Mcnaughten Pointe Nursing and Rehab

Based on medical record review and staff interview, the facility failed to offer/complete therapy orders as expected. This affected one (Resident #64) of three resident medical records reviewed. The census was 125.

Findings Include:

Resident #64 was admitted to the facility on 08/25/23. Her diagnoses were end stage renal disease, dependence on renal dialysis, type II diabetes, hypertensive heart and chronic kidney disease, anemia, congestive heart failure, hyperlipidemia, mild cognitive impairment, insomnia, anxiety disorder, age related nuclear cataract, macular degeneration, and hyperkalemia.

Review of her minimum data set (MDS) assessment, dated 08/13/24, revealed she had a mild cognitive impairment.

Review of Resident #64 physician orders, dated 10/15/24, revealed she was ordered physical therapy three to five times per week, for 30 days.

Review of Resident #64 physical therapy notes, dated 10/15/24 to 10/31/24, revealed her rolling week of therapy was from Tuesdays to Monday. During the first week of ordered physical therapy (10/15/24 to 10/21/24), she was offered therapy on Tuesday, 10/15/24, Friday, 10/18/24, and Monday 10/21/24 of the first week she was ordered physical therapy. She completed therapy on 10/15/24 and 10/21/24, but she did not complete it on 10/18/24; her documentation stated she was unavailable. On the second week of ordered physical therapy (10/22/24 to 10/30/24), she was offered therapy on Thursday, 10/24/24, Friday, 10/25/24, and Monday, 10/28/24. She completed therapy on 10/28/24, but she did not complete therapy on 10/24/24 (documented as being sick), and 10/25/24 (documented as being unavailable). There was no other documentation to support that she was offered therapy more than three times per week, and she was not offered therapy to make up for the days that she missed to meet the ordered three to five times per week.

Interview with Therapy Director #501 on 10/31/24 at 12:45 P.M. confirmed Resident #64 was to have physical therapy three to five times per week. She also confirmed that if a resident misses a therapy session for any reason (being sick, physician/medical appointment, etc), they have enough openings in their schedule each week to offer more therapy opportunities to each of the residents on their case load. She confirmed there were only three attempts to perform physical therapy for Resident #64 and they should have offered it more time. She confirmed she does not know why it wasn't offered more. She also confirmed Resident #64 did not complete physical therapy at least three times per week.

Interview with Director of Nursing (DON) on 10/31/24 at 3:30 P.M. confirmed Resident #64 attends dialysis three times weekly, which would affect the dates/times she would be able to perform physical therapy.

This deficiency represents non compliance under Complaint Number OH00158713.

Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure residents were dressed in a dignified manner. This affected one (Resident #57) out of three residents reviewed for dignity. The census was 117.

Findings include:

Review of the medical record for Resident #57 revealed an admission date of 04/18/23. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, diabetes, and muscle wasting and atrophy.

Review of the Minimum Data Set assessment, dated 12/18/23, revealed Resident #57 was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. Resident #57 required substantial/maximal assist with upper body dressing and was dependent for lower body dressing.

Review of the plan of care, dated 12/21/23, revealed Resident #57 required assistance with activities of daily living (ADL) due to decreased self-performance with interventions to allow time for breaks, max assistance for upper body dressing and dependence on one to two staff for lower body dressing.

Observation and interview on 03/04/24 at 11:45 A.M. revealed Resident #57 was wearing a medical gown. Resident #57 indicated staff had not got her up and dressed for the day.

Observation and interview on 03/05/24 at 9:04 A.M. with Resident #57 revealed she was wearing a medical gown. Resident #57 revealed she would prefer to wear clothes and revealed sometimes staff forget about her and don't get her up and ready for the day since I stay in bed most of the day. She revealed she was not sure how much clothing she had available. Resident #57 gave the state surveyor permission to look in her clothing dresser and only socks and blankets were present in the clothing dresser. Resident #57 revealed she was typically left in a gown at all times.

Observation on 03/05/24 at 1:00 P.M. revealed Resident #57 was wearing a medical gown.

Observation on 03/06/24 at 10:55 A.M., 2:40 P.M. and 5:35 P.M. revealed Resident #57 was wearing a medical gown.

Observation and interview on 03/07/24 at 8:28 A.M. with Resident #57 and State Tested Nursing Aide (STNA) #287 revealed Resident #57 was wearing a medical gown. Resident #57 revealed she had been cleaned up already that morning. STNA #287 confirmed Resident #57 was typically in a medical gown and was wearing a medical gown at the time of interview. STNA #287 revealed Resident #57 had clothes that were likely in the laundry and the laundry gets delivered on Thursday's. STNA #287 revealed staff would put a gown on until her clothes returned from the laundry. STNA #287 also revealed the facility had extra clothing which was kept in the laundry room and was provided to the facility through donations. Resident #57 revealed she was agreeable to the facility providing donated clothing for her to wear.

Based on observations, resident interview and staff interviews, the facility failed to ensure a homelike environment was provided for two Residents (#8 and #9) of two reviewed for homelike environment. Facility census was 117.

Findings include

1. Review of the medical record for Resident #8 revealed an admission date of 12/29/21. Diagnoses included quadriplegia c5-c7 incomplete, respiratory failure, dysphagia, and contracture of multiple unspecified sites.

Review of the Minimum Data Set (MDS) assessment dated 02/12/24 revealed Resident #8 was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15 and required substantial/maximum assistance dependence on staff for mobility and hygiene.

Review of the plan of care dated 02/14/24 revealed resident had oral intake with help of tube feeds with interventions to provide tube feeding as ordered, dressing changes to the tube site and flushes as ordered.

Observation and interview on 03/04/24 at 10:49 A.M. revealed resident had a metal cart with over 10 boxes piled on it and resident stated it was likely his tube feeding supplies. The boxes were stacked chest high against the wall across from resident bed. Resident #8 revealed the boxes had been there pretty much since admission.

Interview on 03/04/24 at 4:50 P.M. with State Tested Nursing Aide (STNA) #272 confirmed items in residents room included feeding tube supplies and wound dressing supplies she revealed she did not know why they were in resident's room and not in a facility storage area. She confirmed having boxes stacked of medical equipment in the residents room next to his bed is not a clean homelike environment.

Interview on 03/04/24 at 5:20 P.M. with Licensed Practical Nurse (LPN) #165 revealed she was working on moving the boxes and placing them in a cabinet that had space in the resident's room. LPN #165 also confirmed having stacked boxes of medical supplies was not homelike. She revealed they were billed under resident's Medicare part B insurance and needed to keep them just for Resident #8.

2. Review of the medical record for Resident #9 revealed an admission date of 01/26/16. Diagnoses included schizoaffective disorder, diabetes, atrial fibrillation, contracture of the right and left hands and unspecified psychosis.

Review of the MDS assessment dated 02/26/24 revealed Resident #9 was cognitively impaired with a BIMS of 8 out of 15 and was dependent on staff assistance for all mobility.

Observation and interview on 03/04/24 at 5:12 P.M. revealed her bedside curtain by the window was dirty with over 20 spots or brown and red splattering from four feet high to the ground. Resident also confirmed the curtain looked dirty.

Observation on 03/05/24 at 10:05 A.M., 2:40 P.M., and 4:55 P.M. revealed curtain remained soiled with several brown and red spots.

Observation on 03/06/24 at 11:20 A.M., 12:50 P.M., and 3:10 P.M. revealed curtain remained soiled with several brown and red spots.

Observation and interview on 03/07/24 at 8:50 A.M. with STNA #259 confirmed Resident #9's curtain had numerous stains on it and was dirty. She revealed it should be taken down and washed and replaced with a clean curtain.

Facility reported they have no policy related to providing and ensuring a homelike environment.

Based on resident interview, staff interviews, and record review ,the facility failed to ensure care conferences were held with members of the interdisciplinary team including resident participation. This affected two Residents (#57 and #64) of three reviewed for care conferences. Facility census was 117.

Findings include:

1. Review of the medical record for Resident #57 revealed an admission date of 04/18/23. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, diabetes, and muscle wasting and atrophy.

Review of the Minimum Data Set (MDS) assessment dated 12/18/23 revealed Resident #57 was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15 and required substantial/maximal assist and dependence on staff for activities of daily living.

Review progress notes dated 01/09/23 revealed a care conference was held with son upon request as well as a meeting on 02/07/23. Progress note dated 06/30/23 revealed family was sent an invitation to schedule a care conference. Progress note dated 09/30/23 revealed family was sent an invitation to schedule a care conference. Progress note dated 12/29/23 revealed resident and family was sent an invitation to schedule a care conference.

Interview on 03/05/24 at 9:04 A.M. with Resident #57 revealed she would like to attend care conferences but revealed she does not know where they were held and when they were. She also revealed she was unsure if she could attend due to not having any shoes to wear when she leaving her room. Resident revealed she was unaware of being invited to attend or getting information about a care conference meeting being offered.

2. Review of the medical record for Resident #64 revealed an admission date of 02/01/22. Diagnoses included dementia, malnutrition, dysphagia, atrial fibrillation, muscle weakness and insomnia.

Review of the MDS assessment dated 01/16/24 revealed Resident #64 had significant cognitive impairment with a BIMS of 99 and required partial to moderate assistance with dressing, toileting, and personal hygiene.

Review of care conference forms dated 01/13/23 and 02/07/23 revealed Social Services and a Unit Manager was present. Resident's family was marked as being in attendance one of the meetings.

Review progress notes dated 01/13/23 revealed a care conference was held with grandson and a second meeting was held on 02/07/23. Progress note dated 06/30/23 revealed the family was sent an invitation to schedule a care conference. Progress note dated 09/30/23 revealed resident and family was sent an invitation to schedule a care conference. Progress note dated 12/29/23 revealed resident and family was sent an invitation to schedule a care conference.

Facility provided documentation (last pages of care plan) where members of the interdisciplinary team signed off each quarter indicating the care plan had been updated.

Interview on 03/05/24 at 5:05 P.M. with Social Services #319 revealed care conferences are offered and letters are sent out to families but revealed if family did not schedule or want to attend, no care conferences were held. She confirmed facility had no documentation for who attended care conferences and what was discussed as care conferences were not held for Residents #57 and #64 since first quarter of 2023.

Interview on 03/06/24 at 5:00 P.M. with Social Services #319 revealed she was unaware all residents should have quarterly care conference discussions even if the resident and family do not attend.

Interview on 03/11/23 at 5:00 P.M. with Social Services #319 provided documentation that the interdisciplinary team reviewed the care plan, but confirmed the interdisciplinary team did not have a discussion regarding residents overall care as part of the quarterly process. Social Services confirmed residents were sent a letter and they can reach out to staff if they want to attend. Revealed she was trained to provide a letter to prove they were offered a care conference instead of talking with the resident to encourage them to participate in a care conference discussion. Social Services also confirmed letters were mailed 6/30/23, 09/30/23, and 12/29/23 to residents and families. Social Services was unable to provide an explanation if these letters were invitations for the following quarter or the current quarter. If the invitations were sent for the current quarter social services was unable to provide reasoning as to why invitations 24 to 72 hour to get the letter and reach out to the facility to meet the timeframe and letters likely would not have reached residents home by mail prior to the end of the quarter. If the letter invitations were for the following quarter, facility was unable to provide any evidence of facility offering or inviting residents and family for Resident #57 and #64 to attend care conferences.

Interview on 03/11/23 at 5:20 P.M. with Social Services #319 confirmed again the care plan was signed off by several members of the team but had no evidence a discussion was had on each individual residents and confirmed a discussion did not take place.

Interview on 03/12/24 at 6:30 P.M. with Regional Nurse #326 confirmed the employees who signed off on the care plan sheets had updated their sections of the resident's care plan but had not had a meeting or discussion of the revisions that were made.

Review of appendix PP revealed the interdisciplinary (IDT) care team would meets its responsibility in developing the care plan through a means determined by the facility. Examples provided included face to face meetings, teleconference and written communication. It also states that when an IDT members participates via written communication, the medical record must reflect involvement of resident, resident representative, and other members of the interdisciplinary team meeting. The Appendix PP also states facility staff have a responsibility to assist residents to engage in care planning process including encouraging participating for resident in care planning and attending care conferences. Facility must provide advanced notice of care planning conferences to enable resident participation.

Facility did not have a policy related to care conferences and interdisciplinary discussions related to resident care.

Based on observations, resident and staff interviews and record review, facility failed to ensure a resident with hand contracture's was provided with nail trimming and care. This affected one Resident (#8) of one reviewed for nail care for dependent residents. Facility census was 117.

Findings include:

Review of the medical record for Resident #8 revealed an admission date of 12/29/21. Diagnoses included quadriplegia c5-c7 incomplete, respiratory failure, dysphagia, and contracture of multiple unspecified sites.

Review of the Minimum Data Set (MDS) assessment dated 02/12/24 revealed Resident #8 was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15 and required substantial/maximum assistance dependence on staff for mobility and hygiene. The MDS also revealed resident had an upper extremity impairment.

Review of the plan of care dated 02/14/24 revealed resident required total assistance with activities of daily living (ADL) due to decreased self-performance with diagnoses of spinal cord injury, multiple contracture's, range of motion impaired to bilateral upper and lower extremities with interventions for bathing assistance of one to two staff and grooming assistance including nails, shaving and hair required maximum assistance.

Review of shower sheets dated 02/07/24, 02/10/24, 02/14/24, 02/17/24, 02/21/24 and 02/28/24 revealed staff answered no to nails being trimmed and when asked on the form to provide reasoning, staff provided no documented response why nail care was not provided each of these dates.

Review of shower sheets dated 02/24/24, 03/02/24, and 03/06/24 revealed the section regarding whether nail care was provided and the section for staff to explain why it was not provided was not completed.

Observations and interviews on 03/04/24 at 10:51 A.M. with Resident #8 confirmed his hands were contracted with tips of his fingers having contact with his palms. Resident had several nails that were long (over ½ inch growth past the nail bed). Resident revealed he received showers and revealed staff had not trimmed his fingernails in several weeks.

Observation on 03/06/24 at 12:30 P.M. revealed resident was observed to have long fingernails.

Observation and interview on 03/07/24 at 8:33 A.M. with Resident #8 revealed he had long nails and was agreeable to have them cut. Resident revealed staff had not offered recently to trim his nails.

Observation and interview on 03/07/24 at 8:50 A.M. with State Tested Nursing Aide #259 confirmed Resident #8 had long nails and no protection from his nails and his palm skin. STNA spoke with resident who informed her he was agreeable to have his nails trimmed and STNA revealed she would return and trim resident's nails.

Facility had no policy related to resident activity of daily living care for dependent residents.

Based on record review, review of skin grid assessments, review of the wound Certified Nurse Practitioner (CNP) notes, review of an After Visit Summary, staff interviews, and facility policy review, the facility failed to complete timely and accurate skin grid assessments, implement treatment changes timely, and follow up on the wound CNP recommendations timely for one resident (Resident #71). The facility also failed to follow up on discharge recommendations as indicated in the After Visit Summary following a hospitalization for one resident (Resident #71). This affected one resident (Resident #71) of one reviewed for non-pressure skin care. The facility census was 117.

Findings include:

Review of the medical record for Resident #71 revealed an initial admission date on 01/29/24 and a discharge date on 03/08/24. Medical diagnoses included chronic respiratory failure with hypoxia, asthma, dependence on respirator (ventilator) status, tracheostomy status, anoxic brain damage, and persistent vegetative state.

Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated 01/10/24 revealed Resident #71 was in a persistent vegetative state with no discernible consciousness. Resident #71 was totally dependent on one to two staff to complete all Activities of Daily Living (ADLs). Resident #71 required suctioning, tracheostomy care, invasive mechanical ventilator, intravenous medications, intravenous access, and oxygen. Resident #71 had an open lesion other than ulcers, rashes, cuts present at the time of the assessment as well as a surgical wound.

Review of the significant change MDS 3.0 assessment date 02/05/24 revealed Resident #71 had an open lesion other than ulcers, rashes, cuts present at the time of the assessment. Review of Resident #71's census revealed the resident was in the hospital from 11/11/23 to 11/22/23 and 01/13/24 to 01/29/24.

Review of the After Visit Summary (AVS) dated 01/29/24 revealed Resident #71 was hospitalized for sepsis and discharged back to the facility on intravenous (IV) antibiotics. Discharge nursing orders included to fax labs including complete blood count (CBC), sedimentation rate (SR), c-reactive protein (CRP), and creatinine to Infectious Disease physician every Monday and to call the Infectious Disease Physician on 02/12/24 with an update to determine stop date, peripherally inserted central catheter (PICC) line plans, oral antibiotics, and a follow up appointment. Wound care instructions for peg site skin breakdown and wound included: may change outer dressing daily as needed for soilage and reapply Triad to maintain dime thickness. Otherwise, change dressing every three days. Please use a plain foam dressing cut with a slit to accommodate the tubing. Remove previous dressing and cleanse wound with mild soap and water, rinse and pat dry. Careful attention to remove all previous cream. Apply triad cream at dime thickness and cover with gauze. Date and time dressing. This will promote autolytic debridement for healing.

Review of Treatment Administration Record (TAR) dated January 2024 revealed Resident #71's wound treatment was implemented to start on 01/30/24. The treatment implemented from 01/30/24 to 02/04/24 was to clean with normal saline, pat dry, and apply calcium silver alginate to small open area and apply quarter size amount of triad paste to site and surrounding area and cover with abdominal (ABD) dressing. The treatment was to be completed every shift and as needed. The treatment order was created by Wound Licensed Practical Nurse (WLPN) #195.

Review of the Skin Grid-Non-Pressure assessment dated 02/01/24 (three days after readmission) and completed by WLPN #195 revealed Resident #71 had a non-pressure area at the peg site (area where gastrostomy tube was placed in the abdomen). The area was an open lesion measuring 1.1 centimeters (cm) long by 2.4 cm wide by 0.2 cm deep with moderate serosanguineous drainage note. The area was unchanged. WLPN #195 noted the area was much improved since last visit with a shallow granular base and surrounding scar tissue. There was no indication of a skin assessment being completed upon admission on 01/29/24 by WLPN #195. There was no indication of a treatment order for the area in the skin assessment.

Review of the Wound Certified Nurse Practitioner (WCNP) #330's note dated 02/01/24 revealed Resident #71 was seen for an open lesion at the resident's peg site. The area measured 1.1 cm long by 2.4 cm wide by 0.2 cm deep. The treatment included to apply triad and silver alginate for moisture control and antimicrobial benefits. WCNP #330 ordered to apply triad first, pack the wound with alginate every shift and as needed. There was no indication to use calcium alginate on the wound or to cover the wound with an ABD dressing.

Review of the TAR dated February 2024 revealed the treatment for Resident #71's peg site wound implemented on 02/04/24 was to clean with normal saline, apply triad paste first then silver calcium alginate. Cover with split gauze and secure with tape every shift and as needed. This treatment remained in place until 03/05/24. The treatment was marked as administered every shift as ordered. The treatment was created by WLPN #195.

Review of the progress notes for Resident #71 dated from 01/29/24 through 03/05/24 revealed there was no indication of any contact with the Infectious Disease physician on 02/12/24 as indicated in the discharge instructions. There was also no indication of labs being drawn or faxed to the Infectious Physician every Monday as ordered in the discharge instructions on 02/05/24, 02/12/24, 02/19/24, 02/26/24, or 03/04/24.

Review of the Skin Grid Non-Pressure assessment dated 02/15/24 and completed by WLPN #195 revealed the peg site area measured 2.4 cm long by 2.6 cm wide by 0.2 cm deep. The area had moderate serosanguineous drainage. The area was improved with a shallow pink base that was hyper granular area. The area was cauterized. The assessment did not mention any concerns with the surrounding skin.

Review of WCNP #330's note dated 02/15/24 revealed Resident #71's open lesion area at the peg site measured 2.4 cm long by 2.6 cm wide by 0.2 cm deep. There was surrounding excoriation to the skin around the site. The area was cauterized. No wound treatment changes were indicated.

Review of the Skin Grid Non-pressure assessment dated 02/22/24 and completed by WLPN #195 revealed Resident #71's peg site open lesion measured 2.2 cm long by 2.8 cm wide by 0.2 cm deep with heavy serosanguineous drainage noted. The area was unchanged but noted a large amount of drainage of tube feeding and stomach contents. Granular tissue was still visible. There was no indication of WCNP #330's recommendation for a general surgery consult or changes to the peri wound.

Review of WCNP #330's note dated 02/22/24 revealed Resident #71's peg site open lesion measured 2.2 cm long by 2.8 cm wide by 0.2 cm deep with a large amount of drainage of tube feeding and stomach contents. The surrounding skin had maceration and excoriation. WCNP #330 noted the area would continue to decline until further evaluation and recommended a general surgery consult for evaluation of peg tube placement. The periwound was noted to be excoriated and macerated. WCNP #330 changed the wound treatment to apply triad first, pack wound with alginate, and cover with an ABD pad every shift and as needed. This wound treatment was not implemented as recommended.

Review of the Skin Grid Non-pressure assessment dated 02/29/24 and completed by WLPN #195 revealed Resident #71's peg site open lesion measured 8.9 cm long by 5.9 cm wide by 0.2 cm deep with heavy serosanguineous drainage noted. The area was declined and noted to be much larger with a large amount of drainage with tube feeding and stomach contents. Increased area maceration and excoriation was noted. The area was 30% granulation and 70% excoriation and maceration. There was no indication the area was cauterized, WCNP #330's recommendation for a general surgery consult, or that the area was noted to be unavoidable.

Review of WCNP #330's note dated 02/29/24 revealed Resident #71's peg site open lesion measured 8.9 cm long by 5.9 cm wide by 0.2 cm deep with heavy serosanguineous drainage. The area was noted to be declined but unavoidable. WCNP #330 again recommended a general surgery consult. Silver nitrate was used to cauterize the excess granulation tissue. There were no wound treatment changes recommended.

There was no evidence of any follow up related to WCNP #330's recommendations for a general surgery consult in Resident #71's medical record.

Interview on 03/07/24 at 11:49 A.M. with WCNP #330 revealed she visited the facility one time a week to assess the facility's residents with wounds, including Resident #71. WCNP #330 reported Resident #71 had several wounds upon readmission from her most recent hospitalization on 01/29/24. WCNP #330 stated the resident's peg site needed surgical intervention. Stated she did change the wound treatment today, 03/07/24, due to continued excoriation and maceration of the skin on the resident's abdomen. WCNP #330 confirmed the area declined on 02/29/24 but she did not make any new treatment recommendations until 03/07/24. WCNP #330 confirmed WLPN #195 should have completed an assessment of Resident #71's peg site prior to her visit on 02/01/24 (three days after readmission). WCNP #330 confirmed WLPN #195's skin grid assessments should be the same as her notes because they complete rounds together. WCNP #330 stated she was available for continued consultation as needed via telephone but had not received any communication from WLPN #195 other than during their weekly rounds. WCNP #330 confirmed the treatments provided to Resident #71 should match the treatment recommendations from her notes.

Interview on 03/07/24 at 4:28 P.M. with WLPN #195 confirmed she was not a wound certified LPN. WLPN #195 confirmed a full skin grid assessment was not completed on Resident #71 until 02/01/24 (three days after readmission). WLPN #195 confirmed the wound treatment implemented on 01/30/24 did not match the discharge wound treatment recommendations on the After Visit Summary. WLPN #195 confirmed wound treatments for any newly identified areas or if WCNP #330 recommended a treatment change for an ongoing wound, the treatment should be implemented immediately. WLPN #195 confirmed any discharge instructions should be reviewed by herself and the unit managers when a resident was readmitted to the facility. WLPN #195 confirmed Resident #71's peg site wound was noted as declined but no treatment changes were ordered until 03/06/24 (six days later). WLPN #195 stated typically if a wound has declined, the treatment was changed.

Interview via telephone on 03/11/24 at 3:15 P.M. with Infectious Disease Registered Nurse (IDRN) #332 confirmed there was not any evidence the facility had faxed any labs to the Infectious Disease Physician's office as ordered in the discharge instructions. IDRN #332 also confirmed there was not any evidence the facility had called the Infectious Disease office on 02/12/24 to determine plans for treatment of Resident #71 as ordered in the discharge instructions.

Interview on 03/11/24 at 3:37 P.M. with the Director of Nursing (DON) revealed she did not provide any oversight or assistance with resident wounds. The DON stated WLPN #195 and WCNP #330 handled all the facility's wounds. The DON confirmed the treatment order implemented on 01/30/24 for Resident #71 did not match the treatment recommendations from the discharge instructions. The DON confirmed the wound treatment implemented on 02/04/24 through 03/05/24 did not match the treatment orders recommended by WCNP #330. The DON confirmed the weekly skin assessments should include a full description of the wound area, the treatment order, any changes from the previous week's assessment, and any recommendations made by WCNP #330. The DON confirmed there was no evidence WLPN #195 had consulted with WCNP #330 in the resident's record.

Review of the facility policy, Nursing Assessments

Based on record reviews, interviews, observations, and facility policies, the facility failed to ensure accurate and timely wound assessments and care was provided for three residents (#51, #71, and #89) out of four residents reviewed for wounds. The facility census was 117.

Findings include:

1. Review of the medical record for Resident #51, revealed an admission date of 10/20/23. Diagnoses included: moderate protein-calorie malnutrition, vascular dementia, unspecified severity, without behavioral disturbance, psychosis disturbance, mood disturbance and anxiety, and end stage renal disease.

Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated 02/09/24 revealed a Brief Interview for Mental Status (BIMS) of resident is rarely/never understood. The resident was assessed to be dependent with all bed mobility.

Review of nursing admission skin assessment for Resident #51 dated 10/20/23 revealed three wounds. Wound #1 was sacrococcygeal moisture-associated skin damage (MASD), wound #2 was a left heel stage 1 (an observable, pressure- related alteration of intact skin whose indicators may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the injury may appear with persistent red, blue, or purple hues) pressure ulcer and wound #3 was a right heel stage 1 pressure ulcer.

Review of treatment administration record (TAR), progress notes, and skilled nurse's notes, for Resident #51 revealed no documentation on wound treatments for all three wounds upon admission until 10/22/23 and resident was sent to out to the hospital on 10/23/23.

Review of nursing readmission skin assessment for Resident #51 dated 11/07/23 revealed three wounds. Wound #1 a sacrum stage 4 (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer, wound #2, a surgical site to the abdomen and wound #3, a right heel deep tissue injury (purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue).

Review of physician order for Resident #51 dated 11/08/23 revealed encourage/assist resident to turn and reposition as tolerated every shift.

Review of nursing wound assessments for Resident #51 dated 11/09/23 revealed 6 wounds. Wound #3 was now a right shoulder unstageable (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound.) wound, wound #5 a left heel deep tissue injury, wound #6 left buttock unstageable pressure ulcer and wound #7 a right buttock stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising) pressure ulcers were not documented on the readmission skin assessment dated 11/07/24 and all stated they were acquired on admission.

Review of physician's order for Resident #51 start date 12/29/23 revealed clean patient sacrum with normal saline and pack with 3 sheets of calcium alginate, then pack with fluff gauze, cover 4 ABD's secure with tape and apply triad paste to surrounding areas. every shift for wound care

Review of the TAR for January 2024 for Resident #51 revealed missing treatments for the sacrum wound for day shift on the following dates: 01/20/24, 01/21/24 and 01/22/24 and for night shift on the following dates: 01/01/24, 01/04/24, 01/05/24, 01/08/24, 01/13/24, 01/14/24, 01/18/24 and 01/19/24.

Review of readmission skin assessment for Resident #51 dated 02/04/24 revealed three wounds. Wound #1 a coccyx stage 2 pressure ulcer, wound #2 a sacrum stage 4 pressure ulcer and wound #3 was a skin tear.

Review of nursing wound assessment for Resident #51 dated 02/05/24 revealed four wounds. Wound #1 a sacrum stage 4 pressure ulcer, wound #4 a right heel unstageable pressure ulcer, wound #5 a left heel unstageable pressure and wound #6 a right buttock stage 3 (full-thickness tissue loss into subcutaneous tissue but does not go into the muscle or bone) pressure ulcer and were all acquired on admission.

Observation of Resident #51 on 03/11/24 revealed at 8:56 AM, 10:58 AM, and 2:15 PM the resident was on her back in bed.

Observation of Resident #51 on 03/11/24 revealed at 9:12 AM, 11:14 AM and 3:23 PM the resident was on her back in bed.

Interview on 03/11/24 at 3:24 P.M. with State Tested Nursing Aide (STNA) #313 revealed Resident #51 was on her back and had not been turned. STNA #313 was also unable to verbalize how often to turn and reposition residents.

Review of the TAR for March 2024 revealed documentation of turning and repositioning resident on day shift for 03/07/24 and 03/11/24 during day shift hours.

Interview on 03/12/24 at 10:49 A.M. with Licensed Practical Nurse (LPN) #195 verified Resident #51's readmissions to the facility did not contain all the residents' wounds as the facility required and verified missing treatments for the month of January with no explanation as to why they were missed. Reviewed the missing treatments for Resident #51 for admission on 10/20/23 and stated, That was a weekend, so the floor nurse should have called the physician for orders until Monday, and it looks like she didn't do that.

2. Review of the medical record for Resident #89, revealed an admission date of 09/15/23. Diagnoses included: quadriplegia, chronic respiratory failure, and latent syphilis.

Review of the most recent MDS 3.0 assessment dated 12/26/23 revealed a BIMS of 15 out of 15. The resident was assessed to be dependent with all care including toileting and rolling left and right in bed and was assessed to have one or more unhealed pressure ulcer: one stage 3 that was present upon admission.

Review of admission skin assessment for Resident #89 dated 09/15/23 revealed six wounds. Wound #1 a right posterior calf stage 3 pressure ulcer, wound #2 a left heel unstageable pressure ulcer, wound #3 a posterior head stage 2 pressure ulcer, wound #4 a sacrum stage 1 pressure ulcer, wound #5 a left ear stage 2 pressure ulcer and wound #6 a right buttock non pressure blister.

Review of readmission skin assessment for Resident #89 dated 10/09/23 revealed five wounds. Wound #1 a left heel unstageable pressure ulcer, wound #2 a right posterior upper calf stage 2 pressure ulcer, wound #3 a sacrum stage 1 pressure ulcer, wound #4 left (unidentified) stage 2 pressure ulcer and wound #5 a right buttock stage 1 pressure ulcer.

Review of nursing wound assessment for Resident #89 dated 10/12/23 revealed five wounds but did not include wound #5 right buttock stage 1 pressure ulcer and included a wound #4 posterior head unstageable pressure ulcer documented as being acquired on admission.

Review of nursing wound assessment for Resident #89 dated 10/19/23 revealed no documentation on the right buttock stage 1 pressure ulcer documented on readmission.

Review of readmission skin assessment for Resident #89 dated 10/24/23 revealed three wounds. Wound #1 a left heel unstageable pressure ulcer, wound #2 a right posterior upper calf stage 1 pressure ulcer, and wound #3 a sacrum stage 2 pressure ulcer.

Review of physician's order for Resident #89 dated 10/26/23 revealed encourage/assist to turn and reposition as tolerated every shift.

Review of nursing wound assessments for Resident #89 dated 11/02/23 revealed three wounds but did not include wound #3 a sacrum stage 2 pressure wound and included a wound #6 left ear stage 3 pressure ulcer.

Review of nursing wound assessments for Resident #89 dated 11/09/23 revealed two wounds. Wound # 6 the left ear stage 3 pressure ulcer was not documented on.

Review of Resident #89's progress notes, skilled nursing notes and MAR and TAR for November and December 2023 revealed no documentation of refusal of care.

Review of dietary note for Resident #89 dated 01/11/24 revealed current diet provides adequate kcal/protein to promote wound healing.

Review of nursing wound assessment for Resident #89 dated 01/18/24 revealed right posterior calf 6.7 centimeters (cm) X 3.1 cm X .4 cm to be a stage 3 pressure ulcer.

Review of nursing wound assessment for Resident #89 dated 01/25/24 revealed right posterior calf 15.2 cm X 6.8 cm X .5 cm to be a stage 4 pressure ulcer.

Review of dietary note for Resident #89 dated 01/25/24 revealed current diet provides adequate kcal/protein to promote wound healing.

Review of progress notes, skilled nurse's notes, MAR and TAR for Resident #89 revealed no documentation of injury and refusal of care occurring to the right posterior calf to worsen wound between the dates of 01/18/24 to 01/25/24.

Observation of Resident #89 on 03/06/24 revealed the resident was on back in bed at 9:50 A.M., 11:52 A.M. and 2:15 P.M.

Observation of Resident #89 on 03/07/24 revealed the resident on back in bed at 9:02 A.M., 10:31 A.M. and 2:14 P.M.

Observation of Resident #89 on 03/11/24 revealed resident on back in bed at 9:34 A.M., 11:45 A.M. and 3:31 P.M.

Interview on 03/11/24 at 9:09 A.M. with LPN #204 revealed unsure of how often residents should be turned and repositioned on the ventilator unit and was the nurse for part of the hall for the day.

Interview on 03/11/24 at 3:32 P.M. with Resident #89 revealed she had not been turned on today and does not get turned on often by the staff. Denied refusing care for wound and turning and wanted to be turned on her side.

Interview on 03/11/24 at 3:46 P.M. with LPN # 204 revealed Resident #89 wanted to be turned and verified she had not been today and stated, I will get an aide to do that.

Interview/Observation on 03/11/24 at 4:12 P.M. with Resident #89 revealed the resident on her back and stated, I have not been turned yet.

Interview on 03/11/24 at 4:13 P.M. with LPN #204 revealed Resident #89 had not been turned yet and stated, the aide is on break, we will get to it when we do, have a good day.

Interview on 03/12/24 at 10:46 P.M. with LPN #195 verified for Resident #89 the discrepancies with documentation from the resident's readmission skin assessments to the weekly wound assessments. Also verified the residents wound worsened on the dates of 01/18/24 to 01/25/24 and denied the resident refuses care and stated sometimes, she wants us to come back at a different time, but she has never refused wound care for me. Verified the readmission assessments should match the weekly wound assessments and verified wounds are typically healed out so the facility can keep track but confirmed wound #5 right buttock stage 1 pressure ulcer and wound #3 a sacrum stage 2 pressure wound were healed out for the resident.

Based on medical record review, observations, staff interview, and policy review, the facility failed to ensure fall interventions were implemented in a timely manner. This affected one (Resident #85) out of two residents reviewed for falls. The census was 117.

Findings include:

Review of the medical record for Resident #85 revealed an admission date of 12/07/22. Diagnoses included hypercholesterolemia, osteoporosis, mild cognitive impairment, artificial right and left hip joints, insomnia, and muscle weakness.

Review of the progress note, dated 12/20/23, revealed Resident #85 was observed on the floor in a sitting position. The STNA informed the nurse who came to assess the resident. Resident #85 had reported she was coming from the bathroom and wanted to get in bed. An assessment was completed and no injuries were identified. The new intervention was for a call don't fall sign. Resident #85 was educated to ask for assistance when going to the bathroom.

Review of the fall investigation, dated 12/20/23, revealed Resident #85 was found sitting on her bottom on the floor in her room with her legs extended outward toward the bathroom door. The fall occurred in Resident #85's room and the call light was not activated. The intervention was to educate Resident #85 to use the call light and a call don't fall sign was to be placed as a visual reminder.

Review of the progress note, dated 01/08/24, revealed Resident #85 was observed to have fallen in her room and was on her buttock. Resident #85 stated she was trying to close the window. An assessment was completed and Resident #85 indicated she had left leg pain. A temporary intervention included a chair alarm and STAT (immediate) left leg x-ray was ordered due to complaint of pain. No fractures were found on the x-ray.

Review of the fall investigation, dated 01/08/24, revealed Resident #85 was found sitting on her bottom on the floor by the window and the call light was not activated. Resident #85 reported she was trying to close the window but the window was found to not be open. The intervention was for a chair alarm to alert staff to resident transfers.

Review of Fall Risk assessment, dated 01/24/24, revealed Resident #85 was at risk for falls.

Review of the Minimum Data Set assessment, dated 02/19/24, revealed Resident #85 was cognitively impaired and required partial moderate assistance for hygiene care, substantial maximal assistance for toileting and dressing, and was dependent for putting on and taking off shoes.

Review of the plan of care, dated 02/22/24, revealed Resident #85 was at risk for falls with interventions for bed in low position, care conference with residents family, encourage and remind to ask for assistance dated, encourage resident to wear non slip socks or shoes when up, ensure call light was within reach, have commonly used articles within reach, monitor and anticipate/intervene for causative factors, and therapy referral as needed, provide assist of one with transfers as needed, restorative referral as needed and staff assistance with ambulation with use of walker, and non-skid strips to bedside.

Review of Resident #85's physician order, dated 03/05/24, revealed an order for a chair alarm to be placed when resident was in the chair and to check for placement and function.

Observation on 03/04/24 at 5:44 P.M. revealed Resident #85 was sitting in a chair in the common area. Resident #85 had no chair alarm in place.

Observation on 03/05/24 at 12:45 P.M. revealed Resident #85 was sitting in a chair in the common area. No chair alarm was observed in place.

Interview on 03/05/24 at 5:45 P.M. with Licensed Practical Nurse (LPN) #215 revealed Resident #85 did not have a chair alarm in place until 03/05/24 in the early evening time.

Observation on 03/06/24 at 5:35 P.M. of Resident #85 revealed the resident was sitting in the chair in the common space with a chair alarm in place.

Interview on 03/07/24 at 8:50 A.M. with State Tested Nursing Aide #259 revealed she had never seen Resident #85 using a chair alarm when she worked with Resident #85 prior to 03/07/24.

Interview on 03/07/24 at 9:13 A.M. with LPN #165 confirmed Resident #85 did not have the chair alarm in place prior to 03/05/24.

Interview on 03/07/24 at 5:30 P.M. with Regional Nurse #326 confirmed some of Resident #85's fall interventions were not on the care plan.

Interview on 03/07/24 at 2:22 P.M. with LPN #198 revealed Resident #85 had the chair alarm put in place late afternoon on 03/05/24. She revealed Resident #85 did not have it in place prior to 03/05/24.

Interview on 03/11/24 at 10:45 A.M. with the Director of Nursing (DON) confirmed Resident #85 had a fall on 12/20/23 with an intervention to place a call don't fall sign. The DON confirmed the call don't fall sign was not added to Resident #85's care plan. The DON confirmed Resident #85 had a fall on 01/08/24 with a new intervention for a chair alarm to be put in place. The DON confirmed the chair alarm was not added to the care plan and was not ordered until 03/05/24. The DON further verified the chair alarm was not put in place until 03/05/24.

Review of facility policy titled Fall Management

2. Review of Resident #83's medical record revealed Resident #83 was admitted to the facility on 05/23/23 with diagnoses including chronic respiratory failure, anoxic brain injury, heart failure, and pneumonia.

Review of Resident #83's signed physician orders revealed an order, dated 02/19/24, to clean respiratory equipment and filters every night shift every Saturday and as needed if soiled.

Review of Resident #83's signed physician orders revealed an order, dated 03/07/24, to change suction canister, tubing, and yankauer every night shift every Thursday.

Review of Resident #83's Treatment Administration Record (TAR), dated February 2024, revealed no evidence the staff changed the suction machine canister, tubing, and yankauer as ordered.

Review of Resident #83's TAR, dated March 2024, revealed on 03/07/24, there was documentation to reflect Resident #83's suction machine canister, tubing, and yankauer had been changed.

Observation in Resident #83's room on 03/05/24 at 10:39 A.M. revealed there was a suction machine with canister and tubing attached to a yankauer (a hard plastic suctioning tip for tubing) which was located in the opened packaging bag. There was a light yellow to white colored liquid noted in the canister and the canister appeared to be almost full of the liquid. The suction tubing, yankauer, and the container were not dated to reflect a day or time of when they may have been changed.

Observation in Resident #83's room on 03/06/24 at 8:18 A.M. revealed the suction machine and undated canister continued to have the same amount of light yellow to white colored liquid, and the tubing and yankauer were still in the opened undated packaging bag located in the drawer of the nightstand.

Interview on 03/06/24 at 3:11 P.M. with the Administrative Registered Nurse (ARN) #190 stated we should be emptying the suction canisters when they get full or at least daily and should be changing out the canisters, tubing, and yankauer every Thursday night. ARN #190 confirmed the undated tubing, yankauer, canister, and noted the canister was almost full with a yellow to white colored liquid.

Observation in Resident #83's room on 03/07/24 at 9:30 A.M. revealed the suction machine was covered with a large clear plastic bag. The undated canister continued to have the light yellow to white colored liquid, and the tubing and yankauer were still in the undated packaging bag located in the drawer of the nightstand.

Based on medical record review, review of hospital records, review of a fall investigation, resident and staff interviews, and facility policy review, the facility failed to provide timely and effective pain management as well as adequately monitor resident pain.

Actual harm occurred on 01/11/24 when Resident #65 fell, complained of pain to her right ankle, was not provided effective pain management, and was subsequently unable to get out of bed on 01/12/24 due to increased pain associated with the fall. The resident was transferred to the hospital on 01/12/24 at 6:52 P.M. (approximately 24 hours after the fall occurred) with complaints of right ankle pain. The resident required Oxycodone-Acetaminophen for pain. Upon assessment, the resident's ankle was resting in an extremely plantarflexed position (top of the foot pointed away from leg) with mild swelling and tenderness to palpation (indicates objective painful symptoms) about the medial and lateral ankle (the inside and outside portions of the ankle). The x-ray of the resident's right foot and ankle revealed a bimalleolar equivalent ankle fracture with medial malleoli avulsion fracture.

This affected one (Residents #65) out of two residents reviewed for pain management.

The facility also failed to ensure non-pharmacological pain interventions were attempted for a resident who received as needed narcotic pain medication. This affected one (Residents #424) out of two residents reviewed for pain management. The facility census was 117.

Findings include:

1. Review of the medical record for Resident #65 revealed an initial admission date of 08/09/20. Medical diagnoses included unspecified sequelae of nontraumatic intra cerebral hemorrhage, secondary Parkinsonism, chronic kidney disease stage four, schizoaffective disorder bipolar type, major depressive disorder, anxiety disorder, and nondisplaced fracture of lateral malleolus of right fibula (added on 01/12/24).

Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/10/24, revealed Resident #65 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The assessment revealed Resident #65 required partial to moderate assistance with transfers and required variable assistance ranging from supervision or touch assistance to substantial or maximum assistance from staff to complete other activities of daily living (ADLs). The resident received scheduled pain medications and had not received any as needed pain medications. No pain had been reported.

Review of a Fall Incident Report, dated 01/11/24 at 6:50 P.M., revealed Resident #65 was in the bathroom calling out for help. Licensed Practical Nurse (LPN) #210 entered the bathroom and noted Resident #65 standing with a walker. LPN #210 cleaned the resident and assisted with putting Resident #65's pants back on. Resident #65 continued standing with a walker. LPN #210 reached for the resident's wheelchair. Resident #65 attempted to sit in the wheelchair, lost her balance, and sat on the floor. Resident #65 twisted her right ankle. Resident #65 was transferred to the bed and assessed. Resident #65 complained of pain to her right ankle. Resident #65 stated, I twisted my ankle. LPN #210 checked Resident #65's range of motion (ROM) and Resident #65 complained of pain to her right ankle. Resident #65's vital signs were within normal limits. LPN #210 used a non-verbal pain scale to determine Resident #65's pain level and documented a pain level of three on the incident report. Resident #65 was alert and oriented to person, place, time, and situation. An injury to Resident #65's right inner ankle was noted. Certified Nurse Practitioner (CNP) #329 was notified. Resident #65's brother was contacted, and a message was left to return the phone call to the facility. There was no indication LPN #210 administered any medication or non-pharmacological interventions for Resident #65's reported pain at the time of the incident.

Review of the Medication Administration Record (MAR), dated January 2024, revealed Resident #65 had an order for Tylenol Extra Strength 500 milligrams (mg) with instructions to give one tablet by mouth two times daily for pain. The order had a start date of 11/24/23. This medication was administered at bedtime on 01/11/24 for what staff documented was a pain level of zero (out of 10), upon rise on 01/12/24 with a pain level of three (out of 10), and at bedtime on 01/12/24 with a pain level of six (out of 10). Resident #65 had an additional order with a start date of 11/01/23 for Tylenol 325 mg with instructions to give two tablets by mouth every eight hours as needed for pain. This medication was not administered to Resident #65 on 01/11/24 or 01/12/24.

Review of the progress notes for Resident #65 revealed on 01/11/24 at 7:47 P.M., LPN #210 noted Resident #65 was in the bathroom, attempting to transfer to the wheelchair, lost balance and sat on the floor, injuring her right ankle. On 01/12/24 at 6:05 P.M., LPN #202 noted Resident #65 was not able to get out of bed today (01/12/24) due to pain in her right ankle as a result of yesterday's (01/11/24) fall. An x-ray was completed and revealed an acute fracture of the distal fibula in the right ankle. Resident #65 was to be transferred to the hospital for further evaluation. Certified Nurse Practitioner (CNP) #329, the Unit Manager (UM), and Resident #65's family were notified.

Review of the care plan for Resident #65, revised on 01/12/24, revealed Resident #65 was at risk for an alteration in comfort due to acute fracture of the distal fibula in the right ankle with cast in place. Interventions included administer medications as ordered, monitor for effectiveness of interventions, monitor for increased levels of pain and notify the physician, monitor for side effects of pain and anxiety medications, notify the physician for review of or change in pain medications if needed, complete pain assessment per facility policy, and offer non-pharmacological interventions.

Review of the hospital records for Resident #65 revealed the resident arrived at the emergency room on 01/12/24 at 6:52 P.M. (approximately 24 hours after the fall occurred) with complaints of right ankle pain. X-rays and a computed tomography (CT) scan of the resident's head and cervical spine were completed. Resident #65 was administered Oxycodone-Acetaminophen for pain. Upon assessment, the resident's ankle was resting in an extremely plantarflexed position (top of the foot pointed away from leg). Mild ankle swelling was noted. There was tenderness to palpation (indicates objective painful symptoms) about the medial and lateral ankle (the inside and outside portions of the ankle). The x-ray of the resident's right foot and ankle revealed a bimalleolar equivalent ankle fracture with medial malleoli avulsion fracture. Post splint x-rays revealed persistent anterior subluxation (partial dislocation) of the talus (the large bone in the ankle that articulates with the tibia of the leg and the calcaneum and navicular bone of the foot). Resident #65 underwent a closed reduction to improve alignment of the tibiotalar joint and splinting in the emergency department. Resident #65 was discharged back to the facility from the hospital on 01/13/24 at 2:02 A.M.

Review of the progress notes dated 01/13/24 at 2:40 A.M. revealed Resident #65 returned to the facility at approximately 2:10 A.M. on a stretcher with two Emergency Medical Services (EMS) staff. Resident #65 returned with a new order for Oxycodone-Acetaminophen (narcotic pain medication) 5-325 mg per tablet with instructions to administer one tablet by mouth every six hours if needed for severe pain for up to three days. On 01/14/24 at 5:00 A.M., Resident #65's right ankle had a dry and intact cast. Resident #65's right foot was warm, and color was within normal limits. Resident #65 was able to wiggle toes and denied pain at that time.

Interview on 03/07/24 at 12:48 P.M. with LPN #213 (the floor nurse for Resident #65) revealed according to the facility's policy, at rise medications should be administered between 5:00 A.M. and 10:00 A.M. and bed time medications should be administered between 6:00 P.M. and 11:00 P.M. Resident #65 usually received her bed time medications closer to 6:00 P.M.

Interview on 03/07/24 at 1:55 P.M. with Resident #65 revealed she was in her bathroom with one staff person (was not sure if it was an aide or a nurse). Resident #65 indicated she attempted to get in her wheelchair and fell. Resident #65 stated the staff member left her alone for a very short time while she went to get help. Resident #65 stated she reported pain in her right ankle and leg. Resident #65 stated she did not receive pain medication until she went to the hospital the next day. Resident #65 stated her right ankle hurt the whole time and it wasn't mild pain.

Interview on 03/11/24 at 12:59 P.M. with LPN #202 revealed she was the day shift nurse for Resident #65 on 01/12/24. LPN #202 stated she was told in report that Resident #65 had a fall on 01/11/24 and Resident #65 had an order for an x-ray. LPN #202 stated she did assess Resident #65 and the resident complained of pain when she touched the right ankle. LPN #202 stated Resident #65 refused to give an exact number on the pain scale which was not abnormal for the resident. LPN #202 stated she would consider Resident #65's pain to have been moderate per her nursing judgement. LPN #202 stated she did administer Tylenol to Resident #65 but did not recall exactly when. LPN #202 revealed the resident did not want to get out of bed on 01/12/24 due to having pain in her right ankle. LPN #202 confirmed she had not administered any as needed pain medications to Resident #65.

Interview on 03/11/24 at 5:21 P.M. with LPN #210 revealed she was the nurse on duty when Resident #65 had a fall in her bathroom. LPN #210 stated she was with Resident #65 when Resident #65 attempted to pivot from standing with a walker to sit in her wheelchair and lost her balance. Resident #65 twisted her right ankle and sat on the floor. Resident #65 immediately complained of pain to her right ankle. A State Tested Nursing Assistant was called to assist and the resident was assisted off the floor and placed in her wheelchair and then transferred into bed. LPN #210 stated she completed a head-to-toe assessment on Resident #65 but was not able to complete a ROM exam on the resident's right ankle due to the resident's complaints of pain. LPN #210 denied asking the resident what her exact pain level was. LPN #210 stated she contacted CNP #329 who ordered an x-ray but did not order any additional pain medication. LPN #210 stated she administered scheduled Tylenol to Resident #65 with dinner between 5:00 P.M. and 6:00 P.M. (before the resident's fall occurred) but did not administer any additional pain medications after the fall. LPN #210 stated the x-ray had not been completed by the end of her shift. LPN #210 stated she left between 8:00 P.M. and 8:30 P.M. on 01/11/24. LPN #210 confirmed she had not assessed Resident #65 for effectiveness of the pain medication administered prior to the fall and had not administered any as needed pain medication to Resident #65 following the fall.

Interview via telephone on 03/12/24 at 6:40 P.M. with LPN #230 revealed she was the night shift nurse for Resident #65 on 01/11/24 into the morning of 01/12/24. LPN #230 stated she was told in report Resident #65 had a fall during day shift on 01/11/24. LPN #230 stated she was not informed Resident #65 had any injuries or had complained of any pain following the fall. LPN #230 stated Resident #65 was alert with some confusion. LPN #230 stated the resident had a history of reporting inaccurate pain levels to the nursing staff and would often either refuse to answer or would give a random number on the pain scale. LPN #230 stated Resident #65 did complain of pain on 01/12/24 in the morning but stated she did not worry about the pain scale number provided by the resident because the Tylenol medication was scheduled and would be administered to Resident #65 regardless of the pain level being reported. LPN #230 stated she administered Tylenol to Resident #65 between 6:00 A.M. and 7:00 A.M. on 01/12/24. LPN #230 stated she had not assessed Resident #65's right ankle or leg during her shift because she was not aware of any injuries or concerns. LPN #230 confirmed she had not administered any as needed Tylenol to Resident #65 or reassessed the resident for effectiveness of the Tylenol that was administered in the early morning.

Review of the facility policy titled Pain Assessment and Management

Based on medical record review, resident and staff interviews, and facility policy review, the facility failed to ensure non-pharmacological pain interventions were attempted for a resident who received as needed narcotic pain medication. This affected one (Residents #424) out of two residents reviewed for pain management. The facility census was 117.

Findings include:

Review of Resident #424's medical record revealed Resident #424 was admitted to the facility on 02/28/24 with diagnoses including fractures of bilateral upper arms, right scapula, and multiple ribs, frostbite to bilateral toes, laceration of the liver, injury to the spleen, alcohol use, anxiety, and depression. Review of the medical record revealed Resident #424 had intact cognition.

Review of Resident #424's care plan, dated 03/05/24, revealed Resident #424 was at risk for alteration in comfort related to multiple fractures related to a motor vehicle accident, status post frostbite to bilateral feet with tissue necrosis, and impaired mobility. Resident #424's goals were to decrease Resident #424's pain to an acceptable level for the resident which allows for participation in ADL's, activities, therapy, and treatments. Resident #424's interventions for reaching these goals included administer medications as ordered, encourage and assist resident to turn and reposition every two hours and as needed, encourage relaxation techniques, and provide activities that the resident enjoys as a diversion from pain/discomfort.

Review of Resident #424's signed physician orders revealed an order, dated 02/28/24, for Oxycodone HCL (narcotic pain medication) tablet five milligrams (mg) give one tablet by mouth every six hours as needed (PRN) for pain. The order was changed on 03/07/24 to Oxycodone HCL tablet five mg give two tablets every six hours as needed for pain. Additionally, there was an order, dated 02/28/24, for Gabapentin (anticonvulsant medication which can be used for pain) capsule 400 mg give two capsules by mouth three times a day for pain for 14 days.

Review of Resident #424's MAR, dated March 2024, revealed Resident #424 was administered Oxycodone as needed on 03/01/24 at 9:01 A.M. and 8:30 P.M. for a pain level of five out of 10; on 03/02/24 at 6:34 A.M. for a pain level of four out of 10, at 12:34 P.M. for pain level of nine out of 10, and at 7:46 P.M. for pain level of four out of 10; on 03/03/24 at 9:45 A.M. for a pain level of eight out of 10, at 3:55 P.M. for a pain level of nine out of 10, at 10:33 P.M. for a pain level of eight out of 10; on 03/04/24 at 5:30 A.M. for a pain level of seven out of 10, at 11:30 A.M. for pain level of eight out of 10, at 5:41 P.M. for a pain level of seven out of 10; on 03/05/24 at 5:19 A.M. for a pain level of four out of 10, at 11:51 A.M. for a pain level of five out of 10, at 6:25 P.M. for a pain level of eight out of 10; on 03/06/34 at 3:35 A.M. for a pain level of eight out of 10, at 10:52 A.M. for a pain level of eight out of 10, at 6:38 P.M. for a pain level of five out of 10, on 03/07/24 at 4:37 A.M. for a pain level at eight out of 10, at 11:08 A.M. for pain level of six out of 10, at 6:35 P.M. for pain level of seven out of 10; on 03/08/24 at 8:19 A.M. for a pain level of five out of 10, at 2:05 P.M. for a pain level of five out of 10; on 03/09/24 at 12:47 A.M. for a pain level of zero out of 10, at 9:09 A.M. for a pain level of eight out of 10, at 3:34 P.M. for a pain level of seven out of 10, at 9:35 P.M. for a pain level of three out of 10; on 03/10/24 at 5:55 A.M. for a pain level of three out of 10, at 12:23 P.M. for a pain level of seven out of 10, at 6:25 P.M. for a pain level of seven out of 10; on 03/11/24 at 12:32 A.M. for a pain level of two out of 10, and at 8:01 A.M. for a pain level of five out of 10.

Review of Resident #424's progress notes, dated 02/28/24 to 03/11/24, revealed the following medication administration notes for the PRN Oxycodone without non-pharmacological interventions listed as having been attempted; on 03/11/24 at 8:01 A.M. and 6:49 A.M.; on 03/10/24 at 6:25 P.M. and 12:23 P.M.; on 03/09/24 at 3:34 P.M., 9:09 A.M., and 12:47 A.M.; on 03/08/24 at 2:05 P.M. and 8:19 A.M.; on 03/07/24 at 6:35 P.M., 11:08 A.M., and 4:37 A.M.; on 03/06/24 at 6:38 P.M., 10:52 A.M., and 3:35 A.M.; on 03/05/24 at 6:25 P.M., 3:54 P.M. and 11:51 A.M.; on 03/04/24 at 5:41 P.M., 11:30 A.M., and 5:30 A.M.; on 03/03/24 at 10:33 P.M., 3:55 P.M. and 9:45 A.M.; on 03/02/24 at 7:46 P.M., 12:34 P.M., and 6:34 A.M.; on 03/01/24 at 8:30 P.M. and 9:01 A.M.; on 02/29/24 at 6:58 P.M. and 12:58 P.M.

Interview on 03/11/24 at 9:15 A.M. with Administrative Registered Nurse (ARN) #190 revealed the nurses were supposed to ask the resident their pain level and offer other non-pharmacological interventions for pain such as repositioning, ice, music, food, etc to help with relaxation or detraction from the pain. The nurses were to document the interventions on the MAR which will flow over into the progress notes.

Interview on 03/11/24 at 10:30 A.M. with Resident #424 revealed the pain has been better controlled since the facility changed the pain medication order on 03/07/24. Resident #424 stated, The nurses will ask me about my pain or I will ask for the medication myself, they don't usually offer me anything else other than the medication.

Interview on 03/12/24 at 8:37 A.M. with the Director of Nursing (DON) confirmed there was no evidence non-pharmacological interventions for pain were attempted for Resident #424's pain control prior to Resident #424's PRN pain medication administration. The DON stated, I see with the orders the intervention option was not activated to prompt the nurses in offering non-pharmacological interventions.

Review of the facility's policy titled Pain Assessment and Management

Based on medical record review and staff interview, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #48) out of five residents reviewed for unnecessary medications. The census was 117.

Findings include:

Review of Resident #48's medical record revealed Resident #48 was admitted to the facility on 06/27/20 with the diagnoses including diabetes mellitus (DM), heart disease, congestive heart failure, Chronic Obstructive Pulmonary Disease, and chronic kidney disease.

Review of Resident #48's signed physician order, dated 06/01/22, revealed an order for insulin lispro solution (fast acting insulin) inject five units subcutaneously before meals for DM. The medication was to be held for blood sugar (BS) less than 120.

Review of Resident #48's Medication Administration Record (MAR), dated January 2024, revealed on 01/01/24 at 11:00 A.M. Resident #48's BS reading was 117 and five units of insulin lispro was administered, on 01/03/24 at 4:00 P.M. Resident #48's BS reading was 99 and five units of insulin lispro was administered, on 01/15/24 at 4:00 P.M. Resident #48's BS reading was 112 and five units of insulin lispro was administered, on 01/16/24 at 6:30 A.M. Resident #48's BS reading was 104 and at 4:00 P.M. Resident #48's BS reading was 118 and five units of insulin lispro was administered at both times, on 01/22/24 at 6:30 A.M. there was no entry of BS reading or administration of insulin lispro.

Review of Resident #48's MAR, dated February 2024, revealed on 02/01/24 at 6:30 A.M. Resident #48's BS was 115 and five units of insulin lispro was administered, on 02/07/24 at 4:00 P.M. Resident #48's BS was 106 and five units of insulin lispro was administered, on 02/11/24 at 11:00 A.M. Resident #48's BS reading was 91 and five units of insulin lispro was administered, on 02/04/24, 02/05/24, 02/18/24, and 02/19/24 at 6:30 A.M. there were no entries for BS readings or the administration of insulin lispro.

Review of Resident #48's MAR, dated March 2024, revealed on 03/01/24 at 11:00 A.M. Resident #48's BS reading was 105 and five units of insulin lispro was administered, on 03/03/24 and 03/04/24 at 6:30 A.M. there were no BS readings documented or any insulin lispro administered.

Review of Resident #48's progress notes dated 01/01/24 to 03/12/24 revealed no entry or note regarding physician or Certified Nurse Practitioner (CNP) notification of the BS readings below the ordered parameters and the administration of insulin lispro.

Interview on 03/12/24 at 3:30 P.M. with Administrative Licensed Practical Nurse (ALPN) #165 confirmed Resident #48 had been administered the insulin lispro when the BS readings were below the ordered parameters. ALPN #165 stated that is a medication error with the insulin being given when the blood sugar is lower then the order requires. The CNP or physician should have been notified and the insulin held.

Based on review of medication storage refrigerator daily temperature logs, observation, staff interview, and facility policy review, the facility failed to ensure medication storage refrigerators were maintained at an appropriate temperature and the temperature was routinely monitored. This affected one (South Unit) medication storage room out of three medication storage rooms in the facility and had the potential to affect all 25 residents (#1, #4, #5, #6, #8, #9, #11, #12, #13, #15, #19, #20, #38, #39, #56, #57, #59, #64, #78, #85, #87, #91, #92, #98, and #108) who received medications from the South Unit medication storage room. The census was 117.

Findings include:

Review of the South Unit medication storage refrigerator daily temperature log for January 2024 and February 2024 revealed four daily temperature entries for the entire month of January 2024 and no daily temperatures for the entire month of February 2024

Observation of the medication storage room located on the South Unit on 03/06/24 at 11:10 A.M. revealed the medication storage refrigerator daily temperature log dated March 2024 only had three daily temperatures recorded from 03/01/24 through 03/06/24. There were no other temperature logs in the medication storage room. The medication refrigerator temperature was observed to be 34 degrees Fahrenheit (F).

Interview on 03/06/24 at 11:05 A.M. with Administrative Registered Nurse (ARN) #190 confirmed the temperature of the medication storage refrigerator on the South Unit was not consistently being recorded in January 2024, February 2024, and March 2024. ARN #190 stated the refrigerator temperatures should be checked daily and documented on the temperature logs.

Interview on 03/06/24 at 11:15 A.M. with Administrative Licensed Practical Nurse (ALPN) #165 confirmed the daily medication refrigerator temperature logs for January 2024, February 2024, and March 2024 for the medication storage refrigerator located in the South Unit's medication storage room were incomplete and the temperature was not routinely being recorded.

Review of the facility policy titled Medication Storage

Based on medical record review, resident interview, staff interview, and review of meal choice sheets, the facility failed to ensure residents were consistently offered meals according to their choices and preferences. This affected two (Residents #34 and #46) out of two residents reviewed for food choices and had the potential to affect all eight Residents (#33, #34, #46, #52, #89, #95, #97, #107) living on the North Hall who receive meals from the kitchen. The census was 117.

Findings include:

1. Review of the medical record for Resident #34 revealed an admission date of 06/13/23. Diagnoses included chronic respiratory failure, vent dependence, diabetes, and dysphagia.

Review of Resident #34's physician orders, dated 08/22/23, revealed an active order for a regular textured diet with low concentrated sweets and no added salt.

Review of the Minimum Data Set (MDS) assessment, dated 02/08/24, revealed Resident #34 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and required set up assistance for eating.

Review of the Plan of Care, dated 02/11/24, revealed Resident #34 had potential for alteration in nutrition and hydration with interventions to honor food preferences as able.

Interview on 03/05/24 at 9:42 A.M. with Resident #34 revealed Resident #34 did not get options for food if he did not like what was being served. Resident #34 revealed he asked a staff member for alternatives and they didn't come back to give him the information on what alternatives were available.

Interview on 03/06/24 at 12:35 P.M. with Resident #34 revealed staff do not go around the unit to get meal choices and he gets stuck with whatever the main special was. He revealed he has asked staff in the past to check on meal items and alternatives but they do not consistently honor alternatives/preferences and sometimes do not return to provide an update to him if his requested item was not available.

2. Review of the medical record for Resident #46 revealed an admission date of 11/16/23. Diagnoses included chronic respiratory failure, vent dependence, diabetes, pulmonary hypertension, and schizophrenia.

Review of Resident #46's physician orders, dated 12/01/23, revealed an active order for a regular textured diet with low concentrated sweets and no added salt.

Review of the MDS assessment, dated 02/08/24, revealed Resident #46 was cognitively intact with a BIMS score of 15 and required set up assistance for eating.

Review of the Plan of Care, dated 02/12/24, revealed Resident #46 had a potential for alteration in nutrition and hydration with interventions to honor food preferences as able and obtain food preferences.

Interview on 03/05/24 at 10:34 A.M. with Resident #46 revealed Resident #46 was concerned about getting choices for food and revealed she only gets offered the main dish.

Interview on 03/06/24 at 12:30 P.M. with Kitchen Manager #151 revealed residents are asked about their food choices by the aides or activity staff (depending on the halls). He stated the North Hall had aides go room to room and take orders every few days and would discuss what was on the menu and offer an alternative from the everyday menu.

Interview on 03/07/24 at 5:25 P.M. with State Tested Nursing Aide (STNA) #309 revealed activity staff was responsible for asking residents about menu choices and alternative meals.

Interview on 03/07/24 at 5:30 P.M. with Licensed Practical Nurse (LPN) #160 revealed activity staff was responsible for asking residents about menu choices and alternative meals.

Interview on 03/07/24 at 5:36 P.M. with Activities Director #170 and Activity Staff #180 revealed the activity staff were responsible for all halls except the North Hall and the Rehab Hall. They revealed they read off the menu for the next few days and make note for each resident if they wanted something the alternative meal or something from the every day menu. They revealed the nurse aides were responsible for taking orders and reviewing the menu with the North and Rehab Halls as those residents were typically more medically complex. The Activity Director revealed they had discussed with the Administrator related to menu choices and were working on a plan for better consistency. The Activity Direcor was not familiar with the current status or what interventions were being put in place for the North Hall. They revealed staff fill out a menu change sheet and provide a few days worth to the kitchen at one time.

Interviews on 03/11/24 from 8:45 A.M. to 8:52 A.M. with STNA #342 and STNA #313 revealed activity staff was responsible to ask residents about menu choices and alternative meals.

Interview on 03/12/24 at 10:30 A.M. with the Administrator revealed the STNA's, kitchen staff and activity staff were responsible for obtaining menu choices from residents. He was unsure who specifically was responsible for the North Hall and revealed they were talking about updating the process, but had no additional information about what the actual the process was.

Interview on 03/12/24 at 11:10 A.M. with Diet Technician #172 revealed obtaining menu choices was not a new process and the staff should know what their responsibilities were. Diet Technician #172 revealed the STNA's should be getting meal choices from the residents on the North Hall.

Review of resident meal choices sheets dated 03/06/24, 03/10/24, and 03/11/24, revealed there were no entries for the North Hall residents including Residents #34 and #46. There were no additional meal choice forms for 03/06/24, 03/10/24, and 03/11/24 that were provided for review.

Based on medical record review, review of hospital records, staff and resident interview, review of facility policy, and review of the Centers for Disease Control and Prevention guidelines, the facility failed to appropriately obtain consent and timely administer a flu and pneumococcal immunizations.

Actual harm occurred on 02/29/24, when Resident #104 was diagnosed with pneumonia and was hospitalized for ten days for treatment including intravenous antibiotic therapy. The resident's representative gave permission for the resident to receive the pneumococcal vaccination on 02/01/24 (admission); however, the facility failed to administer the vaccination to the resident. This affected two (Residents #89 and #104) of five residents reviewed for immunizations. The facility census was 117.

Findings include:

1. Review of the medical record for Resident #104 revealed an original admission date of 02/01/24. Resident #104 was discharged to the hospital on 02/29/24 and readmitted back to the facility on 03/10/24. Diagnoses included respiratory failure with hypoxia, hemiplegia and hemiparesis, dysphagia, dialysis dependence, diabetes, muscle weakness, chronic embolism, and tracheostomy.

Review of Resident #104's Vaccine Consent, dated 02/01/24, revealed Resident #104's representative gave permission for the facility to administer the pneumococcal and flu immunization.

Review of the Minimum Data Set (MDS) assessment, dated 02/08/24, revealed Resident #104 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 (out of 15).

Review of Resident #104's physician orders from 02/01/24 to 02/29/24 revealed no evidence of the pneumococcal or flu immunization having been ordered or administered to Resident #104.

Review of Resident #104's Medication Administration Record (MAR), dated February 2024, revealed no evidence of the flu or pneumococcal immunization having been ordered or administered.

Review of Resident #104's immunization history record revealed no evidence the resident received a pneumonia or flu immunization between 02/01/24 and 02/29/24.

Review of Resident #104's progress notes, dated 02/01/24 to 02/29/24, revealed no mention of the flu or pneumococcal immunization having been administered.

Record review revealed the resident was transported to the hospital on 02/29/24.

Review of a progress note dated 02/29/24 at 2:28 P.M. revealed Resident #104 had muscle weakness present. Further review of the progress notes revealed there was no mention of what change in condition led to Resident #104 being sent to the hospital on 02/29/24.

Review of Resident #104's hospital paperwork, dated 02/29/24 to 03/10/24, revealed Resident #104 presented to the emergency department with tachyarrhythmia and a temperature of 102 degrees Fahrenheit. The resident was admitted to the hospital on 02/29/24 with an admitting diagnosis of pneumonia. Resident #104 was started on intravenous Vancomycin (antibiotic) 0.9% in sodium chloride 500 milligrams/100 milliliters piggyback three times weekly with dialysis and Zosyn 3.375 grams in sodium chloride every 12 hours. A chest Computed Tomography (CT) was done at the hospital on 02/29/24 which revealed Resident #104 had left lower lob infiltrate with small left pleural effusion which could represent lobar pneumonia.

Review of Resident #104 progress note, dated 03/10/24, revealed the resident returned to the facility from the hospital after having been admitted with pneumonia.

Interview on 03/12/24 at 11:45 A.M. with the Director of Nursing (DON) revealed Resident #104's daughter had signed the consents for the flu and pneumonia immunizations upon admission on 02/01/24. The DON revealed Resident #104 was alert and oriented and should have been offered the opportunity to sign the consents herself. The DON confirmed the flu and pneumonia vaccine was never ordered or administered to Resident #104 and confirmed she was diagnosed with pneumonia during her hospital stay on 02/29/24. Upon return from the hospital, the facility spoke with Resident #104 who stated she was agreeable to receive the pneumococcal immunization but declined to receive the flu immunization.

Interview on 03/12/24 at 3:10 P.M. with Resident #104 revealed if she had been offered the choice of getting the pneumococcal vaccine upon admission on 02/01/24, she would have been agreeable. Resident #104 indicated she was still agreeable to receive the pneumococcal vaccine. Resident #104 revealed she had not previously received a pneumococcal immunization.

Interview on 03/12/24 at 5:00 P.M. with the DON revealed the admitting nurse was responsible for obtaining proper consents for immunizations upon admission and if they do not obtain them, the Unit Manager should obtain consent and the resident should be administered the immunization. The DON confirmed Resident #104 was not provided with pneumococcal immunization and was hospitalized and treated for pneumonia.

Review of the facility policy titled Immunization for Pneumococcal, Influenza and COVID-19

Based on observation, interview, record review and Center for Medicare and Medicaid Services (CMS) food temperature guidance the facility failed to ensure temperatures of food leaving the kitchen were at the appropriate temperature to prevent food borne illness, and failed to keep the can opener clean. This had the potential to affect all 85 residents receiving food from the kitchen. Residents #1, #8, #10, #12, #14, #15, #28, #30, #31, #36, #50, #51, #54, #57, #58, #61, #62, #74, #78, #105, and #106 did not receive food from the kitchen. The facility census was 106.

Findings included:

1. Interview on 04/05/23 at 12:08 P.M. with Dietary Supervisor #209 revealed the facility documented temperature checks on the menus and not all food that had been temperature checked prior to leaving the kitchen.

Interview on 04/05/23 at 12:10 P.M. with Registered Dietitian (RD) #202 verified every meal from the kitchen should be temperature checked prior to being served to confirm it has reached a safe temperature to prevent food-borne illness.

Review of food temperature logs from 01/29/23 to 04/01/23 revealed food temperatures were not taken during preparation or during holding. The following dates had one meal with no temperature checks: 02/11/23, 03/06/23, 03/07/23, 03/09/23, and 03/11/23. The following dates had two meals with no temperature checks: 02/05/23 and 02/18/23. The following dates had all three meals with no temperature checks: 02/06/23, 02/08/23, 02/09/23. 02/10/23, 02/14/23, 02/15/23, 01/26/23, 02/17/23, 02/26/23, 02/27/23, 02/28/23, 03/01/23, 03/02/23, 03/03/23, 03/04/23, 03/25/23, and 03/26/23. From 01/29/23 to 04/01/23 was 63 days resulting in a total of 189 meals with food which should have been temperature checked. Sixty meals during this time did not have temperature checks resulting in 31.74% of meals with food not temperature checked. The meals which were not temperature checked included chicken, pork, beef, and fish.

Review of facility form titled, Food Temperature: CMS Interpretive Guidance, undated, provided by RD #202 revealed poultry should reach a final cooking temperature of 165 degrees Fahrenheit, and ground meat should reach a final cooking temperature of 155 degrees Fahrenheit, and fish and other meats (beef, pork, veal) should reach a final cooking temperature of 145 degrees Fahrenheit.

2. Observation on 04/05/23 at 12:00 P.M. of the large can opener revealed a black dried substance on the piece that punctures the can. Further observation revealed the table base which holds the piece that punctures the can to be dirty.

Interview on 04/05/23 at 12:02 P.M. with the Registered Dietitian (RD)#202 verified the can opener was dirty.

Interview on 04/05/23 at 12:05 P.M. with Dietary Supervisor #209 verified the can opener was dirty and not just from use on 04/05/23 but from multiple days of use.

Review of the kitchen cleaning log for 04/05/23 revealed the can opener and base had been cleaned.

This deficiency is an incidental finding investigated under Complaint Number OH00141360.

Based on observation, interview, and facility policy review the facility failed to follow proper hand washing and glove use protocols to prevent infection when providing incontinence care and reconnected ventilator tubing. This affected one resident (#78) of four residents reviewed for incontinence care. The facility census was 106.

Findings included:

Review of Resident #78's medical record revealed an admission date of 02/16/22 with diagnoses including chronic respiratory failure with hypoxia, dependence on ventilator, type two diabetes, persistent vegetative state, supraventricular tachycardia, and essential hypertension.

Review of Resident #78's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/30/23, revealed she was not cognitively independent and always incontinent of bladder and bowel.

Observation on 04/05/23 at 10:45 A.M. of bed bath with incontinence care for Resident #78 with State Tested Nursing Assistants (STNAs) #204 and #205 revealed concerns regarding infection control. STNA #204 and STNA #205 washed their hands and donned (put on) gloves to provide incontinence care. The anterior (front) of Resident #78 was cleaned and dried by STNA #205. Resident #78 was then rolled toward STNA #204 and STNA #204 held Resident #78 on her right side as STNA #205 provided incontinence care posteriorly (back) for Resident #78. Resident #78 had been incontinent of stool and STNA #205 cleaned and dried her. STNA #204 and #205 traded locations and STNA #204 was making the bed while STNA #205 held Resident #78 on her right side. The ventilator tubing became disconnected, and the ventilator alarm started to sound. STNA #204 reached up and reconnected the ventilator tubing with the gloved hands she had just provided incontinence care for urine and stool. She then doffed (removed) her gloves and donned (put on) new gloves at the bedside without washing her hands. While the bed was being made, the ventilator tubing became disconnected again and she reconnected the ventilator tubing.

Interview on 04/05/23 at 11:10 A.M. with STNA #205 verified she did reconnect the ventilator tubing the first time while wearing the gloves she had on when she provided incontinence care of urine and stool. She also verified she did not wash her hands or use hand sanitizer after doffing (removing) the first pair of gloves and donning (putting on) the second pair of gloves at the bedside.

Interview on 04/05/23 at 11:28 A.M. with the Director of Nursing (DON verified that a resident's ventilator tubing which has come disconnected during care should not be reconnected with gloved hands just used to provide incontinence care.

Review of the facility policy titled, Hand Hygiene, revised 11/18/17, revealed staff are to perform hand hygiene (even if gloves are used) in the following situations: before and after contact with the resident, after contact with blood body fluids, or visibly contaminated surfaces or other surfaces in the resident's environment, and after removing personal protective equipment (e.g. gloves, gown, facemask).

This deficiency is an incidental finding investigated under Complaint Number OH00141360.

Based on medical record review, community vendor interview, staff interview, and resident interview, the facility failed to assure proper planning was developed to ensure medical care and treatments were completed. This affected one (Resident #111) of three residents reviewed for medical care. The census was 119.

Findings Include:

Medical record review revealed Resident #111 was admitted to the facility on 08/15/22. Her diagnoses were malignant neoplasm of unspecified part of left bronchus or lung, chronic obstructive pulmonary disease, fracture of nasal bones, hypoosmolality and hyponatremia, type II diabetes, hypokalemia, osteoporosis, panic disorder, post traumatic stress disorder, repeated falls, convulsions, hypothyroidism, bipolar disorder, hypertension, and hyperlipidemia. Review of her Minimum Data Set (MDS) assessment, dated 08/22/22, revealed she was cognitively intact.

Review of Resident #111's medical record revealed she was admitted with the diagnosis and disease of malignant neoplasm of unspecified part of left bronchus or lung. She had a diagnostic scan on 10/18/22 and follow-up appointment on 10/19/22 to determine the extent of that disease. Review of her progress notes, dated 10/25/22, revealed she was to have 33 treatments for cancer (radiation and chemotherapy) at the hospital, which it confirmed Resident #111 had chosen to go through with them. Review of Resident #111's progress note, dated 10/28/22 (late entry written on 11/02/22), revealed a call to the hospital social worker to determine if there was any update to getting Resident #111 admitted to the hospital for her treatments. A message was left. A returned call on 11/02/22 from the hospital social worker was documented in the progress notes; stating they had scheduled four of the 33 treatments for Resident #111. This information was given to the facility Administrator to determine the plan to get her to the appointments. There was no other documentation in Resident #111's medical records to state whether Resident #111 would attend those appointments, when the appointments were scheduled, or any other specifics to the plan to get her to the appointments.

Interview with Director of Nursing (DON) on 11/02/22 at 9:15 A.M. and 10:30 A.M. and 11/03/22 at 10:15 A.M. revealed she had not been directly involved in the process of getting Resident #111 to her treatments. She was aware that Resident #111 was scheduled for chemotherapy and radiation, but Unit Manager #127 and Administrator were the primary staff persons working on this.

Interview with Hospital Social Worker #136 on 11/03/22 at 8:14 A.M. and 4:02 P.M., 11/04/22 at 11:06 A.M., and 11/07/22 at 10:14 A.M. confirmed he scheduled nine total treatment appointments for Resident #111 for 10/24/22 to 10/27/22 and 10/31/22 to 11/04/22, but the facility canceled them because they stated they could not find transportation or a sitter to stay with her while she was in the hospital. He stated the facility has not provided any other information to him about how they are going to get Resident #111 to her appointments. He confirmed Resident #111 wanted to go to the appointments and start her treatment. He is concerned the facility will not send her due to not having enough available staff to sit with her.

Interview with Unit Manager #127 on 11/03/22 at 9:30 A.M. confirmed Resident #111 PET scans were done on 10/18/22 (approximately) and course of action was to be determined after that. The hospital ordered 33 radiation/chemotherapy treatments, and she was aware they were to start the week of 10/31/22. The facility had to cancel that week of appointments because they did not have steady transportation and a sitter to be with her for the treatments. She is not aware of the plan to get her to her appointments at this time, other than trying to get her discharged to the hospital so she can do in-patient treatment. But she confirmed the hospital told her that was not an option for Resident #111.

Interview with Physician #137 on 11/03/22 at 10: 28 A.M. confirmed he was frustrated that Resident #111 had not started treatment yet, and, in his opinion, it seems like the facility was not trying to get her to the hospital.

Interview with Resident #111 on 11/03/22 at 3:23 P.M. confirmed she had not attended any radiation or chemotherapy appointments yet. She confirmed she agreed to go through with the treatments.

Interview with Administrator on 11/03/22 at 4:15 P.M. confirmed they were trying to develop a plan to get Resident #111 to her radiation/chemotherapy appointments. He confirmed they currently do not have the staff to send someone five days a week, for up to eight hours per day, to sit with her at the hospital for her treatments. When asked about nurse managers or other managers sitting, doing a rotation, he stated he would review that with his staff and consider that as an option. But he confirmed they did not have a plan in place to get her to any appointments at that time.

Follow-up correspondence with the Administrator via email on 11/04/22 revealed the facility had a transportation and supervision plan in place for Resident #111 to receive her ordered treatment beginning 11/07/22.

A telephone call with the Administrator on 11/09/22 at 9:25 A.M. revealed Resident #111 had refused to attend her scheduled treatment the previous day stating that she did not feel like attending (per her choice).

This deficiency represents non-compliance investigated under Complaint Number OH00137209 and Complaint Number OH00136995.

Based on observation, record review, medication insert document review, and staff interview the facility failed to ensure medication errors were not greater than 5% when they omitted two medications for Resident #99, did not prime an insulin pen for Resident #30, attempted to administer the wrong resident's insulin pen to Resident #102, and administered the wrong dosage amount of a medication to Resident #85. There was 32 opportunities observed with five medication errors for an error rate of 15.6%. This affected four residents (#30, #85, #99, and #102) of 12 residents observed for medication administration. The facility census was 119.

Findings include:

1. Record review of Resident #99 revealed an admission date of 10/31/22 with pertinent diagnoses including: chronic respiratory failure with hypoxia, dependence on respirator, hypertension, chronic pain syndrome, end stage renal disease, and anemia.

Review of Resident #99 Physicians Orders for 11/01/22 to 11/30/22 revealed medications including polyvinyl alcohol-povidone solution 1.4-0.6% instill two drops in both eyes three times a day for dry eyes. There was also an order for methocarbamol tablet 500 milligrams (mgs) give one tablet by mouth three times a day for muscle spasms.

Observation on 11/03/22 at 8:56 A.M. revealed Licensed Practical Nurse (LPN) #142 administering medications for Resident #99 including : eliquis (a blood thinner), oxycodone (a pain medication), and sevelamar (a medication used to treat increased phosphorous). LPN #142 verified that these three mediations were all Resident #99's morning medications.

Interview with LPN #142 on 11/03/22 at 9:38 A.M. verified she did not give polyvinyl alcohol-povidone solution eye drops or methocarbamol tablet 500 mgs with morning medication pass per the order.

2. Record review of Resident #30 revealed an admission date of 08/27/19 with pertinent diagnoses of: type two diabetes mellitus, anemia, major depressive disorder, and peripheral vascular disease.

Review of Resident #30 Physicians Orders for 11/01/22 to 11/30/22 revealed Novolog Solution 100 unit/milliliter (Insulin Aspart) Inject as per sliding scale: if 0 -150 = 0 IF blood sugar is less than 60, Notify Physician; 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10; 401 - 450 = 12. If BS is greater than 450. Notify Physician. Subcutaneously before meals and at bedtime for diabetes mellitus.

Observation on 11/03/22 at 11:29 A.M. revealed Licensed Practical Nurse (LPN) #147 preparing insulin for Resident #30. Resident #30 blood sugar level was 214 and LPN #147 turned the pen dial to 4 units. LPN #147 did not prime the insulin pen before she administered the shot.

Interview with LPN #147 on 11/03/22 at 11:38 A.M. verified she did not prime the insulin pen prior to administration and LPN #147 was unaware of what priming the insulin pen meant.

Review of the Novolog insulin Aspart prescribing information dated 03/01/21 revealed giving the airshot before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: turn the dose selector to select two units. Hold the Novolog FlexPen with the needle pointing up. Tap the cartridge gently with a finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times. If you do not see a drop of insulin after six times, do not use the Novolog FlexPen.

3. Record review of Resident #102 revealed an admission date of 07/03/19 with pertinent diagnoses of: type two diabetes mellitus, dysphasia following cerebral infarction, chronic respiratory failure, hemiplegia and hemiparesis following cerebral infarction, gastrostomy status, seizures, and hypertension.

Review of Resident #102 Physician's Orders dated 11/01/22 to 11/30/22 revealed Novolog solution 100 unit/milliliter Insulin Aspart inject 12 units subcutaneously before meals for diabetes mellitus.

Observation on 11/07/22 at 8:12 A.M. revealed LPN #159 pulled out Resident #30 insulin pen of Novolog insulin Aspart and she was going to administer it to Resident #102. LPN #159 selected 12 units of insulin Aspart on the dial and was walking into the room to administer the insulin when the surveyor intervened.

Interview with LPN #159 on 11/07/22 at 8:16 A.M. verified she was going to administer Resident #30 insulin to Resident #102.

4. Record review of Resident #85 revealed an admission date of 10/20/17 with pertinent diagnosis of: epilepsy, obsessive compulsive disorder, hypertension, major depressive disorder, pseudobulbar affect, and anxiety disorder.

Review of Resident #85 Physician's Orders dated 11/01/22 to 11/30/22 revealed Oxcarbazepine tablet 600 milligrams (mgs) give one tablet by mouth two times a day for convulsions.

Observation on 11/07/22 at 9:15 A.M. revealed LPN #159 administering medications to Resident #85 including Oxcarbazepine. LPN #159 pulled the prepackaged medications out of the pharmacy bag and administered one tab of 300 mgs Oxcarbazepine and one tab of 150 mgs Oxcarbazepine for a total of 450 mgs.

Interview with LPN #159 on 11/07/22 at 9:50 A.M. verified she only gave 450 mgs of Oxcarbazepine when the order was for 600 mgs.

This deficiency represents non-compliance investigated under Complaint Number OH00136995.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure a shared glucometer was properly cleaned/disinfected between resident use to prevent the spread of infection. This affected two residents (#179 and #209) of the two residents reviewed for glucose monitoring.

Findings Include:

On 10/24/22 from 8:30 A.M. through 9:00 A.M. observation of medication administration revealed Licensed Practical Nurse (LPN) #124 was observed completing glucose monitoring for Resident #179 and #209 using a shared facility glucometer. LPN #124 was observed using the same glucometer between Resident #209 and Resident #179 without cleaning the glucometer between usage.

On 10/24/22 at 9:00 A.M. interview with LPN #124 confirmed the glucometer had not been disinfected in between using it for two different residents and indicated it should have been cleaned.

Review of the facility policy titled Testing Blood Glucose Levels, revised 04/2015 revealed to discard disposables and cleanse and disinfect reusable equipment.

This deficiency is an incidental finding to Complaint Number OH00136157 and Complaint Number OH00136650.