Seven Acres Senior Living at Clifton

Based on review of the medical record and staff interview, the facility failed to complete a baseline care plan within 48 hours after admission. This affected one (#14) of 15 residents reviewed for baseline care plans. The facility census was 51.

Findings include:

Review of the medical record for Resident #14 revealed an admission date of 05/30/24. Diagnoses included acute respiratory failure with hypoxia, pneumonia, dementia, and malignant neoplasm of prostate.

Review of the admission Minimum Data Set (MDS) assessment dated 06/03/24 revealed Resident #14 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of seven. The resident was assessed to require supervision with eating and transfers, and required partial assistance with toileting, bathing, and dressing.

Review of the baseline care plan dated 05/30/24 revealed it was not completed for Resident #14.

Interview on 06/24/24 at 9:55 A.M. with MDS Nurse #22 verified Resident #14's baseline care plan had not been completed.

Based on observation, medical record review, staff and resident interview, the facility failed to ensure residents were provided with timely and adequate personal hygiene. This affected three (#6, #14, and #23) of four residents reviewed for activities of daily living (ADLs). The facility census was 51.

Findings include:

1. Review of the medical record for Resident #6 revealed an admission date of 03/27/24. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD) stage four, and major depressive disorder.

Review of the Minimum Data Set (MDS) assessment dated 06/05/24 revealed Resident #6 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. The resident was assessed to require supervision with eating, substantial assistance with toileting, bathing, and dressing, and partial assistance with transfers.

Review of the care plan dated 03/28/24 revealed Resident #6 had an ADLs self-care performance deficit related to impaired balance. Interventions included physical and occupational therapy and treatment per physician orders, staff to provide maximal assistance with personal hygiene, staff to explain all care to be rendered and cue Resident #6 to do the same if able, and staff encouragement to participate to the fullest extent possible with each interaction.

Observations of Resident #6 throughout the annual survey at random times revealed Resident #6 had facial hair noted on her chin.

Interview and observation on 06/25/24 at 1:45 P.M. with Resident #6 revealed she usually shaved her facial hair while at home but did not bring a razor with her to the facility. Resident #6 verified that staff had not asked her to shave the hair on her chin and she would like it to be shaved. Resident #6 had noticeable hair on her chin during the interview.

Interview on 06/25/24 at 1:48 P.M. with State Tested Nurse Aide (STNA) #102 stated shaving should be completed for residents on shower days, and verified Resident #6 had facial hair noted on her chin.

2. Review of the medical record for Resident #14 revealed an admission date of 05/30/24. Diagnoses included acute respiratory failure with hypoxia, pneumonia, dementia, and malignant neoplasm of prostate.

Review of the admission MDS assessment dated 06/03/24 revealed Resident #14 had severe cognitive impairment as evidenced by BIMS score of seven. The resident was assessed to require supervision with eating and transfers, and partial assistance with toileting, bathing, and dressing.

Review of the care plan dated 05/30/24 revealed Resident #14 had an ADLs self-care performance deficit related to acute respiratory failure with hypoxia. Interventions included podiatry care as needed, staff encouragement to participate to the fullest extent possible with each interaction, staff to praise all efforts at self-care, staff to encourage to use call light for assistance, and staff to explain all care and cue participation.

Observations throughout the annual survey at random times revealed Resident #14's fingernails extended approximately a quarter of an inch to half an inch beyond his fingertips and were yellow in color with jagged edges. Further observation revealed the underside of Resident #14's fingernails were coated in a dark brown substance.

Interview and observation on 06/25/24 at 1:43 P.M. with Resident #14 revealed his fingernails were long with a built up substance under them. Resident #14 stated he had not been asked by staff to cut them and wanted them cut.

Interview on 06/25/24 at 1:51 P.M. with STNA #102 verified residents' fingernails should be trimmed and maintained as needed. STNA #102 verified Resident #14's fingernails were long, jagged, and needed cut.

3. Review of the medical record for Resident #23 revealed an admission date of 03/26/24. Diagnoses included type two diabetes mellitus, CKD, depression, and atrial fibrillation.

Review of the admission MDS assessment dated 03/30/24 revealed Resident #23 had severe cognitive impairment. The resident was assessed to require supervision with eating, substantial assistance with toileting, bathing, and dressing, and dependent with transfers.

Review of the care plan dated 03/26/24 revealed Resident #23 had an ADLs self-care performance deficit related to metabolic encephalopathy and hemiplegia to the right side. Interventions included physical therapy (PT) and occupational therapy (OT) evaluation and treatment per orders, staff to explain all care and cue to do the same, staff to assist with hygiene and bed mobility, and staff to directly supervise all meals.

Observations throughout the annual survey at random times revealed Resident #23's fingernails extended approximately a quarter of an inch to a half an inch beyond his fingertips.

Interview and observation on 06/25/24 at 12:23 P.M. with Resident #23 revealed he wanted his fingernails trimmed and had not been asked by staff for them to be trimmed. Observation of Resident #23 during the interview revealed his fingernails remained untrimmed.

Interview on 06/25/24 at 1:52 P.M. with STNA #102 verified Resident #23's fingernails were long and should be cut. STNA #102 reported nail trimming should be offered during hygiene.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to appropriately assess pressure ulcers as required. This affected one (#51) of one resident reviewed for pressure ulcers. The facility census was 51. Findings include: Review of the medical record for Resident #51 revealed an admission of 04/01/24. Diagnoses included dementia, atrial fibrillation, type two diabetes mellitus, protein-calorie malnutrition, and malignant neoplasm of prostate. Review of the significant change Minimum Data Set (MDS) assessment dated 06/13/24 revealed Resident #51 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of six. The resident was assessed to require supervision with eating, and was dependent with toileting, bathing, dressing, and transfers. Review of the care plan dated 05/15/24 revealed Resident #51 had a stage four pressure ulcer (full thickness skin and tissue loss) of the coccyx/sacrum related to impaired mobility, refusal of care, refusal to get out of bed, and impaired nutrition. Interventions included to administer medications as ordered, staff to administer treatments as ordered and monitor for effectiveness, staff to apply protective skin barrier sprays/ointments as ordered by physician, staff to assess, record, and monitor wound healing with wound care, and staff to encourage and assist with turning and repositioning every two hours. Review of a physician order dated 06/07/24 revealed Resident #51 was ordered for staff to cleanse the area to the sacrum with soap and water, apply betadine fluffed gauze followed by Calmoseptine buttered abdominal pad every morning and at bedtime for wound care with instructions to assess for pain prior to the dressing change. Review of a physician order dated 06/07/24 revealed Resident #51 was ordered weekly skin assessments every Monday evening for monitoring. Review of the weekly skin assessments revealed Resident #51 did not have a weekly skin assessment completed on 05/06/24, 06/14/24, and 06/21/24. Interview on 06/25/24 at 12:00 P.M. with Director of Nursing (DON) verified Resident #51's weekly skin assessments were not completed as ordered. Review of the facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical ProtocolBased on medical record review, staff interview, and review of a facility policy, the facility failed to appropriately assess pressure ulcers as required. This affected one (#51) of one resident reviewed for pressure ulcers. The facility census was 51.

Findings include:

Review of the medical record for Resident #51 revealed an admission of 04/01/24. Diagnoses included dementia, atrial fibrillation, type two diabetes mellitus, protein-calorie malnutrition, and malignant neoplasm of prostate.

Review of the significant change Minimum Data Set (MDS) assessment dated 06/13/24 revealed Resident #51 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of six. The resident was assessed to require supervision with eating, and was dependent with toileting, bathing, dressing, and transfers.

Review of the care plan dated 05/15/24 revealed Resident #51 had a stage four pressure ulcer (full thickness skin and tissue loss) of the coccyx/sacrum related to impaired mobility, refusal of care, refusal to get out of bed, and impaired nutrition. Interventions included to administer medications as ordered, staff to administer treatments as ordered and monitor for effectiveness, staff to apply protective skin barrier sprays/ointments as ordered by physician, staff to assess, record, and monitor wound healing with wound care, and staff to encourage and assist with turning and repositioning every two hours.

Review of a physician order dated 06/07/24 revealed Resident #51 was ordered for staff to cleanse the area to the sacrum with soap and water, apply betadine fluffed gauze followed by Calmoseptine buttered abdominal pad every morning and at bedtime for wound care with instructions to assess for pain prior to the dressing change.

Review of a physician order dated 06/07/24 revealed Resident #51 was ordered weekly skin assessments every Monday evening for monitoring.

Review of the weekly skin assessments revealed Resident #51 did not have a weekly skin assessment completed on 05/06/24, 06/14/24, and 06/21/24.

Interview on 06/25/24 at 12:00 P.M. with Director of Nursing (DON) verified Resident #51's weekly skin assessments were not completed as ordered.

Review of the facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol

Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure resident fall risks were assessed after falls to determine risk factors to the resident. This affected two (#23 and #27) of four residents reviewed for falls. The facility census was 51.

Findings include:

1. Review of the medical record for Resident #23 revealed an admission date of 03/26/24. Diagnoses included type two diabetes mellitus, chronic kidney disease, depression, and atrial fibrillation.

Review of the admission Minimum Data Set (MDS) assessment dated 03/30/24 revealed Resident #23 had severe cognitive impairment. The resident was assessed to require supervision with eating, and substantial assistance with toileting, bathing, and dressing, and dependent with transfers.

Review of the care plan dated 03/26/24 revealed Resident #23 was at risk for falls related to deconditioning and gait/balance problems. Interventions included Dycem (non-slip device) to wheelchair to reduce risk for sliding out of the seat, staff to keep frequently used items within reach, staff to monitor positioning when up in wheelchair, staff to apply nonskid socks to be worn in bed, and staff will ensure the room was free of clutter and spills.

Review of the medical record for Resident #14 revealed a fall risk assessment had not been completed after a fall on 04/03/24, 04/11/24, 04/20/24, and 05/10/24 to identify potential risk factors which contributed to the falls.

Interview on 06/25/24 at 10:49 A.M. with MDS Nurse #22 verified she was only completing a fall risk assessment on residents when they were due for the admission or quarterly MDS assessments.

Interview on 06/26/24 at 1:28 P.M. with the Director of Nursing (DON) verified Resident #23 had not had a fall risk assessment completed after multiple falls.

2. Review of Resident #27's medical record revealed the resident was admitted to the facility on 05/21/24. Diagnoses included chronic obstructive pulmonary disease, heart disease, dementia, anxiety, malnutrition, and chronic constipation.

Review of the MDS assessment dated 05/23/24 revealed Resident #27 had severely impaired cognition and required partial assistance to walk, was dependent on staff for transfers, and required partial assistance for eating. Further review of the the assessment revealed the resident had a history of falls prior to admission within the previous two to six months.

Review of Resident #27's fall investigations revealed the resident fell on 06/03/24 in the lounge area, fell on 06/09/24 which required evaluation in the hospital, fell in the bathroom on 06/19/24, and fell from a reclining chair on 06/21/24 and 06/23/24. Further review of Resident #27's medical record revealed no fall risk assessments were completed following the resident's falls on 06/03/24, 06/09/24, 06/19/24, 06/21/24, or 06/23/24 to identify potential risk factors which contributed to the falls.

Interview on 06/26/24 at 1:30 P.M. with the Director of Nursing (DON) verified there had been no fall risk assessments completed with Resident #27's falls on 06/03/24, 06/09/24, 06/19/24, 06/21/24, and 06/23/24. The DON stated fall risk assessments should be completed at admission, after each fall, quarterly, and if there was a significant change in clinical status.

Review of an undated facility policy titled, Falls, revealed the facility will identify and evaluate the resident's specific fall risks to reduce the risk of falls.

Based on medical record review and staff interview, the facility failed to ensure nutritional assessments were completed and interventions were put into place timely for residents with significant weight loss and at risk for nutritional deficits. This affected two (#18 and #51) of four residents reviewed for nutrition. The facility census was 51.

Findings include:

1. Review of Resident #18's medical record revealed the resident was readmitted to the facility on 11/10/23. Diagnoses include malnutrition, heart failure, atrial fibrillation, congestive heart failure , peripheral neuropathy, anemia, thrombophilia, leukemia, and depression.

Review of the comprehensive Minimum Data Set (MDS) assessment dated 05/04/24 revealed Resident #18 had intact cognition and required supervision for meal assistance. The resident received a no added salt diet and a supplement three times a day.

Review of physician orders revealed weekly weights were ordered by the physician on 11/17/23.

Review of the plan of care revealed Resident #18 was a nutritional risk due to being resistive to eating, refusing to eat, expressing weight loss behaviors, and congestive heart failure. Interventions included received a no added salt diet, provide nutritional supplements, and weight monitoring as ordered by the physician.

Reviewed of the weight log revealed Resident #18 weighed 164 pounds on readmission on 11/10/23. On 06/06/24, Resident #18 weighed 150 pounds.

Review of a nutritional assessment dated 11/13/23 was completed by Registered Dietitian (RD) #106. The assessment revealed Resident #18 had a history of 15 percent (%) weight loss over the previous two months prior to admission, and a current weight of 165 pounds. The weight loss was assessed to be related to a diagnoses of depression and a recommendation was made for a no added salt diet due to congestive heart failure and edema.

Further review of Resident #18's medical record between 11/13/23 through 06/25/24 revealed no further nutritional assessments or progress notes were completed.

Interview on 06/25/24 at 1:22 P.M. with RD #106 verified she had not completed a nutritional assessment for Resident #18 since 11/23/23. RD #106 verified she should have completed a nutritional assessment every three months and after a significant change for Resident #18. RD #106 verified Resident #18 had a history of gradual weight loss and changes due to edema, leukemia diagnosis, and eating behaviors including low food intake. RD #106 stated she did not know Resident #18 had physician orders for weekly weight monitoring and verified she had not completed weekly weight monitoring and documentation.

2. Review of the medical record for Resident #51 revealed an admission of 04/01/24. Diagnoses included dementia, atrial fibrillation, type two diabetes mellitus, protein-calorie malnutrition, and malignant neoplasm of prostate.

Review of the significant change MDS assessment dated 06/13/24 revealed Resident #51 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of six. The resident was assessed to require supervision with eating, and was dependent with toileting, bathing, dressing, and transfers.

Review of the care plan dated 04/02/24 revealed Resident #51 had a potential nutritional problem due to anorexia related to dementia, resistive to eating, and protein-calorie malnutrition. Interventions included to administer medications to stimulate appetite per physician order, administer vitamin and mineral supplements per orders, provide and serve diet as ordered and monitor intake and record every meal, registered dietician to evaluate and make diet change recommendations as needed, and provide and serve supplements as ordered.

Review of the medical record for Resident #51 revealed the resident had a 6.97% weight loss over one month when the resident was noted as weighing 160.8 pounds on 04/12/24 and 149.6 pounds on 05/14/24.

Review of Resident #51's physician orders revealed no interventions were implemented to address Resident #51's weight loss until 06/07/24.

Interview on 06/25/24 at 2:02 P.M. with RD #106 revealed she was not made aware of Resident #51's weight loss and verified proper interventions were not put in place to address timely the resident's weight loss.

Based on observation, medical record review, and staff interview, the facility failed to perform adequate hand hygiene and provide care in a manner to prevent potential contamination during wound and urinary catheter care. Additionally, the facility failed to ensure residents were placed on enhanced barrier precautions as required for residents with wounds and/or indwelling medical devices. This affected one (#51) resident of six residents reviewed for infection control measures. The facility census was 51.

Findings include:

Review of the medical record for Resident #51 revealed an admission date of 04/01/24. Diagnoses included dementia, atrial fibrillation, type two diabetes mellitus, protein-calorie malnutrition, and malignant neoplasm of prostate.

Review of the significant change Minimum Data Set (MDS) assessment dated 06/13/24 revealed Resident #51 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of six. The resident was assessed to require supervision with eating, and was dependent with toileting, bathing, dressing, and transfers.

Review of the care plan dated 05/01/24 revealed Resident #51 had an indwelling urinary catheter related to obstructive uropathy and malignant neoplasm of the prostate. Interventions included to administer medications per physician orders, change drainage bag weekly and as needed, provide catheter care every shift with soap and water, check tubing for kinks each shift and with care, and monitor and document for pain and discomfort due to catheter.

Review of the care plan dated 05/15/24 revealed Resident #51 had a stage four pressure ulcer (full-thickness skin and tissue loss) of the coccyx/sacrum related to impaired mobility, refusal of care, refusal to get out of bed, and impaired nutrition. Interventions included to administer medications as ordered, administer treatments as ordered and monitor for effectiveness, apply protective skin barrier sprays/ointments as ordered by physician, to assess, record, and monitor wound healing with wound care, and staff to encourage and assist with turning and repositioning every two hours.

Review of a physician order dated 06/07/24 revealed Resident #51 was ordered for staff to cleanse the area to the sacrum with soap and water, apply betadine fluffed gauze followed by a Calmoseptine buttered abdominal pad every morning and at bedtime for wound care. Further review included instructions to assess for pain prior to the dressing change.

Review of a physician order dated 06/07/24 revealed Resident #51 was ordered to have staff provide urinary catheter (Foley) care with soap and water every shift.

Observation on 06/25/24 at 11:06 A.M. of wound care to Resident #51's coccyx completed by Licensed Practical Nurse (LPN) #56 revealed LPN #56 washed her hands and put on gloves prior to the dressing change. After removing the soiled dressing, LPN #56 removed her gloves but did not perform hand hygiene. LPN #56 put on a new pair of gloves and cleansed the wound bed.

Observation on 06/25/24 at 11:18 A.M. of catheter care to Resident #51's urinary catheter performed by State Tested Nurse Aide (STNA) #39 revealed STNA #39 assisted LPN #56 with wound care prior to completing catheter care. STNA #39 did not remove gloves or perform hand hygiene before starting catheter care. During catheter care, STNA #39 cleaned the catheter tubing cleaning down and back to the urethra causing potential contamination.

Observation during wound and catheter care on 06/25/24 between 11:06 A.M. and 11:18 A.M. revealed Resident #51 had no signs posted to indicated the resident was on enhanced barrier precautions.

Interview on 06/25/24 at 11:28 A.M. with LPN #56 verified she did not perform hand hygiene when she removed her gloves after removing the old, soiled dressing from Resident #51's coccyx.

Interview on 06/25/24 at 11:30 A.M. with STNA #39 verified she did not remove gloves or perform hand hygiene after assisting LPN #56 with wound care and beginning on Resident #51, and verified she failed to cleanse Resident #51's catheter tubing away from the urethra.

Interview on 06/26/24 at 11:48 A.M. with the Director of Nursing (DON) verified Resident #51 should be in enhanced barrier precautions. The DON reported the facility did not currently have a policy for enhanced barrier precautions.

Based on medical record review, staff interview, and policy review, the facility failed to ensure resident pneumococcal vaccinations were up to date. This affected five (#15, #17, #18, #19, and #37) of five residents reviewed for pneumococcal vaccinations. The facility census was 51. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 11/21/17. Diagnoses included acute kidney failure, major depressive disorder, acute respiratory failure with hypoxia, and metabolic encephalopathy. Review of the medical record for Resident #15 revealed Pneumococcal vaccine Prevnar 13 was given on 07/21/15. Resident #15 should have received Prevnar 20 (PCV20) or Pneumovax 23 (PPSV23) one year after PCV13; however, there was no documentation either was given. 2. Review of the medical record for Resident #17 revealed an admission date of 08/21/17. Diagnoses included type two diabetes mellitus, chronic kidney disease stage three, and chronic obstructive pulmonary disease (COPD). Review of the medical record for Resident #17 revealed the resident refused a pneumococcal vaccine on 08/24/17. Resident #17 was not offered the pneumococcal vaccine since the refusal in 2017. 3. Review of the medical record for Resident #18 revealed an admission date of 08/30/22. Diagnoses included congestive heart failure (CHF), atrial fibrillation, chronic lymphocytic leukemia, and dementia. Review of the medical record for Resident #18 revealed Pneumococcal vaccine Prevnar 13 was given on 06/01/08. Resident #18 should have received Prevnar 20 (PCV20) or Pneumovax 23 (PPSV23) one year after PCV13; however, there was no documentation either was given. 4. Review of the medical record for Resident #19 revealed an admission date of 05/24/22. Diagnoses included CHF, type two diabetes mellitus, and bipolar disorder. Review of the medical record for Resident #19 revealed Pneumococcal vaccine Prevnar 13 was given on 10/10/21. Resident #19 should have received Prevnar 20 (PCV20) or Pneumovax 23 (PPSV23) one year after PCV13; however, there was no documentation either was given. 5. Review of the medical record for Resident #37 revealed an admission date of 08/17/23. Diagnoses included atrial fibrillation, chronic kidney disease stage three, and CHF. Review of the medical record for Resident #37 revealed Pneumococcal vaccine Prevnar 13 was given on 03/18/16. Resident #37 should have received Prevnar 20 (PCV20) or Pneumovax 23 (PPSV23) one year after PCV13; however, there was no documentation either was given.. Interview on 06/26/24 at 1:25 P.M. with the Director of Nursing (DON) verified Resident #15, Resident #17, Resident #18, Resident #19, and Resident #37 were not up to date for the pneumococcal vaccine. Review of the facility policy titled, Pneumococcal VaccineBased on medical record review, staff interview, and policy review, the facility failed to ensure resident pneumococcal vaccinations were up to date. This affected five (#15, #17, #18, #19, and #37) of five residents reviewed for pneumococcal vaccinations. The facility census was 51.

Findings include:

1. Review of the medical record for Resident #15 revealed an admission date of 11/21/17. Diagnoses included acute kidney failure, major depressive disorder, acute respiratory failure with hypoxia, and metabolic encephalopathy.

Review of the medical record for Resident #15 revealed Pneumococcal vaccine Prevnar 13 was given on 07/21/15. Resident #15 should have received Prevnar 20 (PCV20) or Pneumovax 23 (PPSV23) one year after PCV13; however, there was no documentation either was given.

2. Review of the medical record for Resident #17 revealed an admission date of 08/21/17. Diagnoses included type two diabetes mellitus, chronic kidney disease stage three, and chronic obstructive pulmonary disease (COPD).

Review of the medical record for Resident #17 revealed the resident refused a pneumococcal vaccine on 08/24/17. Resident #17 was not offered the pneumococcal vaccine since the refusal in 2017.

3. Review of the medical record for Resident #18 revealed an admission date of 08/30/22. Diagnoses included congestive heart failure (CHF), atrial fibrillation, chronic lymphocytic leukemia, and dementia.

Review of the medical record for Resident #18 revealed Pneumococcal vaccine Prevnar 13 was given on 06/01/08. Resident #18 should have received Prevnar 20 (PCV20) or Pneumovax 23 (PPSV23) one year after PCV13; however, there was no documentation either was given.

4. Review of the medical record for Resident #19 revealed an admission date of 05/24/22. Diagnoses included CHF, type two diabetes mellitus, and bipolar disorder.

Review of the medical record for Resident #19 revealed Pneumococcal vaccine Prevnar 13 was given on 10/10/21. Resident #19 should have received Prevnar 20 (PCV20) or Pneumovax 23 (PPSV23) one year after PCV13; however, there was no documentation either was given.

5. Review of the medical record for Resident #37 revealed an admission date of 08/17/23. Diagnoses included atrial fibrillation, chronic kidney disease stage three, and CHF.

Review of the medical record for Resident #37 revealed Pneumococcal vaccine Prevnar 13 was given on 03/18/16. Resident #37 should have received Prevnar 20 (PCV20) or Pneumovax 23 (PPSV23) one year after PCV13; however, there was no documentation either was given..

Interview on 06/26/24 at 1:25 P.M. with the Director of Nursing (DON) verified Resident #15, Resident #17, Resident #18, Resident #19, and Resident #37 were not up to date for the pneumococcal vaccine.

Review of the facility policy titled, Pneumococcal Vaccine

Based on interview and record review, the facility failed to ensure a resident's pain was addressed. This affected one resident (#29) of one resident reviewed for pain. The facility census was 52.

Findings include:

Review of the medical record revealed Resident #29 admitted to the facility on 03/01/23 with diagnoses including hypertensive heart disease with heart failure, pulmonary hypertension, congestive heart failure, type two diabetes mellitus with diabetic neuropathy, hyperlipidemia, bipolar disorder, gastro esophageal reflux disease without esophagitis, post traumatic stress disorder, anemia, asthma, restless legs syndrome, obstructive sleep apnea, and major depressive disorder.

Review of Resident #29's annual Minimum Data Set (MDS) assessment dated 04/05/24 revealed the resident was cognitively intact. Resident #29 received opioid medication during the review period and rated her worst pain over the past five days as a four out of ten.

Review of Resident #29's opioid medication care plan dated 04/08/24 revealed Resident #29 used opioid medication for treatment of chronic pain. Interventions included administer opioid medication as ordered by the physician and monitor for side effects and effectiveness, the physician to review medications for possible dose reduction and monitor, document, and report as needed any adverse reactions of medications.

Review of Resident #29's pain care plan dated 03/19/24 revealed Resident #29 had chronic pain due to neuropathy, an old injury of the back from a fall, radiculopathy lumbosacral region, restless leg syndrome, arthropathy, diabetes mellitus neuropathy, and chronic headaches. Interventions included administer analgesia and medication for treatment of pain per orders, evaluate the effectiveness of pain interventions, monitor and document for side effects of pain medication, monitor and record pain characteristics and monitor and report to nurse any signs and symptoms of nonverbal pain.

Review of Resident #29's physician order dated 05/26/23 and discontinued 04/22/24 revealed Resident #29 was ordered Oxycodone 10 milligrams (mg) give two tablets by mouth two times a day for pain and give two tablets by mouth every eight hours as needed for pain.

Review of Resident #29's physician order dated 04/08/24 revealed Resident #29 was ordered Oxycodone 10 mg give two tablets by mouth two times a day for pain and give two tablets by mouth every eight hours as needed for pain.

Review of Resident #29's physician order dated 03/09/23 revealed Resident #29 was ordered Lyrica 200 mg give by mouth three times a day for pain.

Review of Resident #29's Medication Administration Record (MAR) from 04/01/24 to 4/30/24 revealed Resident #29's Oxycodone was not given on 04/05/24 at 6:00 A.M., 04/05/24 at 7:00 P.M., 04/06/24 at 6:00 A.M., 04/06/24 at 7:00 P.M., 04/07/24 at 6:00 A.M., 04/07/24 at 7:00 P.M., 04/08/24 at 6:00 A.M., 04/16/24 at 7:00 P.M., 04/18/24 at 7:00 P.M. and on 04/23/24 at 6:00 A.M. Resident #29's MAR listed her pain level as a seven on 04/06/24 at 7:00 P.M. and an ten on 04/08/24 at 6:00 A.M. when her pain medication was not given. Resident #29 did not receive any as needed Oxycodone on 04/05/24, 04/06/24, 04/07/24, 04/08/24, 04/16/24, 04/18/24 and on 04/23/24. Resident #29's Lyrica 200 mg was not given on 04/16/24 at 8:00 P.M., 04/18/24 at 8:00 P.M., 04/20/24 at 12:00 P.M., 04/21/24 at 8:00 A.M., 04/21/24 at 12:00 P.M., 04/21/24 at 8:00 P.M., 04/22/24 at 8:00 A.M., and on 04/22/24 at 12:00 P.M. Further review of the MAR revealed Resident #29's pain assessment was a zero on day shift, a four on evening shift and a five on night shift on 04/05/24, a zero for all three shifts on 04/06/24, a zero on day and evening shift and a ten on night shift on 04/07/24, a ten on day shift, a nine on evening shift and a zero on night shift on 04/08/24, a zero on day and evening shift on 04/16/24, a zero on day and evening shift on 04/18/24 and a seven on day shift and a zero on night shift on 04/23/24.

Review of the facility's fax dated 04/03/23 revealed a request to refill Resident #29's Oxycodone was sent to Resident #29's physician.

Review of Resident #29's progress note dated 04/06/24 revealed the facility was awaiting Resident #29's Oxycodone 10 mg from the pharmacy.

Review of the facility's fax dated 04/07/24 revealed Resident #29 continued with pain complaints. Resident #29 needed Oxycodone refilled. Physician #950 sent back a response that stated, print script and I'll fill out. The facility sent another response to Physician #950 that stated the facility was unable to print a script at that time and asked if Physician #950 could call it in. Physician #950 sent another response that stated no and we don't do refills on the weekends, and I was in Friday.

Review of Resident #29's progress note dated 04/07/24 revealed the pharmacy was unable to send Resident #29's Oxycodone and the physician was unable to call into the pharmacy and unable to send a prescription. A hard copy prescription was requested, and staff will fax in the morning.

Review of Resident #29's progress note dated 04/07/24 revealed Resident #29's Oxycodone was on order and will be given upon arrival.

Review of Resident #29's progress note dated 04/20/24 revealed the pharmacy was notified to send Resident #29's Lyrica.

Review of Resident #29's progress note dated 04/21/24 revealed Resident #29's Lyrica was not available.

Review of Resident #29's progress note dated 04/20/24 revealed the facility was awaiting Resident #29's Lyrica from the pharmacy.

Observation of Resident #29 on 05/02/24 at 9:45 A.M. revealed Resident #29 was laying in her bed in her room. Resident #29 was clean and appropriately dressed.

Interview with Resident #29 on 05/02/24 at 9:45 A.M. revealed Resident #29 did not receive her Oxycodone one weekend and her Lyrica on a different weekend due to her medications running out and the pharmacy being unable to refill her medication on the weekend. Resident #29 did not remember the dates she did not receive her Oxycodone or her Lyrica but reported she was in pain both weekends. Resident #29 reported she was given Tylenol for pain on both weekends but that did not help with her pain.

Interview with the Director of Nursing (DON) on 05/02/24 at 3:15 P.M. verified Resident #29's Oxycodone 10 mg give two tablets by mouth two times a day for pain was not given on 04/05/24 at 6:00 A.M., 04/05/24 at 7:00 P.M., 04/06/24 at 6:00 A.M., 04/06/24 at 7:00 P.M., 04/07/24 at 6:00 A.M., 04/07/24 at 7:00 P.M., 04/08/24 at 6:00 A.M., 04/16/24 at 7:00 P.M., 04/18/24 at 7:00 P.M. and on 04/23/24 at 6:00 A.M. The DON also confirmed Resident #29's MAR listed her pain level as a seven on 04/06/24 at 7:00 P.M. and a ten on 04/08/24 at 6:00 A.M. when her pain medication was not given. The DON also verified Resident #29 did not receive any as needed Oxycodone on 04/05/24, 04/06/24, 04/07/24, 04/08/24, 04/16/24, 04/18/24 and on 04/23/24 due to the facility not having any Oxycodone in the emergency box and Resident #29 not having any Oxycodone in the facility because the as needed and routine Oxycodone was on the same medication card. The DON also confirmed Resident #29's Lyrica 200 mg give by mouth three times a day for pain was not given on 04/16/24 at 8:00 P.M., 04/18/24 at 8:00 P.M., 04/20/24 at 12:00 P.M., 04/21/24 at 8:00 A.M., 04/21/24 at 12:00 P.M., 04/21/24 at 8:00 P.M., 04/22/24 at 8:00 A.M., and on 04/22/24 at 12:00 P.M. The DON also confirmed Resident #29's pain assessment on the MAR on 04/05/24 was a zero on day shift, a four on evening shift and a five on night shift on 04/05/24, a zero for all three shifts on 04/06/24, a zero on day and evening shift and a ten on night shift on 04/07/24, a ten on day shift, a nine on evening shift and a zero on night shift on 04/08/24, a zero on day and evening shift on 04/16/24, a zero on day and evening shift on 04/18/24 and a seven on day shift and a zero on night shift on 04/23/24. The DON stated the facility had sent a refill request for Resident #29's Oxycodone to Physician #950 on 04/03/24 prior to Resident #29 running out of Oxycodone. The DON reported Resident #29's last Oxycodone was administered on 04/04/24 and Tylenol was administered on 04/05/25 and 04/06/24. The DON stated the facility sent faxes to Physician #950 on 04/07/24 and Physician #950 sent back a note stating that they would not refill Resident #29's Oxycodone on the weekends. The DON reported Resident #29's Lyrica refill request was sent to the pharmacy, but the pharmacy had an error and did not send the medication.

Review of the pain assessment and management policy dated September 2021 revealed pharmacological interventions may be prescribed to manage pain.

This deficiency represents non-compliance investigated under Complaint Number OH00152828 and OH00152846.

Based on observation, interview, and record review, the facility failed to ensure a resident's insulin pen was primed according to manufacturer guidelines resulting in a significant medication error. This affected one (Resident #8) of five residents observed for medication administration. The facility census was 52.

Findings include:

Review of the medical record for Resident #8 revealed an admission date of 11/09/19. Medical diagnoses included but were not limited to diabetes mellitus, evans syndrome, dementia and heart failure.

Review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated 02/10/24 revealed a Brief Interview Mental Status (BIMS) score of 14 indicating intact cognition. Resident #8 required moderate assistance for toileting, transfers, and bed mobility.

Review of the active physicians orders for Resident #8 revealed an order dated 03/20/24 for NovoLOG Injection Solution 100 unit/milliliters (ml) (Insulin Aspart), inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, over 400 call the physician, subcutaneously before meals and at bedtime for diabetes mellitus.

Observation on 05/08/24 at 11:50 A.M. of Registered Nurse #00 administering medications to Resident #8 revealed during the administration of 2 units of novolog injection solution, RN #00 took the cap off of the Novolog pen, swabbed the hub with alcohol, applied the needle but did not prime it before she turned the dial to 2. RN #00 verified she failed to prime the needle prior to drawing up the prescribed 2 units of insulin.

Review of the manufacturer's instruction for Novolog insulin revealed step seven was to prime the pen by turning the dose selector to two units and while holding the pen up push and hold the green push button and ensure a drop of insulin appeared at the needle tip.

This deficiency represents non-compliance investigated under Complaint Number OH00152846.

Based on medical record review, observation, and interviews, the facility failed to ensure nurses handled resident medications in a sanitary manner. This affected two (Residents #3 #22) of five residents observed for medication administration. Facility census was 52.

Findings include:

1. Review of the medical record for Resident #3 revealed an admission date of 01/27/23 with diagnoses including but not limited to dementia without behavioral disturbances, hypertension, wernicke's encephalopathy, anemia, and alcoholic cirrhosis.

Review of the quarterly Minimum Data Set (MDS) assessment dated 03/15/24 for Resident #3 revealed intact cognition. Resident #3 was dependent for toileting and transfers, and required moderate assistance for bed mobility and transfers.

Review of the active physicians orders for Resident #3 revealed an order for cranberry oral tablet give two tablets by mouth three times a day.

Observation on 05/08/24 at 11:20 A.M. of medication administration with Registered Nurse (RN) #225 to Resident #3 revealed the nurse carried the large bottle of facility stock (medications used for multiple residents) cranberry tablets into the resident's room and placed the bottle on the dresser. Observations revealed the stock cranberry tablet bottle was placed on Resident #3's dresser without a barrier and without cleaning/disinfecting the surface where the stock medication bottle was placed. RN #225 opened the bottle and poured two tablets into a medication cup and replaced cap. RN #225 administered the medication to the resident and exited the room. RN #225 returned to the medication cart and placed the bottle of cranberry tablets into the medication cart along with other resident medications without cleaning/disinfecting the bottle.

Interview on 05/08/24 at 11:31 A.M. with RN #225 verified she did not clean the multidose bottle of cranberry tablets before placing them back into the medication cart with the other over the counter medication bottles.

2. Medical record review for Resident #22 revealed an admission date of 06/26/18 with diagnoses including but not limited to Alzheimer disease, dementia, hypertension, hypothyroidism, hyperlipidemia, major depressive disorder, dorsalgia, macular degeneration, migraine, and anxiety.

Review of the quarterly MDS assessment dated 04/03/24 for Resident #22 revealed an intact cognition. Resident #22 required supervision for eating, bed mobility and transfers. Resident #22 required moderate assistance for toileting.

Review of the active physician orders for Resident #22 revealed the resident had the following medications scheduled for morning administration: Tylenol Oral Tablet 325 mg give two tablets by mouth two times a day, B-Complex oral tablet give one capsule by mouth one time a day, Senna Plus tablet 8.6-50 mg give 1 tablet by mouth one time a day, zinc tablet 50 mg give 50 mg by mouth two times a day, vitamin D capsule give 1000 units by mouth one time a day.

Observation on 05/08/24 at 9:15 A.M. of RN #225 preparing medication for administration to Resident #22 revealed RN #225 carried facility stock bottles of B-complex, Senna Plus, Vitamin D, Tylenol and Zinc into the resident's room and set them on the bedside table without a barrier and without cleaning the bedside table. RN #225 then completed hand hygiene and donned gloves, poured prescribed medication from each bottle into a medication administration cup and offered it to the resident. RN #225 then completed hand hygiene and returned to the resident's bedside. RN #225 then placed the contaminated gloves she had removed prior to completing hand hygiene onto the top of the Tylenol multidose bottle. RN #225 donned gloves and administered the artificial tears eye drops into both eyes of Resident #22. RN #225 went to the residents bathroom and completed hand hygiene returning to the residents bedside with a second set of contaminated gloves. RN #225 retrieved the plastic cup that had contained water for the resident to take her medication with and put the second pair of gloves into the cup, picked up the contaminated gloves from the top of the Tylenol bottle and placed them in the cup. RN #225 then carried the five bottles in her left arm touching her uniform and returned to the medication cart. RN #225 then disposed of the cup with the gloves in it, and placed the bottles on the cart without cleaning/disinfecting them. RN #225 then placed all five bottles back into the medication cart with other resident medications without cleaning/disinfecting them.

Interview on 05/08/24 at 9:30 A.M. with RN #225 stated she did not dispose of the gloves into the residents trash bin in the bathroom because there was nothing in the trash bin and she did not want to leave trash in the residents room. RN #225 verified she placed contaminated gloves on the top of the Tylenol bottle and should not have. Further verified she does not know the policy for the facility related to the multidose bottles being taken into residents rooms.

Interview on 05/08/24 at 1:35 P.M. with Director of Nursing (DON) verified that multidose bottles of medication should not be carried into the residents rooms. Additionally, verified that gloves should be placed in to the appropriate trash receptacle in the resident bathroom when appropriate.

Request for a policy related to medication administration related to multidose bottles was requested during the survey and was advised by the DON that the facility did not have a policy.

The following deficiency is based on incidental findings discovered during the course of this complaint investigation.