Every finding on record at Wilmington Nursing & Rehab

Based on observation, interview, and policy review, the facility failed to ensure food was distrubuted under sanitary conditions. This had the potential to affect all residents. The facility census was 63.Findings include:Observation on 06/09/2026 at 7:33 A.M. to 7:43 A.M. revealed [NAME] #230 preparing bacon for residents' meal trays. [NAME] #230 was grabbing the bacon using gloved hands and no tongs. [NAME] #230 also grabbed paper slips, trays, plates, and plastic wrappers with doughnuts while she continued grabbing the bacon with the same gloved hands. Interview at the time of the observation [NAME] #230 confirmed not using tongs to prepare the bacon. [NAME] #230 stated the gloves should have been changed after touching other items and surfaces. [NAME] #230 stated they only have two tongs in the kitchen and she does not use them for the bacon.Interview on 06/09/2026 at 7:43 A.M. with the Dietary Manager #226 confirmed gloves should be worn when preparing plates with bacon for residents. Review of the policy titled Employee Sanitary Practices, dated 02/12/26, revealed use utensils to handle food whenever possible.Review of the policy titled Food Preparation and Handling, dated 03/28/25, revealed food items are prepared by methods designed to maintain safe temperatures, avoid cross contamination, prevent food borne illness, conserve maximum nutritive value, and develop and enhance flavor. Food will be served with clean tongs in order to avoid manual contact of prepared foods.

Based on observation, record review, interview, and facility policy, the facility failed to ensure medications were administered with a medication error rate less then 5%. This affected three (#28, #41, and #62) residents observed during medication administration. A total of 29 medication opportunities with three errors were observed for total error rate of 10%. The facility census was 63. Findings include: 1.Review of the medical records for Resident #28 revealed an admission date of 01/03/25. Diagnoses included dementia, peripheral vascular disease, and Alzheimer's disease. Review of physician orders dated 02/18/26 revealed Resident #28 had an order memantine 5 milligrams (mg) two tablets twice a day. Observation on 06/10/26 from 7:20 A.M. through 7:26 A.M. with Registered Nurse (RN) #274 revealed she administered medications to Resident #28. Medications administered included aspirin 81 mg one tablet, furosemide 20 mg one tablet, memantine 10 mg two tablets, and tamsulosin hydrochloride (HCL) 0.4 micrograms (mcg) one tablet. Interview on 06/10/26 at 10:10 A.M. RN #274 verified she administered two tables of memantine 10 mg to Resident #28, for a total dose of 20 mg. RN #274 verified Resident #28's physician order was for memantine 5 mg take two tablets. RN #274 verified the medication card had memantine 10 mg one tablet on the label. 2.Review of medical records revealed Resident #41 had admission date of 04/29/24. Diagnoses included Parkinson's disease with dyskinesia and moderate protein calorie malnutrition. Review of physician order dated 05/27/26 revealed Resident #41 had an order for cimetidine 200 mg two tablets every day. Observation on 06/10/26 from 7:28 A.M. through 7:31 A.M. with RN #274 administered medication to Resident #41. Medications administered included: carbidopa-levodopa 25-100 mg one tablet, cimetidine 200 mg one tablet, memantine 10 mg one tablet, citalopram 100 mg one tablet, and medroxyprogesterone acetate 10 mg three tablets. Interview on 06/10/26 at 10:10 A.M. RN #274 verified Resident #41 had a physician order for cimetidine 200 mg take two tablets. 3.Review of medical record for Resident #62 revealed an admission of 04/30/26. Diagnoses included type two diabetes, morbid obesity, anemia, and depression. Review of physician's order dated 05/01/26 revealed Resident #62 had an order to take furosemide 20 mg two tablets every day. Observation on 06/10/26 from 7:55 A.M. through 8:08 A.M. with RN #273 administered medication to Resident #62. Medications administered included the following: aspirin 81 mg one tablet, cetirizine 10 mg one tablet, Vitamin D3 25 mcg two tablets, Plavix 75 mg one tablet, Vitamin B-12 100 mg gave five tablets, famotidine 20 mg one tablet, iron 325 (65 mg) one tablet, furosemide 20 mg one tablet, glipizide 5 mg extended release one tablet, Jardiance 25 mg one tablet, losartan potassium 100 mg one tablet, Magnesium oxide 400 mg one tablet, metformin 500 mg one tablet, metoprolol succinate extended release 25 mg one tablet, and MiraLAX 17 grams in water. Interview on 06/10/26 at 10:20 A.M. RN #273 verified Resident #62 had only received furosemide 20 mg one tablet with the morning medication. RN #273 verified Resident #62 had a physician order for furosemide 20 mg take two tablets. There were a total of three medication errors out of 29 opportunities for error for a medication error rate of 10 %. Review of the facility document titled General Dose Preparation and Medication Administration, dated 12/01/2007, revealed staff should verify each time a medication was administered that it was the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. This deficiency represents non-compliance investigated under Complaint Numbers 2742658, 2701109, 2722052, 2686679, 2670992, and 2710111.

Based on record review, observation, interview, and policy review, the facility failed to maintain an effective infection control program. This affected seven (#8, #12, #13, #23, #55, #62, and #84) out of 25 residents reviewed during the survey. The facility census was 63. Findings include: 1. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of bladder, unspecified, severe protein-calorie malnutrition, hypo-osmolality and hyponatremia, and anxiety disorder, unspecified. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 had cognitively intact, substantial assistance with toileting, partial assistance with bathing, and substantial assistance with personal hygiene. Review of the provider orders dated 04/15/26 for Resident #8 revealed isolation/transmission-based precautions for an indwelling urinary catheter. Review of the care plan dated 04/20/26 for Resident #8 revealed the resident has infection control risk and requires enhanced barrier precautions (EBP) for an indwelling urinary catheter. Interview on 06/09/2026 at 10:58 A.M. with Registered Nurse (RN) #301 revealed she wasn't sure what EBP stood for or what it was and did not know if Resident #8 was in EBP. Interview and observation on 06/09/2026 at 11:01 A.M. with RN #274 confirmed there was no sign near Resident #8's room, no personal protective equipment (PPE) inside or outside of Resident #8's room and Resident #8 was not in EBP. Interview on 06/09/2026 at 11:20 A.M. with the Director of Nursing (DON) verified no EBP are in place for Resident #8. Interview on 06/09/2026 at 11:17 A.M. with Certified Nursing Assistant (CNA) #300 revealed they have been working here for a month and no EBP has been in place for Resident #8 and no PPE has been worn for Resident #8's personal care. Review of the policy titled Enhanced Barrier Precautions, dated 04/15/26, revealed staff engaging in high contact activities will don both gloves and gown before initiating the activity and remove PPE before exiting the room or area where the activity occurred. Signage indicating the appropriate type of precautions and indicating that visitor should stop at nurses station before entering will be placed on the resident's door. EBP are indicated for high contact activities for high risk residents. High risk residents are those with indwelling catheters. 2. Review of medical records revealed that Resident #13 had admission date 11/22/23. Diagnoses included obstructive and reflux uropathy, neuromuscular dysfunction of bladder, benign prostatic hyperplasia with lower urinary tract symptoms, and urine retention. Review of physician order dated 09/12/25 revealed Resident #13 had an order for isolation and transmission-based precautions every shift, due to having urinary catheter. Review of physician order dared 05/28/26 revealed Resident #13 had an order to cleanse suprapubic catheter site with soap and water and leave open to air twice a day. Review of medical records revealed Resident #55 had an admission date 12/02/24. Diagnoses included type two diabetes, hemiplegia and hemiparesis following cerebral infarction, vascular dementia, and adult failure to thrive. Observation on 06/09/26 at 9:50 A.M. revealed CNA #252 provided suprapubic catheter care to Resident #13. CNA #252 had PPE on including gloves. When CNA #252 was finished with Resident #13's care she was looking for the trash bags. CNA #252 left Resident #13's side of his room and went to Resident #55's side looking for the trash bags. CNA #252 used her dirty gloves and gown to check Resident #55's recliner for the roll of trash bags. CNA #252 touched Resident #55's recliner and two pillows sitting on the recliner with her dirty gloves. Interview on 06/09/26 at 9:52 A.M. CNA #252 verified she did use her dirty gloves to touch Resident #55's recliner and two pillows when looking for the trash bag roll. CNA #252 verified this was cross contamination and she should have disposed of dirty PPE and gloves and performed hand hygiene before touching another resident's property. 3. Observation on 06/09/26 at 12:24 P.M. revealed the treatment cart on the A Hall had a trash can with no lid. There were blue gowns and gloves in the trashcan. Interview at the time of the observation with RN #271 verified the treatment cart had a trash can with no lid. RN #271 verified there were three dirty personal protective gowns and dirty surgical gloves in the trash can and they should have had a lid on them. RN #271 stated she performed treatments that day but had not seen the trash on the treatment cart. RN #271 stated it was not her PPE. Review of the facility policy titled Waste Disposal Policy, dated 06/05/2018, revealed that the facility trash and garbage will be disposed of as needed through the day, and at the end of the day. Prior to disposal, all waste shall be kept in leak proof, non-absorbent, fireproof containers that are kept covered when not in use. The facility identified three ambulatory residents on the A Hall (#12, #23, and #84). 4. Observation on 06/10/26 from 7:55 A.M. through 8:07 A.M. revealed RN #273 who was preparing medication at the medication cart for Resident #62. RN #273 had removed Resident #62's glipizide extended release medication from the medication card. The pill fell on top of the medication cart and into the first drawer that was opened a few inches. RN #273 preceded to use her bare hands to pick the pill up. Then she placed the pill in the medication cup she had ready for Resident #62. Then RN #273 removed the Jardiance 25 mg from the medication card. The pill fell on top of the medication cart. RN #273 picked up the Jardiance pill with her bare hand and placed the pill in Resident #62's medication cup. Interview on 06/10/26 at 8:04 A.M. RN #273 verified she dropped one pill on top of the medication cart and it then rolled into the first drawer of the cart. RN #273 verified she picked it up with her bare hands and placed in a medication cup. RN #273 verified the Jardiance pill had fallen on top of the medication cart. RN #273 verified she used her bare hands to pick up the Jardiance pill and placed it in medication cup. Interview on 06/10/26 at 11:10 A.M. the Director of Nursing (DON) stated she expected nurses to administer medication that was not dropped or touched with hands and use hygiene when preparing medication for any resident for medication pass. Review of the facility document titled General Dose Preparation and Medication Administration, dated 12/01/2007, revealed medications should not come in contact with any surface except for the medication cup. Facility staff should avoid touching the medication with bare hands when opening a bottle or unit dose package. If a medication which was not in a protective container was dropped, facility staff should discard it according to the facility policy.

Based on observation, interviews, record review, and policy review, the facility failed to provide timely pain management for one (#85) out of three residents reviewed for pain management. The facility census was 63. Findings include:Review of medical records for Resident #85 revealed an admission date of 06/08/26 at 11:30 P.M. Diagnoses included complete traumatic amputation hip and knee, peripheral vascular disease, type two diabetes, and abdominal hernia without obstruction or gangrene. Review of the physician orders dated 06/09/26 revealed Resident #85 had an order for Tylenol 325 milligram (mg) two tablets every six hours routine. Times to be administered were 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. Also, Resident #85 had an order for oxycodone/acetaminophen 10-325 mg take one tablet as needed every six hours. Review of the medication administration record dated 06/09/26 revealed that Resident #85 had not been administered Tylenol 325 mg two tablets at 12:00 P.M. Review of Resident #85's vital sign form revealed on 06/09/26 at 2:16 P.M. the resident's pain was assessed to be zero out of 10 pain (zero being no pain and 10 being the worst pain ever) Review of the medication administration record dated 06/09/26 revealed the pain assessment for day shift time, 7:00 A.M. through 7:00 P.M., documented Resident #85's pain was marked a zero. Non-pharmacological intervention provided was marked for rest. Observation and interview on 06/09/26 at 2:20 P.M. Resident #85 was sitting up in her wheelchair. Resident #85 made a groan noise. Resident #85 stated she had alot of pain in her left leg from her amputation. Resident #85 stated the last time she had received pain medication was the prior night and she was given Tylenol. Resident #85 stated she was supposed to be getting oxycodone/acetaminophen 10 mg-325 mg and she was taking is at the hospital before she came. Resident #85 had stated the nurse the prior night said she was ordering the medication right away so it would be here in this morning. Resident #85 stated she had not received any oxycodone/acetaminophen at the facility and has only been given Tylenol. Resident #85 stated the nurse had spoken to her this morning and stated she had no oxycodone/acetaminophen 10 mg-325 mg in her cart. The nurse had told her she was going to call the pharmacy to see where the medication was. Resident #85 stated Registered Nurse (RN) #301 had told her she had no order for Tylenol. Resident #85 stated her pain right now was an eight out of 10 on the pain scale. Resident #85 stated eight was the pain number this morning when she reported her pain to RN #301. Resident #85 stated the nurse had not done anything for her pain. Interview on 06/09/26 at 2:39 P.M. with RN #301 verified Resident #85 had reported her pain level for her left leg amputation was eight out of 10 on the pain scale this morning around 10:00 A.M. or 10:30 A.M. RN #301 stated she told Resident #85 she would follow up and call the pharmacy for her narcotic pain medication. RN #301 stated she had called the pharmacy a few times and on the last call they had stated it was on the way. RN #301 did not call the physician to ask about a different medication. RN #301 verified she had not provided any pain interventions to Resident #85. RN #301 stated the aid had gotten her out of bed to help with pain. RN #85 stated recently Resident #85 had reported her pain was still eight out of 10 on the pain scale. Observation on 06/09/26 at 2:50 P.M. revealed Resident #85's oxycodone/acetaminophen 10-325 mg was delivered. Additional chart review of the medication administration record dated 06/09/26 revealed Resident #85 had received oxycodone/acetaminophen 10-325 mg at 2:54 P.M.Observation on 06/09/26 at 2:55 P.M. with the Director of Nursing (DON) of the Omnicell medication dispenser for stock medications revealed no oxycodone/acetaminophen 10-325mg were in stock. Interview on 06/09/26 at 2:55 P.M. the DON verified the Omnicell medication dispenser had oxycodone 5 mg and oxycodone 10 mg immediate release available. The DON stated if a physician was notified there were other medications available to use for managing pain. Interview on 06/09/26 at 4:42 P.M. RN #301 stated she looked and didn't see an order on the medication administration record for Tylenol for Resident #85. RN #301 stated she now sees the order for the Tylenol routinely. RN #301 confirmed Resident #85 did not receive her Tylenol 325 mg at 12:00 P.M. Interview on 06/09/26 at 5:00 P.M. the DON stated she expected all nurses to administer medication timely and per physician's order to manage resident's pain. The DON stated RN #301 should have called the physician for a new order and recommendation for Resident #85 when she was reporting pain and her pain medication ordered was not available. Review of the facility policy titled General Dose Preparation and Medication Administration, date 12/01/2007, revealed prior to administration of medication, facility staff should verify the correct medication, at the correct dose, at the correct time, for the correct resident. Administer medications within time frames specified by facility policy. Review of the facility policy titled Pain Management Protocol, dated 11/19/2025, revealed the physician or provider will be notified of new onset of pain or significant increase in pain as appropriate. Non-pharmacological interventions will be attempted prior to the administration of as needed pain medications. If non-pharmacological interventions fail then when as needed medications are available with corresponding intensity ratings, the resident will be administered the medication ordered for the corresponding pain rating within the as needed order.This deficiency represents non-compliance with Complaint Number 2710111.

Based on observation, interview, record review and policy review, the facility failed to ensure dental services were provided for a resident with a broken tooth. This affected one (#8) of three residents reviewed for ancillary services. The facility census was 63. Findings include:Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of bladder, unspecified, severe protein-calorie malnutrition, hypo-osmolality and hyponatremia, and anxiety disorder.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 was cognitively intact. The MDS was marked for no dental issues.Review of the provider orders dated 04/01/26 for Resident #8, revealed may see dentist as needed. Observation on 06/08/2026 at 2:15 P.M. revealed Resident #8 had a broken tooth. Interview on 06/09/2026 at 10:44 A.M. Social Service Designee (SSD) #277 revealed the dental provider sends a list of residents that need to be seen and the SSD #277 adds any residents that need to be seen. The SSD #277 confirmed the last dental service came on 05/19/26 and Resident #8 was not seen for dental visit. The SSD #277 confirmed no residents are scheduled for the upcoming dental visit. The SSD #277 was not aware of any residents needing any dental services. Observation and interview with the Director of Nursing (DON) on 06/09/2026 at 11:05 A.M., the DON verified Resident #8 had a chipped tooth and Resident #8 appears to need dental work. The DON stated the admission assessment was done by the MDS nurse and it showed no oral issues. The DON stated the oral issues should be documented in Resident #8's record. Interview on on 06/09/2026 at 11:05 A.M. Resident #8 stated he needed a root canal.Review of the policy titled Social Services, dated 01/15/26, revealed social service is responsible for coordinating needed ancillary services, dental. Social services will ensure referrals are made when needed.

Based on observation, interviews, record review, and facility policy, the facility failed to follow acceptable standards of practice nurse administered medications to two residents in a room at the same time. This affected two residents (#13 and #55). The facility census was 63. Findings include: Observation on 06/10/26 at 7:42 A.M. with Registered Nurse (RN) #273 revealed the nurse was standing at the medication cart holding two unmarked, unlabeled medication cups with unknown pills inside each cup. The cups had no room number, initials, or names on the two cups to identify the resident whose medications were in the cup. RN #273 was getting ready to walk away to take medication to Residents' #13, and #55.Interview on 06/10/26 at 7:45 A.M. RN #273 verified both medication cups had no labels to identify the resident or the medication in the cups. RN #273 stated the medications in Resident #13's cup included allopurinol 100 milligram (mg) one tablet, amlodipine 5 mg one tablet, Vitamin D3 1,000 units two tablets, finasteride 5 mg one tablet, MiraLAX 17 grams in water, and Protonix 20 mg one tablet. RN #273 stated the medications in the cup she identified as Resident #55 medication's included amlodipine 10 mg one tablet, aspirin 81 mg one tablet, isosorbide 30 mg one tablet, Jardiance 25 mg one tablet, Memantine 10 mg one tablet, metoprolol 50 mg one tablet, and Trintellix 20 mg one tablet. Observation on 06/10/26 at 7:48 A.M. revealed RN #273 took both medication cups into Resident #13 and #55's room to administer the medication in their room.Review of medical record for Resident #13 revealed an admission date of 11/22/23. Diagnoses included obstructive and reflux uropathy, neuromuscular dysfunction of bladder, benign prostatic hyperplasia with lower urinary tract symptoms, and urine retention. Review of the medication administration record dated 06/10/26 revealed Resident #14 was administered allopurinol 100 milligram (mg) one tablet, amlodipine 5 mg one tablet, Vitamin D3 2,000 Units one tablet, Finasteride 5 mg one tablet, MiraLAX 17 grams per dose, and Protonix 20 mg one tablet. Review of medical record for Resident #55 revealed an admission date of 12/02/24. Diagnoses included type two diabetes, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, vascular dementia, and adult failure to thrive. Review of the medication administration record dated 06/10/26 revealed Resident #55 was administered amlodipine 10 mg one tablet, aspirin 81 mg one tablet, isosorbide mononitrate 30 mg extended-release one tablet, Jardiance 25 mg one tablet, Memantine 10 mg one tablet, metoprolol Tartrate 50 mg one tablet, and Trintellix 20 mg one tablet. Interview on 06/10/26 at 8:00 A.M. RN #273 stated that it was not the facility practice to deliver medications simultaneously to two residents. RN #273 stated that it was an unsafe practice. RN #273 stated Resident #13 and #55 would be at risk for medication error. Interview on 06/10/26 at 11:10 A.M. the Director of Nursing (DON) stated she expected nurses not to administer medication to two residents at the same time. DON stated it was not the facility practice to pass medication to several residents at same time.

Based on observation, interview, record review and policy review, the facility failed to ensure residents were not smoking near oxygen tanks. This affected one (Resident #32) of one resident at the facility identified to smoke and wear oxygen. The facility census was 63.Findings include:Review of the medical record revealed Resident #32 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, unspecified, chronic kidney disease, stage three unspecified, and anxiety disorder, unspecified.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 was cognitively intact and had oxygen therapy.Review of the care plan dated 04/15/24 revealed a care plan for resident is a smoker, at risk for health issues. Resident is an unsupervised smoker. Resident will be able to enjoy tobacco safely in accordance with policy.Review of the medical record revealed Resident #32 had physician orders dated 03/04/26 for oxygen (O2) via nasal cannula (NC) continuously at three liters per minute (lpm) per NC.Review of the observation detail report for smoking dated 04/06/26 for Resident #32 revealed the resident was safe to smoke.Observation on 06/09/2026 at 12:32 P.M. with the Director of Nursing (DON) revealed Resident #32 was outside in the front of the building smoking with a visitor. The resident's O2 tank was on the back of his wheelchair. Interview at the time of the observation with th DON verified the oxygen was on the back of Resident #32's wheelchair while he was out smoking. The DON removed the tank from the resident's chair.Additional chart review for Resident #32 revealed a progress note dated 06/09/26 written by the DON. The note documented the resident was noted to be sitting in the front parking lot beside the bench. Resident was noted to have a lit cigarette with an O2 cylinder to the back of her wheelchair. The writer was called to the area. Resident #32 was talking with her visitor as the writer walked up. The resident engaged the writer with conversation. The writer asked the resident if she remembered she had the O2 cylinder on the back of her wheelchair. Resident stated she usually takes it off but forgot about removing it this time. The resident stated the nurse should have reminded her. The writer removed the O2 cylinder and moved away from the resident and the visitor, who continued to smoke. The resident did state they had the O2 turned off. The writer educated the resident on removing the O2 prior to going outside to smoke. Interview on 06/09/26 at 1:00 P.M. with Resident #32 revealed she has been in a wheelchair for about two months. Resident #32 stated she goes out to smoke with the O2 tank on the back of the wheelchair, but it is turned off.Interview on 06/09/2026 at 1:11 P.M. with Registered Nurse (RN) #301 revealed gave Resident #32 three cigarettes and a lighter at the nurses' station. RN #301 stated she did not see O2 on the back of Resident #32's wheelchair.Interview on 06/09/2026 at 1:15 P.M. with Certified Nursing Assistant (CNA) #254 revealed Resident #32 signs herself out at the front desk while in her wheelchair and the O2 is on the back. CNA #254 stated Resident #32 is supposed to take the O2 off before going out to smoke. CNA #254 stated Resident #32's O2 tank is always on the back of the wheelchair when Resident #32 goes out front to smoke.Interview on 06/09/2026 at 1:17 P.M. with RN #274 revealed they saw Resident #32 go to get cigarettes from the desk with O2 on the back of her wheelchair. The resident then proceeded to go out front to smoke. RN #274 stated the nurses should take off the O2 from the wheelchair prior to Resident #32 going out front to smoke. RN #274 stated Resident #32 goes out front often to smoke.Review of the policy titled Smoking, dated 09/09/25, revealed no smoking may occur near oxygen or other combustible materials.

Based on observation, record review, interview and review of facilty policy, the facility failed to provide proper incontinence care to one (#48) out of one residents reviewed for incontinence care. The facility census was 63.Findings include: Record review for Resident #48 revealed this resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, muscle weakness, and radiculopathy lumbar region. Review of the MDS assessment dated [DATE] revealed the resident had severely impaired cognition. This resident was assessed to require to be dependent on staff for all activities of daily living (ADLs). Resident is assessed to always be incontinent of bowel and bladder.Observation on 06/10/26 at 9:23 A.M revealed CNA #260 put on a gown and applied gloves. She then put clean washcloths in Resident #48's sink and turned the water on. CNA #260 sat the washcloths on the bedside table on top of a new garbage bag. CNA #260 removed Resident #48's covers and clothes with the same gloves and started to provide incontinence care. CNA #260 cleaned Resident #48's peri area with washcloths with just water on them and then dried the resident with clean, dry washcloths. After completing incontinence care CNA #260 put a clean brief on Resident #48 and readjusted her in bed with the help from RN #265. After, incontinence care was completed CNA #260 kept the same gloves on and turned the sink faucet on. CNA #260 removed their gloves and proceeded to wash their hands.Interview on 06/10/26 at 9:27 A.M with CNA #260 confirmed they are supposed to use two basins to provide incontinence care, one with water and another with soap and water. They are supposed to wash their hands before and after incontinence care. CNA #260 confirmed they did not wash their hands before performing incontinence care and that they did not apply soap to the wet washcloths and only used water to clean up the resident.Review of the facility policy titled Perineal Care Incontinent Care Procedure, dated on 10/30/25, revealed staff members are supposed to have a basin and soap or a no rinse incontinent cleanser. Staff members are supposed to perform hand hygiene prior to performing incontinent care and fill the wash basin with water.This deficiency represents non-compliance investigated under Complaint Number 2979996, 2686679, and 2670922.

Based on observation, interview, record review, and facility policy, the facility failed to be free from significant medication errors for one (#62) resident observed for medication administration. The facility failed to administer medications per physician order for one (#85) out of three residents reviewed for pain management. The facility census was 63. Findings include: 1. Review of medical records for Resident #85 revealed an admission date of 06/08/26 at 11:30 P.M. Diagnoses included complete traumatic amputation hip and knee, peripheral vascular disease, type two diabetes, and abdominal hernia without obstruction or gangrene. Review of the physician orders dated 06/09/26 revealed Resident #85 had an order for Tylenol 325 milligram (mg) two tablets every six hours routine. Times to be administered were 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. Review of the medication administration record dated 06/09/26 revealed that Resident #85 had not been administered Tylenol 325 mg two tablets at 12:00 P.M.Interview on 06/09/26 at 2:20 P.M. Resident #85 stated she had alot of pain in her left leg from her amputation. Resident #85 stated the last time she had received pain medication was the prior night and she was given Tylenol. Resident #85 stated Registered Nurse (RN) #301 had told her she had no order for Tylenol. Resident #85 stated her pain right now was an eight out of 10 on the pain scale. Interview on 06/09/26 at 4:42 P.M. RN #301 stated she looked and didn't see an order on the medication administration record for Tylenol for Resident #85. RN #301 stated she now sees the order for the Tylenol routinely. RN #301 confirmed Resident #85 did not receive her Tylenol 325 mg at 12:00 P.M. Interview on 06/09/26 at 5:00 P.M. the DON stated she expected all nurses to administer medication timely and per physician's order to manage resident's pain. Review of the facility policy titled General Dose Preparation and Medication Administration, date 12/01/2007, revealed prior to administration of medication, facility staff should verify the correct medication, at the correct dose, at the correct time, for the correct resident. Administer medications within time frames specified by facility policy. 2. Review of medical record for Resident #62 revealed an admission of 04/30/26. Diagnoses included type two diabetes, morbid obesity, anemia, and depression. Review of physician's order dated 05/01/26 revealed Resident #62 had an order to take furosemide 20 mg two tablets every day. Observation on 06/10/26 from 7:55 A.M. through 8:08 A.M. with RN #273 administered medication to Resident #62. Medications administered included the following: aspirin 81 mg one tablet, cetirizine 10 mg one tablet, Vitamin D3 25 mcg two tablets, Plavix 75 mg one tablet, Vitamin B-12 100 mg gave five tablets, famotidine 20 mg one tablet, iron 325 (65 mg) one tablet, furosemide 20 mg one tablet, glipizide 5 mg extended release one tablet, Jardiance 25 mg one tablet, losartan potassium 100 mg one tablet, Magnesium oxide 400 mg one tablet, metformin 500 mg one tablet, metoprolol succinate extended release 25 mg one tablet, and MiraLAX 17 grams in water. Interview on 06/10/26 at 10:20 A.M. RN #273 verified Resident #62 had only received furosemide 20 mg one tablet with the morning medication. RN #273 verified Resident #62 had a physician order for furosemide 20 mg take two tablets. This deficiency represents non-compliance investigated under Complaint Numbers 2742658, 2701109, 2722052, 2686679, 2670992, and 2710111.

Based on observation, staff interview, resident interview, and policy review, the facility failed to ensure food was served warm and palatable. This had the potential to affect all but one Resident (#32) who received food from the facility's kitchen. The facility census was 58. Findings include: Review of the lunch menu for 12/26/24 revealed the residents received a choice of fish patty or chicken fingers, broccoli casserole, dinner roll and Jello for dessert. Observation of meal line service on 12/26/24 from 11:00 A.M. to 12:30 P.M., revealed the lunch meal consisted of a choice of a fish patty or chicken fingers, broccoli casserole and Jello for dessert. Cooking temperatures obtained at this time by using a facility thermometer revealed the fish patty was at 180 degrees Fahrenheit, chicken fingers at 190 degrees Fahrenheit and broccoli casserole at 182 degrees Fahrenheit. Steam table holding temperatures obtained by using a facility thermometer, at the time of plating, revealed the fish patty was at 202 degrees Fahrenheit, chicken fingers at 205 degrees Fahrenheit and broccoli casserole at 197.5 degrees Fahrenheit. Food and beverage items prepared for this meal were confirmed to be consistent with the printed menu. Further observation continued as dietary staff plated the lunch meal from a steam table in the kitchen. As the tray line neared an end, the surveyor requested a test tray be prepared and placed on the B-Hall food cart. Observation was made as the test tray was prepared, placed on the cart at 12:28 P.M., and transported by [NAME] #605 to B-Hall nursing unit where it arrived at 12:30 P.M. The test tray remained on the cart in view of the surveyor, until all other trays were distributed to residents. The test tray was removed from the cart at 12:50 P.M. by [NAME] #605 who used a facility thermometer that confirmed the temperatures of the fish patty, chicken finger and broccoli casserole. The fish patty was 97 degrees Fahrenheit, chicken finger 92 degrees Fahrenheit and broccoli casserole 109.5 degrees Fahrenheit. [NAME] #605 verified the test tray temperatures and the surveyor taste-tested the fish patty, chicken finger and broccoli casserole which were found to be at an unsatisfactory temperature, bland in taste and presentation of food items on the plate was not pleasing to the eye. [NAME] #605 verified the fish patty, chicken finger and broccoli casserole were not hot by the time the test tray was served, and the plating was not pleasing to the eye. Interviews on 12/26/24 from 1:00 P.M. to 1:20 P.M. with Residents #14, #16, #28 and #52 verified the fish and chicken were overcooked which made the breading hard and the meat dry, and the broccoli casserole was dry and had no flavoring. Interview on 12/26/24 at 9:02 A.M. with the Administrator verified there is one Resident (#32) who did not receive food from the facility's kitchen. Review of a policy titled, Food Preparation and Handling, revised 01/05/23, revealed food items are prepared by methods designed to maintain safe temperatures, avoid cross-contamination, prevent food borne illness, conserve maximum nutritive value, and develop and enhance flavor. This deficiency represents noncompliance investigated under Complaint Number OH00160920.

Based on record review, resident and staff interviews, and policy review, the facility failed to complete quarterly care conferences for residents residing in the facility. This affected four (#18, #21, #29, and #52) of five residents reviewed for care conferences. The facility census was 63. Findings include: 1. Review of the medical record for Resident #18 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, chronic obstructive pulmonary disease (COPD), convulsions, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had moderate cognitive impairment. Review of the medical record for care conferences for the last 12 months revealed Resident #18 only had two care conferences dated 09/27/24 and 04/10/24. Interview on 07/09/24 at 2:40 P.M. with Social Services Designee (SSD) #145 verified Resident #18 had only received two care conferences in the last 12 months. 2. Review of the medical record for Resident #21 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, emphysema, anxiety disorder, and bronchiectasis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had intact cognition. Review of the care conferences for the last 12 months for Resident #21 revealed he had one care conference completed on 09/01/23. Interview on 07/09/24 on 2:41 P.M. with Social Services Designee (SSD) #145 verified Resident #21 had only had one care conference in the last 12 months. 3. Review of the medical record for Resident #52 revealed an admitted [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis affecting right dominant side, congestive heart failure, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 had intact cognition. Review of the medical record for care conferences for the last 12 months revealed Resident #52 had only received one care conference on 08/23/23. Interview on 07/09/24 at 2:42 P.M. with Social Services Designee (SSD) #145 verified Resident #52 had only received one care conference in the last 12 months. 31404 4. Review of Resident #29's medical record revealed an admitted [DATE]. Diagnoses included cerebral infarction, type two diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction, hypertensive heart disease, dysphagia following cerebral infarction, and chronic pain. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was cognitively intact. Review of Resident #29's medical record for the last 12 months revealed there was only two care conferences in the last year on 08/02/23 and 03/20/24. Interview with Resident #29 on 07/08/24 9:49 A.M. revealed she can not remember having care conferences every three months. Interview with Social Services Designee (SSD) #145 on 07/10/24 at 3:57 P.M. verified the residents should have care conferences every three months. SSD #145 verified Resident #29 only had two care conferences in the last year on 08/02/23 and 03/20/24. Review of the facility's Comprehensive Care Planning Policy dated 03/02/21 revealed a comprehensive care plan must be developed by the interdisciplinary care planning team within seven days after completion of the comprehensive assessment (MDS}. The comprehensive care pan is reviewed and updated at least every 90 days by the interdisciplinary team.

Based on record review, staff interview, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected one (#39) of one resident reviewed for significant medication errors. The facility census was 63. Findings include: Review of the medical record for Resident #39 revealed an admitted [DATE]. Diagnoses included acute embolism and thrombosis of deep veins of lower extremity and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had severely impaired cognition. Review of Resident #39's progress note dated 01/30/24 revealed an order was received to increase Warfarin (blood thinner) to six milligrams (mg) on Monday and Thursday, and continue five mg on Saturday, Sunday, Tuesday, Wednesday, and Friday. Review of Resident #39's physician orders revealed an order dated 01/30/24 to 02/15/24 for Warfarin five mg once a day with special instructions for Sunday, Tuesday, Wednesday, Friday, and Saturday. The physician orders dated 02/01/24 to 02/15/24 was for Warfarin six mg once a day with special instructions for Monday and Thursday. Review of the Medication Administration Record (MAR) from 02/01/24 to 02/29/24 revealed Resident #39 was administered both doses of Warfarin five mg and Warfarin six mg on eight days (02/03/24, 02/04/24, 02/05/24, 02/06/24, 02/08/24, 02/09/24, 02/10/24, and 02/11/24). Review of the progress note dated 02/13/24 revealed the MAR displayed double orders for two different doses of Warfarin with special instructions for different days, but the orders were entered to be repeated every day. Interview on 07/11/24 at 12:53 P.M. with the Director of Nursing (DON) confirmed Resident #39 was administered both doses of Warfarin five mg and Warfarin six mg on 02/03/24, 02/04/24, 02/05/24, 02/06/24, 02/08/24, 02/09/24, 02/10/24, and 02/11/24. Review of the facility policy titled General Dose Preparation and Medication Administration, revised 04/30/24, revealed facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, and for the correct resident.

Based on medical record review, resident and staff interviews, observation, and policy review, the facility failed to ensure residents received timely foot care. This affected one (#18) of three residents reviewed to activities of daily living. The facility census was 63. Findings include: Review of the medical record for Resident #18 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus (DM II), chronic obstructive pulmonary disease (COPD), convulsions, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had moderate cognitive impairment. Resident #18 was dependent on staff with bathing. Review of the podiatry note dated 10/27/23 revealed Resident #18 was seen and needed to follow up in two to three months. The podiatry note dated 01/12/24 revealed Resident #18 refused to be seen. The podiatry appointment dated 03/29/24 revealed Resident #18 was supposed to be seen but the podiatrist canceled. The podiatry appointments dated June 2024 revealed Resident #18 was not seen in June 2024. Observations on 07/08/24 at 11:12 A.M. and 07/10/24 at 9:34 A.M. revealed Resident #18's toenails were overgrown and curling under his toes. They were thick and yellow and the surrounding skin was dry and peeling. Interview on 07/10/24 at 9:24 A.M. with Resident #18 revealed he wanted his toenails cut because they were extremely long and curling under his toes. Interview on 07/10/24 at 9:33 A.M. with Assistant Director of Nursing (ADON) verified Resident #18's toenails were overgrown and curling under his toes, which could put Resident #18 at risk for skin impairment. Interview on 07/10/24 at 10:34 A.M. with Social Services Designee (SSD) #145 verified Resident #18 was scheduled to be seen in March, but the podiatrist canceled. SSD #145 stated Resident #18 was not scheduled to be seen in June 2024 because she had troubles with 360 care not rescheduling residents when appointments were scheduled. SSD #145 verified she did not follow up on Resident #18 to ensure he was rescheduled. Review of the facility policy titled Social Services Policy dated 03/01/24 revealed social services would ensure follow up to any ancillary services.

Based on resident and staff interviews and review of the resident right's handbook, the facility failed to ensure residents received mail on the weekends. This had the potential to affect all 63 residents residing in the facility. Findings include: Interviews on the annual survey on 07/08/24, 07/09/24, and 07/10/24 with Residents #18, #21, #27, #47, #52, and #53 revealed mail was not delivered on the weekends, only Monday through Friday. Interview on 07/11/24 at 10:49 A.M. with Business Office Manager (BOM) #155 revealed residents were supposed to receive mail on Saturdays except insurance related mail. BOM #155 reported the activities department was who passed out the mail. Interview on 07/11/24 at 11:13 A.M. with Activities Director #125 verified mail was not handed out on Saturdays, but only Monday through Friday. Review of the resident rights handbook revealed the resident had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility for the resident thought a means other than a postal service including privacy of such communication consistent with this section, and access to stationary, postage, and writing implements at the resident's own expense.

Based on observations, staff interview, and review of the facility policy the facility failed to store, prepare, distribute, and serve food under sanitary conditions. This had the potential to affect all 65 residents residing in the facility. Findings include: 1. Observation of the kitchen on 11/07/23 from 9:00 A.M. to 9:41 A.M. with Dietary Manager #100 revealed the following concerns: Observation of the four tray line warmers revealed the water under each bin the water was milk- like in color withfloating white particles. One of the bins had dried food on the sides of the bin. Observation of the shelves directly underneath the serving area revealed there food particles, a dirty scoop, a bottle of syrup, crumbled aluminum file and a plastic bin containing non-kitchen items. Observation of the plate warmer on the left side revealed the outside of the warmer was dirty with food particles, fingerprints, and an identified dry white substance near the top of the warmer. Observation of the outside of the microwave oven revealed the handle was covered with a dry crusty like substance, and the door window had fingerprints and dried food on it. There were salt crystals scattered over the top of the microwave. Observation of the counter/work area revealed there was a bottom shelf with food particles on it, a plastic serving tray with two quarter size brown spots on it. There was also a plastic serving tray with 15 covered bowls of dry cereal which were not dated. Observation of the to of the coffee pot revealed a plastic bin with 10 individual sealed coffee packets. The plastic bin had coffee grounds all over the bottom with one loose coffee filter. Observation of the stand-alone side by side refrigerator revealed two thermometers inside with a temperature of 57 degrees Fahrenheit. The refrigerator contained the following items: 38 small cartons of chocolate health shakes, 96 cups of grape juice, 20 small cups of strawberry yogurt, 10 pre-poured cups of lemonade covered with no date, 12 pre-poured cups of tea covered with no date, two bottles of Gatorade, a can of soda and a bottle of an energy drink belonging to the facility staff. Observation of the clean dish area revealed a four-shelf unit with boxes of juices on the top shelf and clean dishes on the lower shelves. On the floor around the left front leg of the shelf there was a white bath towel with blue stains all over it. Observation of the walk-in cooler revealed the following food items: a tub of 15 hardboiled eggs shelled and covered with no date, a tray of 12 small bowls of fruit cobbler covered with no date, a tray with three bowls of pudding covered with no date. Interview on 11/08/23 at 9:42 A.M. with DM #100 confirmed all of the concerns identified during the tour. 2. Observation on 11/08/23, at 11:26 A. M. revealed Maintenance Director (MD) #170 walked past the prep area as Cook #120 was preparing turkey and cheese sandwiches. MD #170 was not wearing a hair net or a ball cap while in the kitchen. Interview on 11/08/23 at 11:26 A.M. with MD #170 confirmed he was not wearing a hair net or ball cap while in the kitchen. 3. Observation on 11/08/2023, at 12:10 P. M. revealed Housekeeper #180 walked into the kitchen without a hair net leaned against the food preparation table while Dietary Aide (DA) #118 was preparing lunch and asked for a cup of coffee. Staff gave Housekeeper #180 a cup of coffee and she exited the kitchen. Interview on 11/08/23 at 12:15 P.M. with DA #118 confirmed Housekeeper #180 entered the kitchen food prep area without a hairnet while food was being prepared. Review of the facility policy titled Food Preparation and Handling Policy dated 01/05/23 revealed all cold meat salads, poultry salads, egg salads, cream filled pastries and other potential hazardous foods should be prepared from chilled products and refrigerated below 41 degrees Fahrenheit immediately after preparation. Leftovers must be dated, labeled, covered, and stored in the refrigerator. The kitchen would be clean, neat, and orderly. Review of the facility policy titled Freezers and Refrigerators dated 06/09/21 revealed all refrigerator and frozen foods must be appropriately dated to ensure proper rotation by the expiration date. Refrigerators and freezers would be kept clean, free of debris and cleaned with sanitizing solution on a scheduled basis and more often as necessary. This deficiency represents non-compliance investigated under Complaint Number OH00146856.

Based on record review, observation, staff interview, and review of the facility policy the facility failed to ensure residents received a mechanical soft textured diet as ordered. This affected three (Residents #14, #30, and #32) of three residents with orders for a mechanical soft diet. The facility census was 65. Findings include: Review of the facility menu for the lunch meal on 11/08/23 revealed the lunch entree for that date was a turkey and cheese sandwich. Review of the dietary spreadsheet signed by the facility dietitian for the lunch entree on 11/08/23 revealed residents with physician order for a mechanical soft diet should receive a scoop of ground turkey and two slices of bread. Observation of the lunch service line on 11/08/23 from 11:15 A. M. to 12:20 P. M. revealed the staff prepared a scoop of ground turkey as the entree from Residents #14, #30, and #32, facility-identified residents with orders for mechanical soft diet. Residents #14, #30, and #32 did not receive bread with the meal as specified per the dietary spreadsheet. Interviews on 11/08/23 at 12:20 P.M. with Dietary Manager (DM) #100 confirmed the facility did not serve bread to residents on a mechanical soft diet and did not offer a substitute for the bread to meet the nutrient value of the lunch served to Residents #14, #30, and #32 on 11/08/23. Review of the facility policy titled Diet Order Policy dated 07/27/20 revealed the DM will utilize a tray card identification system to ensure that each resident receives his or her diet as ordered. Review of the facility policy titled Mechanical Soft Diet undated revealed foods that are difficult to chew are replaced with foods altered into a form that can be easier to chew. Bread/starches include well moistened bread and fat and oils, including a slice of cheese. Review of the facility policy titled Mechanically Altered Diet Changes dated 10/01/23 revealed kitchen staff should check recipes and dietary spreadsheets prior to each meal and pay close attention to resident diet cards /tickets when serving food.

Based on record review, observations, staff, resident, Physician and Nurse Practitioner interviews, review of information from the Centers for Disease Control and Prevention (CDC) and policy review, the facility failed to implement their policy regarding reporting infectious diseases as required. This affected two (#13 and #14) of three resident reviewed for infections. Facility census was 62. Findings include: 1. Review of medical record for Resident #14 revealed admitted [DATE]. Diagnoses include diabetes mellitus type 1, stage 4 kidney disease, depression and dementia. The resident remains in the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 10 indicating Resident #14 had impaired cognition. She required extensive two-person assistance for toileting, one person assistance for bed mobility, total dependence for transfer and supervision for eating. Record review of the 08/11/23 Dermatology office note for Resident #14 revealed no rash, scabies resolved return as needed. Record review of the physician orders for Resident #14 revealed an order for Ivermectin three milligrams, give six tablets daily with a start date of 06/30/23, Permethrin External Cream five percent (%) apply neck to feet at bedtime every Saturday with a start date of 06/23/23 and Hydrocortisone external cream 2.5 % apply to face at bedtime with a start date of 06/23/23. Observation and interview on 09/19/23 with Resident #14 at 10:25 A.M. in the courtyard revealed she had on a long sleeve sweatshirt during the interview her exposed hands revealed have several scabbed and open, superficial scratches. Resident #14 stated she scratches her hands in her sleep. Resident #14 acknowledged that she had a rash in the past but stated it had cleared up. Interview on 09/19/23 at 2:33 P.M. with the Assistant Director of Nursing (ADON) #9 and Director of Nursing (DON) revealed Resident #14 had a rash which was originally diagnosed as allergic dermatitis. The rash came and went, but subsided when she had dialysis during a hospitalization . An appointment was made for a dermatologist, but it took a few months for an available appointment. Resident #14's appointment was 06/23/23 and she was prescribed Permethrin cream (scabies), Ivermectin (scabies) and hydrocortisone (topical steroid). ADON #9 and DON were unable to answer why the medication was ordered if the rash was not present. ADON #9 stated they had tried to contact the office but were unable to and they were unable to produce the office note from the visit. They continued to share the wound physician had seen Resident #14 for her rash and believed it was attributed to elevated uric acid levels. They stated Resident #14 was seen by Certified Nurse Practitioner (CNP) #34 and originally treated for scabies but there was no improvement, and he was subsequently seen by Physician #32 who diagnosed him with atopic dermatitis. Interview on 09/20/23 at 12:38 P.M. with Physician #32 revealed he did not have concern of scabies at the facility. He stated Resident #14 had dialysis and her rash cleared, and he felt it was caused by an increase of Uric Acid in her system. He stated CNP #34 treated Resident #14 for what she felt was scabies but the rash did not go away. He added scabies was usually found in the folds of the skin, and no staff including himself have contacted anything therefore he felt it did not fit the criteria. Interview on 09/22/23 at 10:55 A.M. with Dermatology CNP #35 revealed Resident #14 was seen on 06/23/23 and presented with signs and symptoms of scabies. Dermatology CNP #35 did not have the resource to perform a scaring for a definitive diagnosis, however she did have a rash, and accompanied redness and excoriation which was seen with scabies. For that reason, she prescribed Permethrin and Ivermectin as well as a topical steroid cream for treatment of scabies. The rash had resolved by her follow up visit in August. 2. Review of medical record for Resident #13 revealed admitted [DATE]. Diagnoses include hypertension, heart failure and diabetes mellitus type II. The resident remains in the facility. The quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating Resident #13 had intact cognition. He required extensive two-person assistance for toileting, one person assistance for bed mobility, transfers and independent for eating. Record review of the 08/30/23 skin assessment for Resident #13 revealed he presented with a red rash to upper extremities originally treated with Permethrin. The rash was documented as dry and fading upon assessment. Record review of the 09/12/23 CNP #34 note for Resident #13 revealed he had potential scabies exposure and had been treated with a dual round of Permethrin Cream. According to the documentation, nursing staff had informed CNP #34 his linens and room were treated per policy. Physician #36 was consulted, and the case was discussed for possible Permethrin resistant scabies. Given the symptoms had not worsened, further treatment was held, noting the itching and rash can linger for several weeks after Permethrin treatment. Review of the 09/13/23 Physician #32 note for Resident #13 revealed rash appeared as atopic dermatitis. Treatment for presumptive scabies for several weeks, rash remained with some improvements. Consult from Dermatology CNP #35 to determine if rash is scabies or dermatitis. No contagion noted and staff had not developed rash which was atypical for scabies. Dermatology CNP #35 had considered biopsy, but none scheduled at the time of visit. Interview on 09/21/23 at 1:30 P.M. with the Administrator, DON and ADON #9 revealed they did not report a potential scabies concern to the heath department as required regarding the potential scabies diagnoses for Resident #14 and #13. The DON revealed she was unaware of the details for Dermatology CNP #35's 09/13/23 for Resident #14. The DON restated the facility did not report the cases to the health department because they had conflicting diagnosis of scabies between the CNP's and Physicians. Review of information from the CDC at https://www.cdc.gov/parasites/scabies/health_professionals/control.html revealed the health department should be notified of any outbreak that may have community implications. In addition, an institution-wide information program should be implemented to instruct all management, medical, nursing, and support staff about scabies, the scabies mite, and how scabies is and is not spread. Epidemiologic and clinical data should be reviewed to determine the extent of the outbreak and risk factors for spread. Review of Ohio Administrative Code Chapter 3701-3 revealed scabies is listed as a Class C and should be reported by the end of the next business day. Review of the facility policy for infection prevention and control last revised 05/11/23 revealed they would notify local, state and federal bodies of all reportable diseases. This deficiency represents non-compliance investigated under Complaint Number OH00146217.

Based on record review, observations, staff interviews and policy review, the facility failed to ensure fall interventions were in place for a resident who was at risk for falls. This affected one (#20) of three reviewed for falls. Facility census was 62. Findings include: Review of medical record for Resident #20 revealed admitted [DATE]. Diagnoses include Cerebral Palsy, epilepsy and incontinence. A care plan initiated 06/20/23 revealed Resident #20 was a fall risk and interventions included Dycem (nonslip material) to wheelchair. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #20 had severe cognitive impairment. Resident #20 required extensive one person assistance for bed mobility, transfers, eating and toileting. Observation on 09/20/23 at 11:16 A.M. revealed Resident #20 had requested to go to the bathroom and was seated in a wheelchair. Further observations of Resident #20's wheelchair revealed there was no Dycem present. State tested Nursing Assistant (STNA) #33 also present during the observation and verified Resident #20's wheelchair did not have Dycem. Interview on 09/20/23 at 1:41 A.M. with the DON revealed she was made aware the Dycem was not present on Resident #20's wheelchair. The DON confirmed Dycem is used as a fall risk intervention for Resident #20. Review of the facility policy titled Fall Prevention and Management Policy last revised 12/09/19 revealed individualized interventions would be implemented which may help to prevent further falls. This deficiency represents non-compliance investigated under Complaint Numbers OH00145970 and OH00146553.

Based on observations, staff interview, policy review, review of information from the Centers for Disease Control and Prevention (CDC) and review of information from the Centers for Medicare and Medicaid Services (CMS), the facility failed to properly don (put on) personal protective equipment (PPE) and/or wash their hands to potentially prevent the spread of Coronavirus Disease 2019 (COVID-2019). This had the potential to affect all 62 residents residing in the facility. The facility census was 62. Finding include: 1. Observation on 03/08/22 at 2:44 P.M. of the facilities laundry room revealed housekeeper manager (HM) #114 and housekeeper (HK) #116 folding laundry with no mask or eye protection. Interview with HM #114 on 03/08/22 at 2:44 P.M. revealed she decided not to wear a mask or eye protection because she is in laundry today and the room is hot. HM #114 confirmed she has never receiving training to work in laundry and does not know how she would handle potentially infectious laundry. HM #114 stated she is guessing she would put on gloves. Interview with HK #116 on 03/08/22 at 2:45 P.M. stated she does not wear eye protection or mask in the laundry room due to the heat. HK #116 confirmed she does not working in laundry and has not received training on how to handle potentially contaminated laundry or linen. 2. Observation on 03/09/22 at 11:57 A.M. revealed HM #114 mopping the hallway floor on the resident hallway with her mask sitting below her nose. Interview on 03/09/22 at 11:57 A.M. with HM #114 confirmed her mask was sitting below her nose as she. 3. Observation on 03/07/22 from 8:04 A.M. until 8:30 A.M. of the breakfast tray line revealed the Dietary Aide (DA) #109 wore her surgical mask below her nose during observation of the tray line. Further observations revealed during the tray line, Cook #112 removed her gloves and donned another pair of gloves without washing her hands. Interview on 03/07/22 at 8:38 A.M. with Cook #112 confirmed she had not washed her hands after doffing gloves and donning new gloves during the tray line. Interview on 03/07/22 at 8:39 A.M. with the DA #109 confirmed she was wearing her surgical mask below her nose during the tray line. Interview on 03/07/22 at 10:40 A.M. with the Dietary Manager #156 confirmed dietary staff are required to wear surgical masks appropriately, covering their mouth and nose. Dietary Manager #156 also confirmed staff are to wash their hands after removing gloves and prior to donning new gloves. Review of the facility policy titled, Clinical: Infection Control, dated 09/15/21, revealed under the Employee Section, on page 3, supports resident safety by adhering to all policies and procedures related to infection prevention. Review of an online resource from CMS titled COVID-19 Nursing Home data at https://data.cms.gov/covid-19/covid-19-nursing-home-data revealed the county in which the facility was situated was experiencing a moderate spread (yellow) of COVID 19 with a positivity rate of 7.6% for the week ending in 03/01/22. Review of an online resource per the CDC titled Infection Control Guidance for Healthcare Professionals about Coronavirus (COVID-19) at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html revealed the use of eye protection in healthcare facilities is recommended in areas with moderate to substantial community transmission and staff should don eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area.

Based on medical record review, staff and Nurse Practitioner (NP) interview and policy review, the facility failed to notify the facility physician of a change of condition for Resident #215. This affected one (#215) out of three resident reviewed for notification of change. The facility census was 62. Findings Include: Review of the medical record for the Resident #215 revealed an admitted [DATE] and he was discharged to the hospital on 11/27/21. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 11/23/21, revealed the Resident #215 had intact cognition as evidenced by a score of 14 on his brief interview for mental status (BIMS) examination. Resident #215 required extensive assistance from staff with bed mobility and eating. Further review of the MDS assessment revealed Resident #215 was totally dependent on staff with transfers, toilet use, personal hygiene, and bathing. Review of the nursing progress notes for Resident #215 dated, 11/23/21, revealed Resident #215 had difficulty swallowing including a gurgle at the back of his throat. The nursing staff notified speech therapy for further evaluation and the Resident #215's surgeon, however, no documentation was identified notifying the facility physician. Further review of Residents #215's nursing progress notes revealed on 11/24/21 resident had a productive cough, and the nurse practitioner ordered a chest x-ray. Resident 215 was evaluated by the physician on 11/26/21 and discharged to the hospital on 11/17/22. Interview on 03/15/22 at 09:11 A.M. with the director of nursing (DON) revealed she was unable to confirm the facility physician was notified regarding the change of condition for Resident #215 on 11/23/21. Interview on 03/15/22 at 10:55 A.M. with the facility NP #300 confirmed the facility did not notify her of the Resident #215 having trouble swallowing on as noted on 11/23/21. NP #300 stated the nursing staff is her eyes and ears for the resident because she is only at the facility on day per week. NP #300 stated she did not recall ever being notified of issues with Resident #215's ability to swallow and gurgling at the back of his throat. Review of the facility policy titled, Resident Change in Condition Policy, 07/02/21 stated, Physician/Provider and the Family/Responsible Party will be notified as soon as the nurse as identified a change in condition and the resident is stable. This deficiency substantiates Complaint Number OH 403.

Based on staff and physician interviews and review of the medical record, the facility failed to follow the hospital discharge medication list as well as transcribe verbal physician orders [REDACTED]. Actual harm occurred to Resident #38 when the facility failed to transcribe orders for blood glucose testing and subsequently the resident was found unresponsive with gurgling respirations, her skin tone was red, and she was in respiratory distress and had to be hospitalized for [REDACTED]. This affected one (#38) of three residents who were reviewed for quality of care. This had the potential to affect nine residents who had physician orders [REDACTED]. The facility census was 54. Findings include: Closed record review for Resident #38 revealed the resident was admitted to the facility on [DATE]. On 01/30/21, the resident was sent to the hospital related to a [MEDICAL CONDITION]. She returned to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the five-day Minimum Data Set (MDS) assessment, dated 02/05/21, revealed the resident had intact cognition. Review of the care plan, dated 01/21/21, revealed the resident was at risk for unstable blood glucose related to diabetes mellitus. Interventions included to administer oral hypoglycemics and/or insulin as ordered by the physician, monitor/educate resident on signs and symptoms of [DIAGNOSES REDACTED], and to assess blood glucose levels as ordered and as needed. Review of the resident's physician orders [REDACTED]. The resident had an order for [REDACTED].) tablet twice daily with meals. On 01/30/21, the resident was sent to the hospital. Review of the resident's discharge medication list from the hospital, dated 02/02/21, revealed the resident returned back to the facility and the discharge medication list stated FSBS (finger-stick blood sugar) and had been written in at the bottom of the list. It did not specify how often the FSBS should be completed. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 02/02/21 through 02/05/21, revealed the facility staff had not documented blood glucose testing for Resident #38. Review of the nurse's progress note, dated 02/05/21 at 4:00 P.M., revealed the resident was found non-responsive with gurgling respirations, her skin tone was red, and she was in respiratory distress. Emergency 911 was called and Medical Doctor (MD) #888 was notified. Resident #38 was found to have a blood glucose level of 38 when the paramedics arrived. The nurse's progress note, dated 02/05/21 at 10:41 P.M., revealed Resident #38 was admitted to the hospital with [REDACTED]. Interview with Registered Nurse (RN) #208 verified FSBS was written in at the bottom of the discharge medication list for Resident #38. RN #208 stated the FSBS stood for finger stick blood sugars. RN #208 verified the MAR and TAR for Resident #38 did not contain documentation of blood glucose testing. Interview with RN #219 on 03/01/21 at 2:40 P.M. revealed she transcribed the medication list for Resident #38 on 02/02/21. She stated Resident #38 had been at the facility prior and had been ordered to have her blood glucose levels monitored by staff. RN #219 stated when Resident #38 returned from the hospital on [DATE] she did not have blood glucose testing ordered so she called Medical Doctor (MD) #888 to clarify whether to reorder them. RN #219 stated MD #888 gave the orders over the telephone for Resident #38 to have blood glucose testing performed by facility staff which was why she wrote FSBS at the bottom of the order page. Interview with MD #888 on 03/01/21 at 2:55 P.M. revealed she was familiar with Resident #38 as she had been her doctor when she was at the facility before and when she saw her as an outpatient. MD #888 stated she could not recall the exact order she gave on 02/02/21 for blood glucose monitoring for Resident #38, but verified she would have provided the nurse with orders due to Resident #38 being diabetic and only returning to the facility on oral hypoglycemic medication. MD #888 stated she was not aware the facility had not been performing blood glucose testing for Resident #38 until facility staff called her on 03/01/21. This was an incidental finding during the complaint investigation.

Based on record review and staff interview, the facility failed to ensure one resident (#7) assessed at high risk for falls received appropriate supervision to prevent an avoidable fall which resulted in a broken nose and a laceration to the forehead requiring sutures. This affected one of three sampled residents out of a total census of 53. Findings include: Review of clinical record of Resident #7 revealed the resident was readmitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had long and short tem memory problems and could be combative with care. The assessment further indicated the resident required total assistance of two staff persons for transfers and toileting. The assessment also indicated the resident's balance was unsteady when moving from a seated to standing position and when moving on and off the toilet and transfers between the bed, chair or wheelchair and she required staff assistance to stabilize. The resident was assessed at high risk for falls and had a history of [REDACTED]. Resident #7 was also receiving Hospice services. Review of the resident's "Resident Care Card" revealed Resident #7 was identified as totally dependant for transfers and toileting and required two persons for transfers and toileting. Further review of the clinical record revealed Resident #7 sustained a fall from the bedside commode on 08/10/12. The resident was transported to the hospital and returned with [DIAGNOSES REDACTED]. Review of the nursing note for the incident revealed Licensed Practical Nurse (LPN) #66 documented the resident was transferred by two staff members onto the bed side commode at approximately 5:50 A.M. The notes stated LPN #66 was called to the room by State tested Nurse Aide (STNA) #77 where the resident was on the floor and appeared to have a sustained a laceration to the right side of her face above the brow. The physician was called and the resident was transported to the hospital for evaluation and treatment. Review of the hospital documentation revealed Resident presented at the hospital with swelling present to the face and head injury to the forehead and nose. The right temporal area was open and bleeding. The resident was treated and returned to the facility with [DIAGNOSES REDACTED]. Interviews with the Administrator on 08/28/12 between 7:30 A.M. and 10:00 A.M. revealed the facility conducted an investigation of the resident's fall and found STNA #77 transferred the resident to the commode by herself and was the only staff in the room toileting the resident. A witness statement from STNA #77 stated she placed the resident on the commode and was reaching for a personal care item while holding the back of the chair when the resident fell on her right side and hit her head. The Administrator confirmed the transfer and the toileting were performed by one staff member and the nursing documentation was incorrect. Further interview with the Administrator on 08/28/12 at 2:00 P.M. verified the current Resident Care Card was in place 08/1012 when the resident was transferred by one staff member and fell . This certification deficiency substantiates Complaint Control Number OH 761.

Based on observation, resident and staff interview, the facility failed to ensure adequate supervision and assistive devices to prevent resident's falls with injuries. This affected one (#64) sampled resident who had repeated falls and falls with injuries during inadequate staff assistance with transfers. This affected one of four sampled residents. The facility identified 54 of 70 current residents required assistance with transfers. Findings include: Review of the medical record of Resident #64 revealed an original admission date of [DATE] and a readmission date of [DATE]. [DIAGNOSES REDACTED]. Review of the resident's plan of care for transfers dated 02/04/11, revealed the resident required up to extensive assistance of one for transfers to and from the bed to the wheelchair due to an old cerebrovascular accident and [DIAGNOSES REDACTED]. Review of fall risk assessments dated 03/20/11, 05/06/11 and 08/30/11 revealed the resident was identified at risk for falls. Review of the resident's undated Resident Care Card, a plan of care used by the staff to guide the resident's care, revealed the resident was independent with assistance of one for bed mobility, required supervision with assistance of one for transfers to and from a chair, and required supervision to assistance of two persons for transfers to and from the bed. The Care Card further revealed the resident required supervision with assist of one for showers and supervision with assist of one for toileting needs. The Care Card stated the resident was paralyzed on the left side due to a stroke. Review of a facility fall investigation dated 08/30/11 revealed the resident's left leg gave out while she was being transferred from her wheelchair to the shower chair and the state tested nurse aide (STNA) had to lowered the resident to the floor. As a result of the fall, a new fall prevention intervention was implemented for two person assistance with transfers with showers until a therapy assessment was completed to determine the resident's necessary transfer assistance. Review of the Rehabilitation Services Screening dated 09/02/11 revealed the resident was unchanged and therapy was not indicated at that time. The Screening stated the resident was currently on restorative therapy for management. A fall risk assessment dated [DATE] indicated the resident remained at risk for falls. Review of a facility fall investigation dated 11/09/11, revealed Resident #64 was lowered to the floor while being ambulated. The investigation included no interventions in place at the time of the fall. A new fall prevention intervention for a therapy screen was implemented. Nurse's notes dated 11/14/11 and identified as late entry for 11/09/11, stated state tested nurse aide (STNA) #109 reported she lowered the resident to the floor during ambulation to the restroom. The resident was assisted to sit in an electric wheelchair and voiced no complaints. Review of STNA #109's statement of the incident dated 11/14/11, revealed she was assisting Resident #64 to her electric wheelchair when the resident's leg gave out and she lowered the resident to the floor. STNA #109 stated Resident #64 reported she had been feeling weak from therapy. STNA #90 stated she told Resident #64 she needed to let the staff know if she was feeling weak so they could get extra help before transferring her. The fall risk evaluation dated 11/16/11 revealed interventions of two persons for transfers, therapy working with resident and to educate staff on what a fall was. Fall risk assessments dated 11/16/11 and 12/06/11 indicated the resident remained at risk for falls. On 12/08/11, the resident was placed on the facility's Falling Leaf program. Review of the current Activities of Daily Living care plan dated 12/14/10, revealed the resident required up to extensive assistance of two persons for bed mobility, transfers, and toileting and she was non-ambulatory. A fall care plan dated 12/14/10 revealed the resident was alert and oriented with good memory and recall. She was mobile in her wheelchair and called for assistance to transfer and toilet. The care planned stated the resident required assistance to transfer and toilet due to left sided hemiparesis from and old stroke. The care plan identified the resident was at risk for falls and possible injury. The care planned interventions included to encourage safety precautions, encourage the resident to seek and await assistance, encourage the use of the call light and to observe for patterns, risk factors and tendency to falls. On 12/15/11, physical therapy per plan of care was added to the care plan. The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #64 had one fall without injury for that observation period. Review of fall risk assessments dated 12/28/11 and 01/31/11 revealed Resident #64 remained at risk for falls. Physical therapy progress notes dated 01/25/12 stated Resident #64 demonstrated minimal to moderate assistance times one with difficulty initially, with going from sitting to standing secondary to quad weakness and moderate assistance times one with standing activity. The notes stated the resident was having difficulty with using her upper extremity during standing. Review of nurse's notes dated 01/30/12 at 9:10 P.M. revealed the STNA called the nurse to Resident #64's room for assistance. The notes stated the resident was observed lying on her back with her feet in front of the commode and her head in the doorway to the restroom. Red fluid was noted beneath the resident's head along with a 2 centimeter (cm) by 3 cm laceration to the top of the left side of the resident's head. The resident was assessed as alert and oriented and assisted up with the help of two staff. The physician was notified and an order was received to send the resident to the emergency room for evaluation. Neurological checks were started and the resident was sent to the emergency room . A nurse's note dated 01/31/12 at 1:45 P.M. stated the resident returned to the facility alert and oriented with five staples to her left posterior scalp. A facility fall investigation dated 01/30/12 revealed the resident was found on floor on her back after a STNA assisted the resident to the bathroom and the resident lost her grip and fell backwards. The investigation stated staff went to move the wheelchair and the resident lost her grip and fell backwards. A new care planned intervention of staff education regarding the use of a gait belt for all transfers was implemented. During interview on 02/28/12 at 8:45 A.M., Resident #64 stated in August 2011 she was standing in the shower holding the grab bar while a STNA switched her wheelchair to a shower chair. The resident stated her leg gave out and she had to be lowered to the floor. Resident #64 stated she had a fall in November 2011 when STNA #109 attempted to transfer her alone from a wheelchair to her power scooter. Resident #64 stated at the time of that fall she was supposed to have two persons for assistance with transfers. Resident #64 further stated in January 2012 she had a fall when STNA #90 took her to the bathroom. She stated STNA #90 assisted her to stand and then left her in the bathroom while he took her wheelchair into her room. She stated she lost her balance, took a few steps back and fell back hitting her head on the floor. Resident #64 stated STNA #90 was not in the bathroom at the time of the fall. She stated at the time only one STNA was routinely assisting her to the bathroom. Resident #64 stated she had to have five staples in her head and the emergency room physician thought she might have a concussion. She stated the emergency room staff kept her awake until 4:00 A.M. because of the possibility of a concussion. Resident #64 stated STNA #90 was new and maybe did not know she needed more assistance. Resident #64 stated she experienced headaches, hip pain and bruising to her shoulder, in addition to the staples to her head as a result of the fall. She stated she was also nervous about STNA #90 transferring her again. During telephone interview on 02/28/12 at 2:40 P.M., former STNA #109 stated when she helped Resident #64 transfer from her wheelchair to her electric scooter on 11/09/11, the resident's leg gave out and she had to lower the resident to the floor. STNA #109 stated she was told the resident required one person for assistance with transfers and that Resident Care Card stated the resident required one person assistance for transfers. STNA #109 stated she was unsure if she had a gait belt on the resident at the time of the fall. She stated STNA #110 helped her get the resident up from the floor. Telephone interview with former STNA #110 on 02/28/12 at 3:00 P.M. verified he assisted STNA #109 to get Resident #64 up from the floor into her chair on 11/09/11. He stated at the time of the fall the resident required one person assistance for transfers. STNA #110 stated he did not remember if the resident was wearing a gait belt. According to STNA #110, after that fall Resident #64 was increased to two persons for assistance with transfers. Interview with Physical Therapy Assistant (PTA) #100 on 02/28/12 at 4:00 P.M. revealed at the time of the resident's fall on 11/09/11, Resident #64 was being assisted by one person in therapy, but not for nursing. She stated the resident should be transferred with a gait belt. PTA #100 stated when a resident had a need for assistance, the staff member should always be at the resident's side with a hand on the resident and using a gait belt. PTA #100 stated the therapy department was working on training the STNA's so Resident #64 could be assisted by one person. PTA #100 stated at the time of the resident's fall on 01/30/12 only STNA #31 had been trained. During interview on 02/29/12 at 3:30 P.M., STNA #90 stated on 01/30/12 he assisted Resident #64 to the bathroom alone. He stated he was told by other staff the resident required one person assistance for transfers. STNA #90 denied checking the resident's Resident Care Card. He stated he normally would pull Resident #64 into the bathroom in her wheelchair but on 01/30/12 he pushed her in the bathroom in her wheelchair. He stated the bathroom is small and he could not get around the wheelchair to assist the resident. He stated the resident grabbed the grab bar and he assisted the resident to a standing position by pushing her back with his hand. STNA #90 stated as the resident stood holding on to the bar he backed the wheelchair out into her room and left the resident standing alone in the bathroom. He stated when the resident let go of the bar he was unable to reach her and she fell landing across the bathroom with her head in the doorway to her room. STNA #90 stated there was blood under the resident's head and he went and got the nurse. The resident did not have a gait belt on and he stated he should have used a gait belt and stayed with the resident. Review of STNA #90's personnel file revealed a hire date of 12/28/11 and current certification. The file contained documentation of counseling dated 01/31/12 for failure to use a gait belt in the transfer of the resident resulting in a fall with injury. Interview with Physical Therapist #104 on 03/01/12 at 1:00 P.M. revealed Resident #64 complained of headaches after the fall on 01/30/12 and experienced some decreased motivation to participate in therapy. Interview with the Director of Nursing (DON) on 03/02/12 at 10:30 A.M. revealed the STNA's receive report regarding the level of residents' care needs from the other STNA's or they can look at the Resident Care Cards. The DON stated the Resident Care Cards are updated by the DON, the nurses and the assessment nurses. Interview with RN #107 on 03/02/12 at 12:00 P.M. revealed all residents who have been identified at risks for falls are to be transferred using a gait belt. She stated the gait belt is not listed on the plan of care since it is required for all transfers. Review of the facility's Gait Belt Policy and Procedures dated 02/2011, revealed the policy states the facility will utilize the use of gait belts to provide staff with a tool to use during transfers and ambulation to prevent injury to residents or themselves. Utilization of gait belts will ensure the safety of all residents and staff during resident transfers and ambulation. Each staff member will receive a gait belt during orientation and the employee with demonstrate prosper use of the belt. The gait belt will be used during transfers and ambulation unless otherwise determined by the physician and or identified in the resident's care plan. If the gait belt is not used the employee will be subject to disciplinary action This certification deficiency substantiates Complaint Control Number OH 448.

Based on observation, record review, and interview, the facility failed to ensure one resident had interventions in place to prevent an avoidable, unstageable suspected deep tissue injury which resulted in harm for one resident, and failed to complete dressing changes in a manner to promote healing. This affected two residents (#45, #16) of four residents reviewed with pressure sores. The facility identified four residents with pressure sores. Findings include: 1. Resident #45 entered the facility on 03/15/11 after a fall resulting in a fracture of her left heel. The resident had additional [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE], and review of indicators for pressure ulcers identified the resident extrinsic risk factors as confined to bed/chair all or most of the time (pressure), diabetes, pain, and immobility. Review of the physician orders for the resident revealed she had a heel lift boot to the left foot (due to the [MEDICAL CONDITION] heel) with skin assessments twice a week on Tuesday and Saturday, and the boot may be removed for skin checks and hygiene. The skin assessment sheets dated 03/19, 03/22, 03/26, and 03/29/11 were silent to any areas to the left heel. There was no skin assessment for Resident #45's right heel from admission until 3/30/11. Review of the medical record including physician orders, and plans of care did not contain any interventions to prevent pressure to the right heel. Review of nursing notes from admission to 03/30/11 did not contain any documentation Resident #45 was turned and repositioned or had the right heel to avoid pressure to the heel. A nursing note dated 03/30/11 at 11:10 A.M. revealed the nurse was called to the resident's room. Resident #45 had an area to the right heel that appeared as a white area with purple underneath. The area measured 4.0 centimeters (cm) x 5.2 cm. The physician was notified and nurses notes on 03/30/11 at 12:40 P.M. stated new orders for skin prep (protective barrier wipes) to the right heel every shift, cover with dry dressing. Interview with the treatment nurse #5 on 03/30/11 at 1:30 P.M. revealed she was notified on 03/30/11 about the area on right heel from the night shift nurse. Treatment nurse #5 affirmed there were no care planned interventions in place to prevent Resident #45's right heel from pressure. STNA #10 said she was told about the heel in report that morning that it was red and bruised. On 03/31/11 at 9:30 A.M. the right heel was observed with treatment nurse #5 present. The resident was in her wheelchair, preparing to go to the wound clinic for the left foot. A dry dressing was removed exposing a large purple area covering the resident's right heel. An interview with Resident #45 at 9:30 A.M. on 03/31/11 revealed the resident to be alert and oriented. During the interview, Resident #45 stated she was not able to turn and reposition herself in the bed, and, until last night she was not turned and repositioned by staff. She said she had been "lying real still on my back" keeping her left leg (with the heel boot) straight. She said her right foot was on the mattress until staff found the area on the heel. Report from the wound clinic dated 03/31/11 identified the wound status type as a pressure ulcer to the right lateral heel measuring 45 millimeters (mm) length x 65 mm width x 1 mm depth. Stage was documented as suspected deep tissue injury. The report further stated some situations, which may have contributed to deep tissue damage, include pressure resulting from immobility. 2. Review of Resident #16's accumulative [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required assistance of two with all care. The plan of care for skin revealed interventions of low air loss mattress, turn and reposition every two hours side to side, and pressure relief cushion to wheel chair. Review of the resident's treatment order dated 02/24/11 revealed a daily treatment to an identified in-house Stage II Pressure sore (a partial thickness loss of dermis presenting a shallow open ulcer with a red or pink wound bed without slough). The treatment order was to cleanse the coccyx with normal saline, apply moist [MEDICATION NAME] and cover with a dry dressing. Review of the facility's wound sheet revealed the Stage II Pressure Sore was identified on 12/07/10, measuring 2 centimeter (cm) x 0.5 cm x < 0.1 cm. Review of the most recent measurements of 03/21/11 revealed 1.5 cm x 0.5 x < 0.1 cm. Observation of Resident #16 during her daily dressing change on 03/30/11 at 9:25 A.M. revealed measurements of 1.7 cm x 1.3 cm x < 0.1 cm. The wound was larger both in width and length. Licensed Practical Nurse (LPN) #5 washed her hands prior to the start of the dressing change. The resident was placed on her side by another LPN. LPN # 5 removed the dressing off the resident's coccyx. A small amount of dried yellow drainage was noted on the old dressing. The sore was round in shape with pink edges and a beefy red center. LPN #5 discarded the dressing in the trash. LPN #5 cleansed the area using normal saline and 4 x 4 gauzes. She then removed her gloves, applied a new pair of gloves and applied the [MEDICATION NAME] (a non woven absorptive dressing made from sea weed) dressing, and a dry 4 x 4 gauze and covered with a occlusive dressing. LPN #5 washed her hands and left the room. Interview with LPN #5 on 03/30/11 at 9:35 A.M., revealed she did not wash her hands after removing the soiled dressing and touching the clean dressings. Interview with the DON on 03/30/11 at 10:00 A.M., revealed LPN #5 should have washed her hands when she removed her gloves after removing the old dressing and before touching the clean dressings. Review of the facility policy dated 07/08 revealed hands should be washed after handling items potentially contaminated with blood , body fluids or secretions.