also acknowledged if the injury was not known and observed to occur it should be reported timely and then the investigation would be initiated. A follow-up interview on 12/23/25 at 10:56 A.M. with RN #200 verified she filled out the incident report related to the Resident #44's skin tear but reported she had not completed the section asking what happened. She reported that was filled out by another staff after the investigation was completed. Interview on 12/23/25 at 10:56 A.M. with the Assistance Director of Nursing (ADON) #315 verified she updated the incident report reasoning after facility completed the investigation as they did not know how the injury occurred. Interview on 12/23/25 at 11:20 A.M. with the Regional Administrator #250 and the DON revealed the facility felt they could determine the cause of the injury based on the information obtained in the investigation and that Resident #44 had just been transferred by using the Hoyer. She stated it most likely occurred from a buckle from the Broda chair. They acknowledged it was not reported to the state agency until 09/11/25 after family had reported concerns. Interview on 12/23/25 at 1:10 P.M. with CNA #210 reported Resident #44's injury was found after a Hoyer transfer, but reported their was no incident that occurred that would have caused the large skin tear injury during that transfer. CNA #210 reported she was unsure what would have caused the injury. Interviews on 12/23/25 with Hospice staff #360 and #370 reported Resident #44 did not have a skin tear, it was a deep laceration through the subcutaneous tissue. They reported they were not witnessed to care the morning of the transfer prior to the injury being found by staff. They stated Hospice spoke with Resident #44's family as well as the DON and the ADON #315 on 09/04/25 and at that time a cause of the injury was under investigation and had not been determined. Review of the facility policy titled Abuse, Neglect and Exploitation dated 07/2025, revealed facility shall report allegation to the administrator and the state agency within required timeframes. The Administrator shall follow up with state agencies with updates and to report final findings within five days. This deficiency represents non-compliance investigated under Complaint Number 2627023.

Based on medical record review, staff interview, review of the self-reported incidents and policy review, the facility failed to timely investigate an injury of unknown origin. This affected one (#44) of three residents reviewed for injuries. The facility census was 40. Findings include Based on medical record review, staff interview, review of the self-reported incidents and policy review, the facility failed to timely investigate an injury of unknown origin. This affected one (#44) of three residents reviewed for injuries. The facility census was 40. Findings include:Review of the medical record for Resident #44 revealed an admission date of 02/01/22 and death/discharge date of 09/11/25. Diagnoses included vitamin D and B12 deficiencies, dementia with behavioral disturbance, malnutrition and Alzheimer's disease late onset.Review of the care plan dated 02/01/22 revealed Resident #44 had the potential for skin impairment related to fragile skin and decreased mobility with interventions to wear geri-sleeves for bilateral arms. Review of the physician orders dated 10/17/23 revealed Resident #44 should be transferred using the Hoyer lift (mechanical lift). On 11/20/24 revealed an order for geri-sleeves or long sleeves for bilateral hands every shift. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) assessment was not completed as resident was rarely/never understood indicating impaired cognition and Resident #44 was dependent for all activities of daily living and mobility. Review of the progress note dated 09/03/25 revealed a skin tear was noted on Resident #44 in the morning measuring five and a half centimeters by one centimeter (cm). The skin tear was cleansed with normal saline and a foam dressing was applied. Hospice was notified and would be in the facility on 09/04/25 to assess. Review of the incident report dated 09/03/25 revealed a Registered Nurse (RN) #200 was alerted of a skin tear (5.5 cm by 1.0 cm). Preview of the progress note dated 09/04/25 revealed staff spoke with Resident #44's daughter about the skin tear found on 09/03/25. The note stated their was an ongoing investigation to ascertain the cause of it. Review of the skin assessment dated [DATE] revealed a laceration to the right upper extremity measuring 5.5 cm by 0.6 cm by 0.1 cm. Review of the self reported incident dated 09/11/25 revealed Residents daughter alleged Resident #44 received a skin tear due to mistreatment. The investigation summary reported the skin tear was identified on 09/03/25 by the aide during the morning shift and the nurse obtained treatment orders. According to the investigation, the resident had a history of striking out at others during care and had an order for geri-sleeves. Resident #44 also used a Broda chair and the investigation found no evidence of abuse or mistreatment. Interview on 12/23/25 at 8:42 A.M. with Registered Nurse (RN) #200 revealed she was informed of Resident #44 having a skin tear. She revealed at the time of the aide report, she was not aware how it occurred and did not ask staff present if they knew how she obtained the injury. RN stated she assumed it occurred during the Hoyer transfer but acknowledged she did not ask staff. Interview on 12/23/25 at 9:42 A.M. with Certified Nursing Aide (CNA) #99 revealed she observed some blood on residents arm after a Hoyer transfer and revealed she informed the other CNA also participating in the Hoyer transfer. They lifted the resident's sleeve and found a large skin tear and they informed the nurse. CNA #99 reported no issues during the transfer and no reason to believe it occurred during the Hoyer transfer. She reported she was unsure how the skin tear occurred. Interview on 12/23/25 at 10:34 A.M. with the Director of Nursing (DON) revealed she was informed of the injury of unknown origin the next day (09/04/25). The DON verified the facility investigation was started on 09/11/25 after the family reported Resident #44 was mistreated. Interview on 12/23/25 at 10:56 A.M. RN #200 verified she filled out the incident report related to the Resident #44's skin tear but had not completed the section asking what happened. She reported that was filled out by another staff after the investigation was completed. Interview on 12/23/25 at 10:56 A.M. the Assistance Director of Nursing (ADON) #315 verified she updated the incident report reasoning after the facility completed the investigation as they did not know how the injury occurred. Interview on 12/23/25 at 11:20 A.M. the Regional Administrator #250 and the DON revealed the facility felt they could determine the cause of the injury based on the information obtained in the investigation and Resident #44 had just been transferred by using the Hoyer. She stated it most likely occurred from a buckle from the Broda chair. They acknowledged the Self reported incident (SRI) investigation was not started until after 09/11/25 and verified staff and resident interviews were done after 09/11/25. Interview on 12/23/25 at 1:10 P.M. the CNA #210 reported Resident #44's injury was found after a Hoyer transfer, but reported their was no incident that occurred that would have caused the large skin tear injury during that transfer. CNA #210 reported she was unsure what would have caused the injury. Interviews on 12/23/25 with the Hospice staff #360 and #370 reported Resident #44 did not have a skin tear it was a deep laceration through the subcutaneous tissue. They reported they were not witness to care the morning of the transfer prior to the injury being found by staff. They stated Hospice spoke with Resident #44's family as well as the DON and the ADON #315 on 09/04/25 and at that time a cause of the injury was under investigation and had not been determined. Review of the Self Reported incident investigation revealed staff statements were obtained after 09/11/25 with a final summary report dated 09/17/25. The incident had not defined a cause of the injury, but determined the evidence supported abuse and neglect did not occur. Review of the facility policy titled Abuse, Neglect and Exploitation dated 07/2025, revealed the facility shall begin an immediate investigation after a suspicion of abuse and neglect. This should include identifying staff responsible for the investigation, interviews with any witnesses or anyone with knowledge of the allegations and provide documented evidence of a thorough investigation. The Administrator shall follow up with state agencies with updates and to report final findings within five days. This deficiency represents non-compliance investigated under Complaint Number 2627023.

Based on medical record review, hospital record review, interview, observation, review of the mechanical lift instructions, and policy review, the facility failed to use appropriate slings for the mechanical lift and failed to maintain the mechanical lift per the manufacturer's instructions resulting in significant resident injury with mechanical lift transfers. Actual harm occurred on 07/20/25 when Resident #4, who required extensive assistance from two staff members and a mechanical lift with transfers, experienced a fall during a mechanical lift transfer when staff used the incorrect sling and the sling straps broke. The resident was transferred to the emergency room for evaluation and subsequently admitted to the surgical trauma intensive care unit overnight due to multiple rib fractures and a right occipital scalp contusion and hematoma. Additionally, an incident of actual harm occurred on 07/18/25 when Resident #1, who required extensive assistance from two staff members and the use of a mechanical lift with transfers, was transferred from her bed to her wheelchair and was struck in the forehead with the swivel bar of the mechanical lift after the transfer was completed. The resident sustained a laceration to the forehead requiring four staples. This affected two (Resident #1 and Resident #4) of three residents reviewed for falls. The facility census was 48. Findings include: 1. Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, diabetes mellitus, Parkinson's disease, kidney failure, congestive heart failure, syncope and collapse, and mild cognitive impairment.Review of the care plan, dated 07/21/25, revealed the resident had activities of daily living (ADL) self-care deficits related to general decline and collapse and was dependent upon staff for transfers with a mechanical lift. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/27/25, revealed the resident had intact cognition and required physical staff assistance for transfers and mobility. Review of a nursing progress note, dated 07/20/25 at 9:05 A.M., revealed Registered Nurse (RN) #70 was called into the room by a Certified Nursing Assistant (CNA) and observed Resident #4 on the floor, lying on his left side. The CNA (unidentified) stated while using the mechanical lift, the sling broke/ripped and the resident fell to the floor, on his left shoulder, head, neck, left ribs, and left hip. The resident stated it hurt to take a deep breath, and he was tearful. Nine-one one (911) was called. The physician and family were notified. The resident was transported to the Emergency Department (ED).Review of the Fall Investigation/Incident Report revealed on 07/20/25 at 9:05 A.M. revealed Resident #4 was being transferred into bed with a mechanical lift when suddenly the sling broke and the resident fell onto the floor, hitting the left side of his head, neck, ribs, shoulder and hip. The sling being used was not the appropriate mechanical lift sling and was a thin, hospital sling. The immediate intervention implemented was to ensure the correct sling is used. All thin, hospital slings were removed to ensure they would not be used again. Review of the After Visit Summary from the ED dated 07/20/25-07/21/25 revealed the resident was admitted to the Surgical Trauma Intensive Care Unit (ICU) due to fracture of multiple ribs. Imaging tests included computed tomography (CT) of the cervical spine, chest, abdomen, pelvis, maxillofacial, and head, and x-rays of the chest, pelvis, and right knee. The resident sustained an acute mildly displaced fracture of the left sixth lateral rib. There were multiple additional remote bilateral rib fractures. Upon discharge back to the facility, the resident was prescribed oxycodone for pain control.Interview on 08/29/25 at 11:20 A.M. with Resident #4 revealed he fell from the Hoyer lift when the sling broke and he hit his head and broke his rib.Interview with CNA #72 on 08/29/25 at 1:18 P.M. revealed she and another CNA were transferring Resident #4 with the wrong type of sling when it broke during the transfer resulting in the resident falling (from the lift) and caused the resident to hit the floor. CNA #72 stated the sling was already beneath the resident (when they secured the sling to the mechanical/Hoyer lift) and they didn't change the sling to a correct one. Interview on 08/29/25 at 11:59 P.M. with the Assistant Director of Nursing (ADON) confirmed Resident #4 fell during a mechanical lift transfer due to the night shift staff placing an incorrect, thin hospital sling under him. The day shift staff utilized the incorrect sling, and it broke during the transfer resulting in Resident #4 suffering fractured ribs. Review of the manufacturer's pamphlet titled, Electric Patient Lift, revealed specific slings are made for the Electric Patient Lifts. For the safety of the patient, do not intermix slings and patient lifts of different manufacturers.Review of the facility's policy titled, Safe Resident Handling/Transfers, revision date of 07/18/25, revealed it is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Guidelines include ensuring the sling designed for the lift is utilized with that specific lift and two staff members must be utilized when transferring residents with a mechanical lift.2. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, convulsions, mood disorder, heart failure, hemiplegia and hemiparesis, and a history of transient ischemic attack and cerebral infarction.Review of the care plan, dated 01/13/25, revealed the resident had activities of daily living (ADL) self-care deficits related to hemiparesis and was dependent upon staff for transfers with a mechanical lift. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/27/25, revealed the resident was rarely understood and required physical staff assistance for transfers and mobility. The assessment indicated there was impairment on one side of the upper extremities and impairment on both sides of the lower extremities. Review of the Fall Investigation/Incident Report revealed on 07/18/25 at 7:15 A.M. Resident #1 was injured from the Hoyer lift after being placed in a chair. The resident sustained a one to one and a half inch laceration on the top, left area of her head. The wound continued to bleed and 911 was called. Interview with Certified Nursing Assistant (CNA) #62 stated she was moving the mechanical lift away from the chair when the metal part made contact with the resident's head and caused the laceration. The resident received four staples in the ED. The immediate intervention implemented was to fit the mechanical lift cradle swing bar (swivel bar) with padding (as included with the lift as a main component of the assembly) to prevent further injury.Review of a nursing progress note, dated 07/18/25 at 10:16 A.M., revealed Resident #1 was injured this morning while getting out of bed via Hoyer lift and sustained a 1-1.5-inch laceration to the head. The wound was bleeding continuously, and the resident was sent to the emergency department (ED). The resident's daughter was notified. Review of the After Visit Summary from the ED dated 07/18/25 revealed the resident was seen due to a head injury and laceration of the scalp. Imaging tests included computed tomography (CT) of the cervical spine and head, and x-rays of the chest, right femur, right forearm, right hip with pelvis, right humerus, and right tibia fibula. The laceration was closed with four staples. Diphtheria, Tetanus Toxoid, and Acellular Pertussis immunization was administered.Interview with CNA #62 on 08/29/25 at 1:21 P.M. revealed she and CNA #68 transferred the resident from her bed to the wheelchair. At this point, CNA #68 left the room. While moving the mechanical lift away from the wheelchair, CNA #62 stated the metal edge of the cradle hit the resident in the head and she immediately started bleeding from the laceration. CNA #62 stated she applied a towel to the resident's head and called for the nurse. CNA #62 stated to prevent this from happening again she will always have two staff present until the mechanical lift is moved away from the resident. Interview on 08/29/25 at 1:32 P.M. with the Assistant Director of Nursing (ADON) confirmed Resident #1 was struck in the head with the cradle of the mechanical lift when CNA #62 was moving the mechanical lift away from the resident's wheelchair. The ADON stated the intervention put into place following the accident was for padding to be placed on the swing arm of the mechanical lift, as advised in the manufacturer's instructions.Observation on 08/29/25 at 1:45 P.M. of the mechanical lift revealed a swivel bar fabric protective cover that resembled the wrap illustrated in the Electric Lift Patient Manual.Review of the manufacturer's pamphlet titled, Electric Patient Lift, revealed the lift included a swivel bar protective covering as part of the main assembly components.This deficiency represents non-compliance investigated under Complaint Number 2566262.

Based on record review, interview and review of facility policy, the facility failed to develop comprehensive care plans for Resident #10, #12, #15, #34, and #41. This affected five residents (#10, #12, #15, #34, and #41) of 18 records reviewed for care planning. The facility census was 45. Findings include: 1. Review of Resident #34's medical record revealed an admitted [DATE] with diagnoses including major depressive disorder, anxiety disorder, Parkinson's disease, occipital neuralgia, and spondylosis without myelopathy. Review of Resident #34's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had a moderate cognitive impairment. Review of Resident #34's physician order dated 06/05/24 revealed an order for Clonazepam (benzodiazepine) 0.5 milligrams (mg) one tablet by mouth for anxiety. Review of Resident #34's physician order dated 09/01/24 revealed an order for Sertraline (antidepressant) tablet 75 mg by mouth one time a day for depression and anxiety. Review of Resident #34's physician order dated 09/27/24 revealed an order for Lorazepam (anti-anxiety) 0.5 mg for anxiety. Review of Resident #34's plan of care on 11/04/24 revealed it did not address the resident's use of medications for anxiety and depression. Interview on 11/05/24 at 3:19 P.M. with MDS Nurse #113 verified Resident #34's medications for anxiety and depression were not addressed in the care plan. 2. Review of Resident #10's medical record revealed an admitted [DATE] with diagnoses including chronic respiratory failure, hypertension, chronic pain, osteoporosis, unspecified dementia, and chronic obstructive pulmonary disease. Review of Resident #10's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition. Review of Resident #10's physician order dated 10/10/24 revealed an order for chlorthalidone (a diuretic) 25 milligrams one time a day. Review of Resident #10's skin assessment dated [DATE] revealed she had a vascular wound to her left shin and left posterior calf. Review of Resident #10's skin assessment dated [DATE] revealed the resident had a vascular wound to her left calf and her left shin wound had healed. Review of Resident #10's skin assessments dated 10/21/24, 10/28/24, and 11/4/24, revealed the resident's vascular wound to her left calf remained. Review of Resident #10's plan of care on 11/04/24 revealed it did not include the use of diuretics and the resident's vascular wounds. Interview on 11/05/24 at 3:19 P.M. with MDS Nurse #113 revealed she updated care plans quarterly with MDS assessments. She verified there were no wound or diuretic care plans for Resident #10 and there should have been. 49039 3. Review of the medical record for Resident #12 revealed an admitted [DATE] with diagnoses of hypertension, hypothyroidism, anemia, major depressive disorder, gastro-esophageal reflux disease, and muscle weakness. Review of the quarterly MDS assessment completed 09/13/24 revealed Resident #12 had minimal difficulty with hearing when wearing a hearing aid or other hearing appliance and is moderately cognitively impaired. Review of progress notes dated 10/05/24 revealed Resident #12 is scheduled to see the Audiologist on 11/11/24. Review of Resident #12's care plan does not note the current hearing impairment, nor does it include interventions to address or manage this issue. Interview on 11/04/24 at 11:31 A.M. with Resident #12 revealed the resident voiced concerns about her hearing aid, stating that it has been broken for some time and that she has not received any updates regarding its repair or replacement. Resident #12 was unable to provide further details due to severe hearing impairment without the hearing aid. Interview on 11/05/24 at 9:33 A.M. with Scheduling Certified Nursing Assistant (CNA) #133 confirmed that Resident #12 had a hearing aid and requires some assistance with its use. CNA #133 also confirmed the resident is currently experiencing issues with the functioning of the hearing aid. CNA #133 noted Resident #12 is very social and struggles with communication when the hearing aid is not working, as it is extremely difficult for her to engage without it. Interview on 11/05/24 at 3:23 P.M. with MDS Nurse #113 confirmed Resident #12's care plan did not include her hearing impairment, nor were there interventions in place to manage or prevent complications related to her hearing impairment. 4. Review of the medical record for Resident #41 revealed an admitted [DATE] with diagnoses of dementia, metabolic encephalopathy, dysphasia, cerebral infarction, muscle weakness, and insomnia. Review of the MDS assessment completed 10/01/24 revealed Resident #41 is severely cognitively impaired, requires partial/moderate assistance for walking 10 feet and wheeling 50 feet, and had no wander alarms in place. Review of Wandering Risk assessment completed 07/28/24 and 10/01/24 revealed Resident #41 cannot follow instructions, can move independently in a wheelchair, cannot communicate, and had a medical diagnosis of dementia, placing him at high risk for wandering. Review of the care plan revealed no interventions were implemented to prevent Resident #41 from wandering or eloping from the facility. Review of physician orders dated 10/05/24 for Resident #41 revealed new orders stating the resident should never be left alone in his room while in the wheelchair. Interview on 10/07/24 at 9:08 A.M. with ADON #115 revealed Resident #41 was assessed on 07/28/24 and 10/01/24 as being at risk for wandering. ADON #115 confirmed the care plan should reflect the risk of elopement due to wandering, along with interventions to prevent it. 37100 5. Resident #15 was admitted to the facility on [DATE]. Her diagnoses were atrial fibrillation, pain in shoulder, rhabdomyolysis, lymphedema, hypertension., hyperlipidemia, candidiasis, and heart failure. Review of her MDS assessment, dated 10/01/24, revealed she was cognitively intact. Review of Resident #15's current physician orders found that she was prescribed Zoloft (anti-depressant) 25 milligrams (mg) at bedtime for depression, This order was started in June 2024. Review of Resident #15's current care plan revealed no care plan to identify the use of Zoloft (anti-depressant), no interventions or documentation to identify targeted behaviors for the use of an anti-depressant. Interview with MDS Nurse #113 on 11/05/24 at 3:15 P.M. confirmed there was no care plan for the use of Zoloft. She confirmed there should have been a care plan for this medication. Review of the policy, Care Plans-Comprehensive, undated, revealed an interdisciplinary team should develop and maintain a comprehensive care plan for each resident that identified problem areas, incorporate risk factors associated with identified problems, reflecting treatment goals and objectives, identifying the professional services that are responsible for elements of care, prevented declines in the resident's functional status, and enhance the optimal functioning of the resident by focusing on a rehabilitated program. The comprehensive care plan should be developed within seven days of the completion of the resident's comprehensive assessment Care plans were to be revised as changes in the resident's condition dictates.

Based on observation, record review, staff interviews, and resident interviews, the facility failed to ensure all residents received dignified choices to remain in their room. This affected one (Resident #300) out of one resident reviewed for dignity. The facility census was 45. Findings include: Review of the medical record for Resident #300 revealed an admitted [DATE] and diagnoses of hypertension, hyperlipidemia, hypothyroidism, chronic pain syndrome, anxiety disorder, primary insomnia, depression, polyneuropathy, tachycardia, urinary tract infection (UTI), and encephalopathy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #300 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Resident #300 had no behavioral problems. Review of the care plan for Resident #300 revealed a goal that the resident will be free of falls. The intervention stated, personal alarm when in bed or chair at all times. Review of the physician orders for Resident #300 dated 10/15/24 revealed an order for the resident not to be in room by herself and a personal alarm to chair and bed at all times. Review of the progress note for Resident #300 on 10/16/24 at 3:20 P.M. revealed the Assistant Director of Nursing (ADON) found Resident #300 trying to get out of bed without support and noted she would need to be monitored at all times outside of her room. Additionally, on 10/20/24 at 10:57 A.M. a nursing note stated Resident #300 requested to spend time in her room and she was advised by a nurse that she needed to stay with the group at all times for her safety. On 10/24/24 at 9:06 P.M. a nursing note reported Resident #300 was upset and doesn't understand why she can't be in her room by herself. During an interview on 11/04/24 at 11:26 A.M., Resident #300 became visibly upset and cried, she expressed frustration stating she wanted to return to her room more frequently even if just to use the bathroom. Resident #300 reported she hears the staff whispering, don't let her go back to her room. Observation on 11/05/24 from 1:28 P.M. to 1:55 P.M. revealed Resident #300 sitting in her wheelchair sleeping or watching television (TV) in the common area with her personal alarm attached to her gown. Observation on 11/05/24 at 2:30 P.M. revealed Resident #300 sitting back in the common area watching TV During an interview on 11/05/24 at 2:30 P.M., Certified Nursing Assistant (CNA) #157 stated Resident #300 needs more assistance with one-on-one staffing due to a high fall risk, so staff keep her in the common areas for additional help. She stated they do it for her safety and when the resident isn't at an activity with a group, staff usually have her sit in the common area in front of the TV when staff are busy so they can keep an eye on her.

Based on observation, staff interviews, and resident interviews, the facility failed to provide a comfortable, homelike environment for Resident #35. This affected one resident (#35) of six residents reviewed for comfortable living spaces. The facility census was 45. Findings Include: Resident #35 had an admitted [DATE] with diagnoses including retention of urine, hypertension, neuromuscular dysfunction of bladder, age related osteoporosis with current pathological fracture of vertebrae, assistance with personal care, muscle weakness, abnormalities of gait and mobility, insomnia, urinary tract infection, and anxiety disorder. Observations on 11/04/24, 11/05/24, and 11/06/24 revealed a minimum of 11, and a maximum of 12 packages of incontinence briefs stacked and stored along the wall in Resident #35's bathroom. Some packages were opened with briefs scattered randomly about the space on the floor and on top of the unopened packages creating a disorderly, and uncomfortable living space for Resident #35. Interview with Resident #35 on 11/04/24 at 9:52 A.M. confirmed that she didn't like her bathroom being used for storage of her personal incontinence briefs because the bathroom isn't a closet. I've asked them several times to put them in my closet. Resident #35 confirmed that she felt the space was disorderly and uncomfortable due to the briefs being scattered about the bathroom. Interview with Certified Nursing Assistant (CNA) #157 on 11/06/24 at 10:07 AM confirmed that Resident #35 had 11 bags of incontinence briefs stacked and stored in her bathroom, with some briefs scattered randomly about the space on the floor and on top of the unopened packages. CNA #157 stated that staff keep the briefs in the resident's bathrooms for easy access, unless they have a closet large enough to store them. CNA #157 stated that Resident #35 had a small closet, so the briefs were stored in her bathroom.

Based on observation, resident and staff interview, and record review, the facility failed to document ongoing assessments to evaluate the need for the use of physical restraints. This affected two residents (#28 and #300) of eight residents reviewed for the use of restraints. The facility census was 45. Findings include: 1. Resident #28 had an admitted [DATE] with diagnoses including major depressive disorder, cardiac arrhythmia, hypertension, overactive bladder, gastroesophageal reflux disease (GERD), diverticulosis, cognitive communication deficit, and dementia. Review of the care plan dated 11/09/22 for Resident #28 on 11/07/24 at 12:53 P.M. revealed that Resident #28 was a high risk for fall, and had an intervention listed to place a personal alarm to wheelchair and recliner every shift. Review of the medical record for Resident #28 on 11/07/24 at 11:02 A.M. revealed no initial assessment, nor ongoing assessments for the use of alarm devices and/or restraints. Review of the medical record for Resident #28 on 11/07/24 at 12:53 P.M. revealed a progress note entry dated 09/17/24 at 10:13 A.M., Licensed Dietician (LD) #180 documented that on 9/16/24, LD #180 heard Resident #28's chair alarm sounding. LD #180 entered Resident #28's room and found Resident #28 standing in front of her recliner. LD #180 cautioned Resident #28 to sit down in her recliner and Resident #28 did return to sitting position in her recliner. LD #180 educated Resident #28 on use of the call light to get help instead of standing up. Resident #28 agreed. Observation on 11/05/24 at 1:16 P.M. revealed Resident #28 in her room seated in the recliner with non-slip material and a chair alarm visible and in place. Interview with Resident #28 on 11/05/24 at 1:16 P.M. confirmed Resident #28 was aware of the chair alarm, and felt restricted with her voluntary body movement because the alarm would make a loud, audible signal to alert the staff. Resident #28 stated that she wouldn't stand, because if she stood up, the alarm would make a very loud sound that you can hear in the front of the building and they all come running in here! Resident #28 stated that she can still walk, but the office and the nurses won't allow her to walk by herself, or get up by herself so she doesn't fall. Interview with the Director of Nursing (DON) on 11/05/24 at 4:09 P.M. confirmed that the facility does not complete restraint assessments for alarms, because they aren't considered to be restraints. The DON stated that there are physician's orders for the alarms and the nurses check to ensure that they are in place. The DON confirmed the alarms should be used to notify staff of the resident falling, but should not be used to prevent a resident from getting up. 51068 2. Review of the medical record for Resident #300 revealed an admitted [DATE] and diagnoses of hypertension, hyperlipidemia, hypothyroidism, chronic pain syndrome, anxiety disorder, primary insomnia, depression, polyneuropathy, tachycardia, urinary tract infection (UTI), and encephalopathy. Review of Resident #300's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #300 had intact cognition with no behavioral problems. Review of Resident #300's physician orders dated 10/15/24 revealed an order for personal alarm to chair and bed at all times. Review of Resident #300's progress note on 10/16/24 revealed Resident #300 was attempting to get out of bed without support. She was found by the Assistant Director of Nursing (ADON) and was immediately redirected to put her feet back on the bed. The resident will need to be monitored at all times outside of her room. Review of Resident #300's assessments from 10/15/24 to 11/07/24 revealed no evidence of a restraint assessment. Observation on 11/04/24 at 11:26 A.M. revealed Resident #300 sitting on the side of her bed with an alarm in place. Interview on 11/04/24 at 11:26 A.M. with Resident #300 revealed the resident did not like the sound the alarms made, stating, they make an awful noise when I stand up. Observation on 11/05/24 from 1:28 P.M. to 1:55 P.M. revealed Resident #300 sitting in her wheelchair with an alarm in place. Interview on 11/05/26 at 4:08 P.M. with the Director of Nursing (DON) confirmed the facility did not conduct a restraint assessment for Resident #300. Observation on 11/06/24 at 9:15 A.M. revealed Resident #300 sitting in her wheelchair with an alarm in place.

Based on record review, resident family interview, staff interview, and facility policy review, the facility failed to provide the resident or resident representative with a written notice of a bed hold. This affected one (Resident #25) out of two residents reviewed for hospital transfers. The facility census was 45. Findings include: Review of the medical record for Resident #25 revealed an admitted [DATE] with diagnoses of dementia, chronic kidney disease, type two diabetes mellitus, parkinsonism, hypertension and muscle weakness. Review of the admission Minimum Data Set (MDS) 3.0 assessment completed 10/09/24 revealed Resident #25 was moderately cognitively impaired, exhibited no behaviors, and required partial/moderate assistance with toileting and bathing. The resident required substantial/maximal assistance with bed mobility. Review of progress notes dated 10/09/24 revealed Resident #25's wife shared concerns about finances and the resident's long-term stay. She noted that while they had long-term care insurance, it only covered $100 per day, and she was worried they would run out of funds. Review of progress notes dated 10/17/24 revealed Resident #25's wife expressed frustration with the United States of America's medical system, citing that Resident #25 had medical needs and issues their finances could not fully cover. She stated she was very concerned they would run out of money. Review of progress notes dated 10/18/24 revealed Resident #25 was discharged to the local hospital due to a change in condition. The notes indicate the wife will reach out with any questions. However, there was no confirmation a bed-hold notice was given to the family at the time of transfer. Review of bed-hold notice dated 10/18/24 for Resident #25 revealed residents with Medicare will be charged a bed-hold rate of $373.00 per day. However, the notice did not include a signature confirming the resident or their representative had received the bed-hold notice. Interview on 11/06/24 at 9:53 A.M. with Resident #25's wife denied that she or the resident had received a copy of the bed-hold notice, which should have included the daily rate upon transfer to the hospital. The wife stated had she seen the bed rate, it may have influenced her decision regarding the facility's bed-hold policy. She expressed continued concerns about the financial strain of her husband's stay in the facility. Interview on 11/06/24 at 10:02 A.M. with Administrative Coordinator (AC) #102 and #103 said nursing staff are responsible for completing the bed-hold notice before a transfer occurs. This notice is then provided to emergency medical personnel, who are responsible for delivering it to hospital staff. AC #102 and #103 confirmed the medical record for Resident #25 did not contain any evidence indicating the bed-hold notice had been properly delivered to the wife. They further explained all residents transferred out of the facility are required to receive a bed-hold notice, and admission staff are expected to contact the resident's family within 24 hours of transfer to review the bed-hold details. AC #102 and #103 confirmed the wife was called; however, they could not provide documentation to support this. Interview on 11/06/24 at 3:11 P.M. with Registered Nurse (RN) #122 confirmed nursing staff are responsible for completing the bed-hold notice prior to transfer. These notices are handed off to emergency medical personnel along with the resident's medications list. However, RN #122 stated she does not follow up with residents to ensure they receive the bed-hold notice and does not have a system in place to confirm delivery. She also denied completing a bed-hold notice for Resident #25, stating long-term residents are not required to receive the notice since they pay on a monthly rate. Review of bed-hold notice upon transfer policy dated 02/18/24 revealed the facility is required to provide the resident and/or resident representative with written notice specifying the duration of the bed-hold policy, as well as explaining the return of the resident to the next available bed. In the event of an emergency transfer, the facility is to provide written notice within 24 hours. The policy also stated the facility will keep a signed and dated copy of the bed-hold notice in the resident's file.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure Resident #34's dressing changes for a skin tear were completed as ordered. This affected one resident (#34) of two residents reviewed for skin conditions. The facility census was 45. Findings include: Review of Resident #34's medical record revealed an admitted [DATE] with diagnoses including major depressive disorder, anxiety disorder, Parkinson's disease, occipital neuralgia, and spondylosis without myelopathy. Review of Resident #34's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had moderate cognitive impairment. Review of Resident #34's progress note dated 10/26/24 revealed she had a fall and obtained an 'area on the left hand.' She was sent to the hospital due to a different injury. Review of Resident #34's fall investigation dated 10/26/24 revealed she had a fall and received first aide, there was a dressing on the left hand. Review of Resident #34's progress note dated 10/27/24 revealed she returned from the hospital. There were no mentions of her left hand injury. Review of Resident #34's physician order dated 10/28/24 revealed an order related to the left hand skin tear. Nursing was to cleanse the area with normal saline, pat the area dry, apply xeroform and then a nonadherent dressing, and wrap with Kerlix. This was to be done every Monday, Wednesday, and Friday. Review of Resident #34's skin assessment dated [DATE] revealed she had two skin tears to her left palm. One measuring 2.2 centimeters (cm) by 0.2 cm by 0.1 cm and one measuring 3.0 cm by 0.4 cm by 0.1 cm. Observation on 11/04/24 at 9:02 A.M. of Resident #34 revealed her left hand was wrapped in gauze dated 10/30/24. Interview on 11/04/24 at 9:12 A.M. with Certified Nursing Assistant (CNA) #126 verified her bandage was dated 10/30/24. Interview on 11/04/24 at 9:17 A.M. with Licensed Practical Nurse (LPN) #129 reported the treatment nurse was supposed to change her dressing on Monday, Wednesday, and Friday. Interview on 11/07/24 at 9:16 A.M. with the Director of Nursing (DON) verified there were no wound measurements until 10/28/24. Review of the policy 'Wound Treatment Management' dated 02/18/24 revealed wound treatments were to be provided in accordance with physician's orders including frequency of dressing changes.

Based on observation and record review the facility failed to ensure the resident environment remained free of accident hazards by safely storing portable oxygen per the facility policy/procedure. This had the potential to affect one (Residents #38) of one resident reviewed. The facility census was 45. Findings include: Observation on 11/04/24 at 9:22 A.M. revealed three portable oxygen tanks stored in Resident #38's room. Two of the tanks were stored using a transport cart, one tank was freestanding and unsecured, leaning against the wall. Interview with Certified Nursing Assistant (CNA) #157 confirmed the oxygen tanks stored in Resident #38's room were not currently in use, and the one oxygen tank that was freestanding and unsecured, should be on a cart. CNA #157 confirmed the three oxygen tanks should be returned to the designated oxygen storage room. Review of the facility's policy titled, Oxygen Safety dated 02/18/22, and revised on 02/18/24, on revealed the facility's policy was to provide a safe environment for residents, staff, and the public. Compliance guideline number four stated oxygen storage locations shall be in an enclosure, or within an enclosed interior space with doors or gates that can be secured against unauthorized entry. Cylinders should be properly chained or supported in racks or other fastenings (i.e. sturdy portable carts, approved stands) to secure all cylinders from falling, whether connected, unconnected, full, or empty.

Based on record review and interview the facility failed to document nutritional supplement intake and complete an annual nutrition assessment. This affected three (Resident #25, #36 and #41) of eleven reviewed for the use of nutritional supplements. The facility census was 45. Findings include: 1. Review of the medical record for Resident #25 revealed an admitted [DATE] with diagnoses of acute kidney failure, dementia, type two diabetes mellitus, protein calorie malnutrition and parkinsonism. Review of the Minimum Data Set (MDS) assessment completed 10/09/24 revealed Resident #25 was moderately cognitively impaired and required setup or clean-up assistance with eating. Review of weight summary dated 09/25/24 revealed Resident #25 weighed 200 pounds, and on 11/01/24, Resident #25 weighed 189 pounds, reflecting a 5.5% weight loss over a two-month period. Review of Nutrition - Fluids plan of care response history revealed no documented fluid intakes from 10/07/24-11/07/24 for Resident #25. Review of physician orders dated 10/10/24 revealed Resident #25 was ordered to receive Glucerna (nutritional supplement) with meals, with dietary to provide the shake at each meal. Review of the care plan dated 10/10/24 revealed Resident #25 had a nutritional problem or potential nutritional problem. Interventions include providing and serving supplements as ordered: 8 ounces of Glucerna three times a day with meals. Review of Mini Nutritional Assessment completed 10/08/24 revealed Resident #25 had a moderate decrease in food intake, is bed/chair bound, had mild dementia, and a basal metabolic rate of 31 (overweight). These factors placed Resident #25 at a high risk for malnutrition. Interview on 11/06/24 at 11:40 A.M. with Registered Nurse #117 confirmed Resident #25 received Glucerna supplements. She was not responsible for administering the supplement, as dietary staff provided it during meal tray pass. She confirmed she has no way to verify whether the resident actually received the supplement or how much was consumed. The nurse noted that dietary staff documents the amount of food the resident eats, but the amount of the supplement consumed was not recorded. The nurse explained on some days, Resident #25 drinks all of the supplement, while on other days, the resident may drink half or none. Interview on 11/07/24 at 8:57 A.M. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #115 revealed that intakes, specifically the amount of Glucerna consumed, are not available in the electronic medical record. Staff do not document how much of the supplement is consumed; only the percentage of food and drinks the resident eats is recorded. The DON and ADON acknowledged the gap in tracking the resident's complete nutritional intake and confirmed this omission could potentially affect the ability to monitor Resident #25's nutritional progress and needs accurately. Interview on 11/07/24 at 9:06 A.M. with Dietician #111 revealed Resident #25's medical record does not include specific documentation of the amount of supplement consumed. Dietician #111 confirmed that for an accurate reflection of the resident's nutritional status and to ensure appropriate adjustments to the care plan, the intake of supplements should be documented. She confirmed the lack of detailed documentation could result in missed opportunities for timely intervention or adjustments in the resident's care. 2. Review of the medical record for Resident #41 revealed an admitted [DATE] with diagnoses of dementia, metabolic encephalopathy, dysphasia, cerebral infarction, muscle weakness and protein-calorie malnutrition. Review of the MDS assessment completed 10/01/24 revealed Resident #41 is severely cognitively impaired and requires setup or clean-up assistance with eating. Review of Weight Summary revealed on 08/02/24 Resident #41 weighed 142.0 pounds and on 10/25/24 he weighed 145.5 pounds. Review of Nutrition - Fluids plan of care response history revealed no intakes documented from 10/07/24-11/07/24 noting the resident's fluid intakes. Review of physician orders dated 07/30/24 for Resident #41 revealed an order for a Magic cup (nutritional supplement to add calories and protein for those experiencing involuntary weight loss) with meals and an additional order placed on 09/27/24 for Resident #41 to receive Ensure (nutritional supplement) at bedtime. Review of the care plan dated 08/15/24 revealed Resident #41 had a nutritional problem of underweight basal metabolic rate, significant unplanned weight loss, and inadequate oral intake of food and beverages. Interventions included providing and serving supplements as ordered and monitoring intakes, recording every meal. Review of Medical Nutritional Therapy assessment dated [DATE] revealed Resident #41 was underweight, needs improved oral intake with supervision at meals, had chewing and swallowing problems, and required improvement in meal intake to 75%. Magic cups were consumed three times daily to meet needs. Interview on 11/07/24 at 8:57 A.M. with the DON and ADON #115 revealed intakes, specifically the amount of Ensure and Magic cups consumed, are not available in the electronic medical record. Staff do not document how much residents drink of the supplements; they only record the percentage of food and drink they consume as a whole on the tray. The DON and ADON acknowledged the gap in tracking the resident's full nutritional intake. They confirmed the omission could potentially affect the ability to monitor Resident #41's nutritional progress and needs accurately. Interview on 11/07/24 at 9:06 A.M. with Dietician #111 revealed Resident #41's medical record does not include the specific amount of the supplement he drinks. Dietician #111 stated in order to have an accurate reflection of the resident's nutritional status and ensure appropriate adjustments to the care plan, the intake of supplements should be fully documented. She confirmed this lack of detailed documentation could potentially lead to missed opportunities for intervention or adjustment in the resident's care. 37100 3. Resident #36 was admitted to the facility on [DATE]. Her diagnoses were hypertension, anemia, atherosclerotic heart disease, overactive bladder, acute respiratory failure, osteoporosis, cognitive communication deficit, and cerebral infarction. Review of the MDS assessment dated [DATE] revealed Resident #36 had a severe cognitive impairment. Review of Resident #36's nutritional assessments found her most recent assessment was completed on 06/01/23. There was not another assessment completed until 11/05/24. Review of Resident #36's physician/nutritional orders, dated 10/22/24, revealed an order for Ensure with dinner. There was nothing listed in the order or nutritional notes to indicate how much Ensure was to be given to Resident #36 during dinner. Review of Resident #36's Medication Administration Records (MAR) dated October 2024 to November 2024, revealed no documentation to support how much of the Ensure Resident #35 consumed during each offering. Interview with Dietitian #180 on 11/05/24 at 3:00 P.M., 3:35 P.M. and 11/06/24 at 9:30 A.M. confirmed she did not complete an annual nutritional assessment as required for Resident #36. She confirmed the assessments had been completed on 06/01/23 and 11/05/24. Also, she confirmed there was no documentation to support the amount of nutritional supplement Resident #36 consumed each time it was given; she stated she will simply monitor weights and determine if a new interventions should be put in place. Interview with Registered Nurse (RN) #117 on 11/06/24 at 10:20 A.M. confirmed they do not document the amount of a nutritional supplement consumed by a resident; they simply document if it was provided to the resident or not.

Based on record review and staff interview, the facility failed to follow ordered medication administration parameters, and failed monitor a resident for side effects of anticoagulant use. This affected two (Resident #33 and Resident #25) of six resident reviewed for medications. The facility census was 45. Findings include: 1. Review of the medical record for Resident #33 revealed an admitted [DATE] with diagnoses of pseudomonas, muscle weakness, type II diabetes, anxiety disorder, paroxysmal atrial fibrillation, hypertension, hyperlipidemia, primary osteoarthritis, glaucoma, protein calorie malnutrition, and urinary tract infection (UTI). Review of the Minimum Data Set (MDS) assessment completed 09/27/24 revealed a Brief Interview for Mental Status (BIMS) score of nine indicating the resident had cognitive impairment with no behavioral problems in place. Review of Resident #33's care plan dated 09/09/24 revealed the resident had hypertension and atrial fibrillation and will remain free of complications. Interventions included give anti-hypertensive medications as ordered. Review of Resident #33's physician order dated 09/09/24 revealed Sotalol (antiarrhythmic that can decrease blood pressure) tablet 80 milligrams (mg) by mouth one time daily for hypertension, hold if blood pressure is less than 110/70 or heart rate is less than 60. Review of Resident #33's Medication Administration Record (MAR) from 10/01/24 to 11/07/24 revealed Resident #33 received Sotalol 80 mg on days when the blood pressure (BP) was outside the ordered parameters for administration as follows: 10/02/24 BP 109/60, 10/09/24 BP 98/56, 10/16/24 BP 93/74, 10/21/24 BP 111/65 medication held, 10/30/24 BP not taken, 10/31/24 BP not taken, 11/01/24 BP not taken, 11/02/24 BP not taken, 11/03/24 BP not taken, 11/04/24 BP not taken. Additionally, Resident#33's MAR did not have any documentation of the resident's pulse being taken at the time of the Sotalol administration for any of the doses provided. Interview on 11/06/24 at 9:40 A.M. with the Director of Nursing (DON) revealed the nursing staff will follow the parameters for medication administration prior to administering medications to the residents. The DON confirmed Sotalol was being administered outside of the parameters for Resident #33. 49039 2. Review of the medical record for Resident #25 revealed an admitted [DATE] with diagnoses of acute kidney failure, dementia, type two diabetes mellitus, protein calorie malnutrition, atrial fibrillation, atrioventricular block and parkinsonism. Review of the MDS assessment completed 10/09/24 revealed Resident #25 was moderately cognitively impaired, had a diagnosis of atrial fibrillation or other dysrhythmias, and was prescribed an anticoagulant. Review of physician orders dated 09/27/24 revealed an order for Rivaroxaban (anticoagulant) 15 milligrams by mouth in the evening for atrial fibrillation. Additional orders dated 10/28/24 indicated a change to Apixaban (anticoagulant) 2.5 milligrams orally, twice a day, for atrial fibrillation. Review of the care plan dated 10/18/24 revealed that Resident #25 was on anticoagulant therapy for atrial fibrillation. Interventions included daily skin inspection, monitoring for abnormal bleeding or bruising, and documenting any adverse reactions related to anticoagulant therapy. Review of the medical record from 09/27/24 to 11/04/24 revealed no documentation indicating the monitoring of bleeding or bruising was completed due to anticoagulant therapy for Resident #25. Review of physician orders dated 11/05/24 for Resident #25 revealed updated orders to monitor for prolonged signs of bruising or bleeding, including daily checks for bleeding or bruises due to anticoagulant therapy, in accordance with recommended clinical practices for anticoagulant use. Interview on 11/05/24 at 1:33 P.M. with the Administrator confirmed that documentation supporting the monitoring of bleeding or bruising due to anticoagulant therapy was not available in the medical record. Interview on 11/07/24 at 8:59 A.M. with Assistant Director of Nursing #115 confirmed that the medical record did not include evidence supporting the monitoring of increased bruising and/or bleeding for Resident #25. This monitoring is typically part of routine anticoagulant management to prevent undetected complications.

Based on medical record review and staff interview, the facility failed to adequately identify and monitor targeted behaviors for residents who use psychotropic medications. This affected one (Resident #15) of five residents reviewed for unnecessary medications. The census was 45. Findings include: Resident #15 was admitted to the facility on [DATE]. Her diagnoses were atrial fibrillation, pain in shoulder, rhabdomyolysis, lymphedema, hypertension., hyperlipidemia, candidiasis, and heart failure. Review of Resident #15's Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. Review of Resident #15's current physician orders found she was prescribed Zoloft (anti-depressant) 25 milligrams (mg) at bedtime for depression. This ordered was started in June 2024. Review of Resident #15's current care plan revealed no care plan to identify the use of Zoloft, nor any interventions or documentation to identify targeted behaviors for the use of an anti-depressant. Review of Resident #15's behavior tracking documents dated 10/07/24 to 11/06/24 revealed the following behaviors were listed on the tracking form: frequent crying, repeated movements, yelling/screaming, kicking/hitting, pushing, grabbing, pinching/scratching/spitting, biting, wandering, abusive language, threatening behavior, sexually inappropriate, rejection of care, none of the above observed, resident not available, resident refused, and non applicable. There was nothing listed within the behavior tracking document nor other medical documents that identified specific/targeted behaviors for Resident #15's use of Zoloft. Interview with MDS Nurse #113 on 11/05/24 at 3:15 P.M. confirmed there was no care plan for the use of Zoloft. She confirmed there should have been a care plan for this medication. She confirmed there was no care plan or documentation to support targeted behaviors for Resident #15's use of Zoloft. Interview with Director of Nursing (DON) on 11/05/24 at 3:45 P.M. confirmed the facility documented behaviors on a hard copy log for each resident. She confirmed they do not individualize the behavior tracking logs, they have all possible behaviors listed on it. She confirmed there were no identified targeted behaviors listed or being tracked/monitored for Resident #15.

Based on observation, staff interview, and record review, the facility failed to remove, inactivate, or destroy pathogenic organisms on the surface of a multi-use device (glucometer) to the point where it was rendered safe for handling and re-use. This had the potential to affect three residents (#9, #297, #25) receiving glucometer checks on the Skilled Unit. The census was 45. Findings include: Observation on 11/06/24 at 11:46 A.M. of Registered Nurse (RN) #117 completing a finger stick blood glucose stick (FSBS) on Resident #297 revealed prior to going into the resident room, RN #117 swiped the top of the glucometer with a sani wipe, and then entered Resident #297's room, placed the glucometer on the over bed table without placing a barrier on the table, performed the FSBS check, exited the room after performing hand hygiene and then placed the glucometer on top of the medication cart without the use of a barrier. RN #117 then documented the FSBS in the electronic health record and placed the glucometer in the top drawer of the medication cart without cleansing or sanitizing the glucometer. Interview with RN #117 after she placed the glucometer in the medication cart confirmed there was one glucometer used for the three residents on the skilled unit who required FSBS checks. RN #117 verified she had completed the FSBS procedure. When asked if she sanitized the glucometer prior to placing it back in the medication cart she verified she had not. Observation of the sani-wipe container with the RN at this time also confirmed the manufacturer's direction for dry time on the sani-wipe used to swipe the top of the glucometer prior to the procedure required a two-minute dry time. The nurse confirmed the glucometer was just swiped and did not have the two minute dry time as recommended by the manufacture. Review of the facility's policy titled Glucometer Policy and Procedure, undated, on 11/06/24 at 2:12 P.M. revealed that the policy of the facility is to prevent the spread of bloodborne pathogens. The policy listed recommendations (guidance) for cleaning and decontamination of glucometers that may be contaminated with blood and body fluids. The recommendations included to clean and disinfect glucometers if they must be reused between patients, disinfect the exterior surfaces of the glucometer after each use (even if there is no visible blood or soil) following the manufacturer's directions.

Based on record review and interview the facility failed to follow guidance within their antibiotic stewardship program to ensure antibiotics were ordered appropriately. This affected two (Resident #33 and #101) out of three reviewed for appropriate antibiotic usage. The facility census was 45. Findings include: 1. Review of the medical record for Resident #101 revealed an admitted [DATE] with diagnoses of spinal stenosis, Crohn's disease, anxiety, urinary tract infection, osteoporosis and anemia. Review of Minimum Data Set (MDS) 3.0 assessment completed 09/13/24 revealed Resident #101 was cognitively intact, required substantial to maximal assistance with toileting, and was occasionally incontinent of urine. Review of hospital records dated 09/06/24 revealed Resident #101 was admitted for elective decompression and fusion of the L3-L5 vertebrae. Complications during the hospital stay included acute-on-chronic anemia and a urinary tract infection (UTI) (possibly present on admission). It was noted the UTI was suspected to have developed during the hospital stay, although it was unclear whether symptoms of dysuria or increased urinary frequency were present at admission. No culture and sensitivity testing was performed. Review of admission vitals from 09/06/24 revealed no concerns for fever or increased temperature. The hospital record showed Resident #101 received the first dose of Macrobid (antibiotic) on 09/06/24 at 9:16 A.M. Review of the Medication Administration Record (MAR) for September 2024 showed Resident #101 received Macrobid 100 mg capsules, administered by mouth two times a day for infection. The second dose was given on 09/06/24 at 9:00 P.M., with a discontinue dated of 09/08/24 at 9:00 A.M. Review of the Temperature Summary from admission to 09/19/24 revealed no abnormal temperatures. Review of the infection control log dated 09/06/24 to 09/30/24 revealed Resident #101 had a community-acquired urinary tract infection (UTI) with an onset date of 09/06/24, acquired during hospitalization . The prescribed antibiotic therapy was Macrobid 100 mg, two times a day for two days, as ordered by the hospital. Review of the Revised McGeer Criteria for Infection Surveillance Checklist dated 09/06/24 for Resident #101 revealed the infection checklist had not been completed and had not noted appropriate antibiotic usage according to McGeer criteria for urinary tract infections. McGeer criteria for prescribing antibiotics require the presence of either: -Marked acute dysuria or pain, swelling, or tenderness, and fever with at least one of the following symptoms: suprapubic pain, gross hematuria, increased incontinence, increased urgency, or frequency; OR if there is no fever or leukocytosis, then at least two of the above symptoms must be present. -Additionally, a urine sample must show greater than or equal to 10,000 CFU/mL (colony-forming units per milliliter) or no more than two species of organisms. Review of Resident #101 medical revealed she did not meet these criteria. No symptoms such as fever, suprapubic pain, or increased incontinence were documented, and a urine culture was not obtained to support the diagnosis. Therefore, the decision to prescribe antibiotics was not fully aligned with the McGeer criteria for UTI management. Interview on 11/07/24 at 8:44 A.M. with Assistant Director of Nursing (ADON) #115 confirmed Resident #101 did not meet the McGeer criteria for antibiotic usage. ADON #115 explained that, despite not meeting the criteria, there are constant difficulties in obtaining lab results from the hospital once residents admit to the facility. She confirmed that she did not have the necessary lab results for Resident #101 to confirm whether the antibiotic usage was appropriate nor documentation supporting these records were requested. Furthermore, the medical record did not indicate physical signs or resident complaints consistent with a urinary tract infection, such as dysuria, fever, or increased urinary frequency. ADON #115 stated that she did not see the need to discontinue the antibiotics ordered by the hospital, given that the UTI diagnosis was made during hospitalization and antibiotic treatment had already been initiated. 51068 2. Review of the medical record for Resident #33 revealed an admitted [DATE] with diagnoses of pseudomonas, muscle weakness, type II diabetes, anxiety disorder, paroxysmal atrial fibrillation, hypertension, hyperlipidemia, primary osteoarthritis, glaucoma, protein calorie malnutrition, and urinary tract infection (UTI). Review of end of protective payment stay (PPS) part A stay Minimum Data Set (MDS) Assessment completed 9/27/24 revealed a brief interview for mental status (BIMS) score of 09 indicating the resident had cognitive impairment with no behavioral problems in place. Review of progress note on 10/17/24 revealed Resident #33 started experiencing hallucinations and his son stated, that is his behavior when UTI is started. An order for stat urine was obtained. Urine was collected per straight catheterization. Review of the physician orders on 10/17/24 revealed orders to obtain a urine analysis. Review of progress note on 10/18/24 the urine sample was sent to the lab for analysis and culture. MD was notified and ordered to start Keflex three times daily, two days prior to receiving the urine culture results. Review of the infection log confirmed Resident #33 had an identified organism of pseudomonas aeruginosa with date of onset on 10/18/24. Review of physician orders start date 10/18/24 and end date 10/21/24 revealed Keflex oral capsule 500 milligram by mouth three times daily. Review of the lab results for the urine culture was collected by American health associates was collected on 10/18/24 and reported on 10/21/24. Review of progress note on 10/21/24 the physician was notified of the urine analysis lab results. Review of physician orders revealed the resident was ordered to have Cipro oral tablet 250 milligrams by mouth three times daily, with a start date 10/21/23 and discontinued date 10/23/24. Review of physicians note on 10/23/24 revealed due to the urine culture results the physician changed the antibiotic from Cipro to Cefepime due to the urine culture results. Review of physician orders revealed Cefepime Hydrochlorothiazide (HCI) injection solution reconstituted one gram injected intramuscularly every 12 hours, with a start date 10/24/24 and completed date 10/29/24. Review of the progress note on 10/30/24 revealed Resident #33's son was concerned about the resident's confusion and the doctor advised three more days on Cefepime and placed the order. Review of the physician orders revealed Cefepime Hydrochlorothiazide (HCI) injection solution reconstituted one gram injected intramuscularly every 12 hours, with a start date of 10/31/24 and completed date 11/01/24. Review of the physician orders on 11/01/24 revealed orders to obtain a urine analysis stat. Review of progress note on 11/01/24 revealed clean catch urine is ready for stat pickup. Review of progress note on 11/04/24 revealed the stat order had not been received. Review of the Medication Administration Record (MAR) revealed the first dose of Keflex began on 10/18/24 and ended on 10/21/24. Additionally, revealed the first does of Cipro began 10/21/24 and ended on 10/23/24, and the first dose of Cefepime began 10/24/24 and ended on 10/28/24. The second order of Cefepime began 10/31/24 and ended 11/02/24. Review of the care plan dated 09/09/24 for Resident #33 revealed the resident's risk for septicemia will be minimized/prevented via prompt recognition and treatment of symptoms of UTI with interventions including monitoring/document for signs and symptoms of UTI. Review of the medical record revealed no evidence of a urine culture to support a diagnosis of a UTI prior to the start of Keflex or the extension of Cefepime. Interview on 11/06/24 at 9:22 A.M. with LPN #129, confirmed when a UTI is suspected after a resident has signs and symptoms of a UTI they will notify the doctor to let them know what symptoms they are seeing. The physician will order a urine analysis and await the results and notify the responsible party of the order. Once the order is received, the physician will prescribe an antibiotic based on the results of the culture and notify the responsible party of the medication. Interview on 11/06/24 at 9:30 A.M. with director of nursing (DON), confirmed the process for UTI's is to wait for a urine analysis result prior to administering any medications directed towards a UTI. DON confirmed the physician was waiting for the results from the urine culture and the physician started Resident #33 on Keflex. DON stated once the culture came back it appeared to be something different, so they switched him to Cipro. DON stated they switched him to Cefepime because Cipro was causing more confusion. The urine analysis stat request was sent on 11/1/24. DON reported they contacted the lab on 11/04/24 but the culture was still not available. Review of the revised McGeer criteria for infection surveillance checklist revealed that a UTI without indwelling catheter requires both signs and symptoms and microbiologic criteria prior to administering antibiotics.

Based on personnel record review and staff interview, the facility failed to ensure a nurse had a valid license. This affected one (Former Staff #59) of 23 nurses who work in the long term care section of the facility. Findings include: Review of Former Licensed Practical Nurse (LPN) #59 by the Board of Nursing on an unrelated matter revealed LPN #59 was employed by the facility without a valid state license. It was determined by the Board of Nursing through the e-license system that LPN #59 was issued a temporary LPN license under Ohio Governors Covid 19 Omnibus Amendment. LPN #59 failed to complete the NCLEX exam within the 90 day period and his license was closed and abandoned as of 03/01/21. LPN #59 continued to work as a nurse at the facility until 05/07/23 without a valid state license. Review of LPN #59's personnel file revealed a hire date of January 2021. The facility verified LPN #59's license on on 01/07/21 which documented LPN #59's license was current through 10/31/22. There was no indication LPN #59 had a temporary license due to COVID 19 and still needed to take his NCLEX exam. Review of license checks revealed the facility checked for current licenses on 08/24/22. In February they identified they missed checking LPN #59's license. On 02/28/23 at 2:26 P.M., LPN #59's license check was done and the license was listed as closed, sub status abandoned. The license issue date was 12/24/20 and expiration date 03/01/21. Review of the payroll records revealed LPN #59's last day of work was 05/07/23. Review of the termination notice revealed LPN #59 was terminated 05/10/23 for not having a current license. During an interview 05/26/23 at 2:18 P.M., Human Resource Staff #60 stated when LPN #59 was hired, the facility did not know he had a temporary license. She does not check the licenses every two years to see if they are current. The facility discovered there was an issue with LPN#59's license when an employee called in a complaint to the board for an unrelated matter. During interview 05/26/23 at 5:22 P.M., the Director of Nursing (DON) stated the Assistant Director of Nursing (ADON) did a license check on LPN #59 in February, but neither she or the ADON read the report. They verified licenses in August 2022 and should have checked in October, because they expire the end of October. During an interview 05/26/23 at 5:30 P.M., the Administrator stated LPN #59 had been employed without a valid nursing license. This deficiency represents non-compliance investigated under Complaint Number OH00142799.