Continuing Healthcare of Toledo

Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure residents were provided with interventions to prevent skin breakdown in accordance with physician orders and nursing plans of care. This affected three (#1, #2, #3) of three sampled residents reviewed for skin integrity. Facility census was 69.

Findings include:

1. Resident #1 admitted to the facility on 05/23/22 with diagnoses including, polyosteoarthritis, anemia, chronic fatigue, polyneuropathy, congestive heart failure, peripheral vascular disease, spondylosis, absence right leg above knee, and covid-19.

According to the most current Minimum Data Set (MDS) assessment dated 09/01/24 revealed Resident #1 had severe cognitive impairment, was dependent on staff for the completion of activities of daily living including bed mobility, always incontinent of bowel and bladder, and was at risk for pressure ulcer development with no skin breakdown.

Review of nursing plans of care noted on 07/07/23 a care plan was developed to address Resident #1's potential/actual impairment to skin integrity related to fragile skin. Interventions included, follow facility protocols for treatment of injury, the resident needs low air loss mattress to protect the skin while in bed, and offloading boots to foot while in bed. Further review of the medical record discovered an additional plan of care dated 01/24/23 addressing Resident #1's bowel incontinence related to immobility with interventions including, check resident every two hours and assist with toileting as needed.

On 08/30/24 a Braden scale for predicting pressure sore risk scored Resident #1 at risk for pressure sore development.

According to weekly wound evaluation documentation dated 10/30/24 Resident #1 was assessed with a healed stage two pressure ulcer to the sacrum that was acquired on 10/09/24. Instructions included continued application of zinc.

On 11/04/24 weekly skin observation documentation noted the resident with intact skin. Risk factors for impaired skin integrity were incontinence and limited mobility with interventions including check and change and low air loss mattress.

Observation on 11/05/24 at 7:34 A.M. with Certified Nurse Aide (CNA) #201 discovered Resident #1 in bed with two incontinence briefs applied. Resident #1 was unable to indicate when last checked for incontinence or repositioning. CNA #201 stated she assumed care of Resident #1 at 7:00 A.M. and this was her first observation of the resident. CNA #201 went on to state CNA #202 provided care for the resident on the previous shift and had left the facility before CNA #201 received a report regarding the last incontinence check or repositioning for Resident #1. Resident #1 was also discovered without the offloading boot in place and Resident #1 left foot resting on the mattress surface. CNA #201 was unaware the offloading boot was to be applied and was unable to locate the boot in Resident #1's room.

According to task, bowel and bladder monitoring documentation, Resident #1 was documented as incontinent on 11/04/24 at 9:23 P.M. with repositioning documented as taking place at 9:24 P.M. No further bowel and bladder tracking was documented in the medical record.

On 11/05/24 at 7:45 A.M. interview with the Director of Nursing (DON) revealed residents are not to be double briefed due to creating an increased potential for skin breakdown and infections. CNA's are to document incontinence checks and repositioning in the medical record under tasks. The DON also stated resident skin breakdown interventions are contained in the nursing plan of care and also included incontinence frequency checks for the specific resident.

2. Resident #2 admitted to the facility on 11/28/18 with diagnoses including, rheumatoid arthritis, major depressive disorder, dysphagia, congestive heart failure, muscle wasting and atrophy, protein calorie malnutrition, anxiety disorder, hypertension, atrial fibrillation, type 2 diabetes mellitus, right eye blindness and atrioventricular septal defect.

According to the most current MDS assessment dated 10/09/24 revealed Resident #2 had severe cognitive impairment, was dependent on staff for the completion of activities of daily living including bed mobility, always incontinent of bowel and bladder, and was at risk for pressure ulcer development with no current skin breakdown.

On 09/19/24 Braden scale for predicting pressure sore risk scored Resident #2 at moderate risk for pressure sore development.

On 09/21/24 a Bladder Incontinence Data Collection Tool was completed and Resident #2 was assessed as incontinent of bladder requiring staff to complete incontinence care. Resident does not verbalize the need to use toilet.

A nursing plan of care was developed on 09/30/24 to address Resident #2's Activity of Daily Living (ADL) self-care performance deficit related to fatigue, impaired balance, limited mobility, vision loss, osteoarthritis, and episodes of pain. Resident transfers extensive assist of one but Hoyer lift with assist of two is often needed. Interventions included, the resident is totally dependent on one to two staff to provide bath/shower as necessary, for bed mobility, the resident requires extensive to dependent assistance by two staff, the resident is bedfast all or most of the time, the resident requires skin inspection with care, observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse, the resident is totally dependent on two staff for toilet use, and the resident is totally dependent on two staff for transferring. On 09/23/24 to address Resident #2's potential alteration in elimination frequently incontinent of bowel and bladder, interventions included the following: monitor for skin redness and irritation and provide incontinent care as needed (PRN). No frequency was indicated related to providing turning or repositioning or checking the resident for incontinence episodes.

On 11/04/24 weekly skin observation documentation noted the resident with intact skin. Risk factors for impaired skin integrity were incontinence and limited mobility with interventions including check and change and low air loss mattress.

According to task, bowel and bladder monitoring and repositioning documentation, Resident #2 was documented as incontinent on 11/04/24 at 11:48 P.M. No further bowel and bladder tracking or reposition was documented in the medical record.

Observation on 11/05/24 at 7:02 A.M. noted Resident #2 in bed. Certified Nurse Aide (CNA) #203 entered the room and proceeded to complete an incontinence check. CNA #203 discovered Resident #2 had two adult incontinence briefs applied and the resident was soiled of a moderate amount of urine. CNA #203 indicated she had just assumed the shift at 7:00 A.M. and was unaware when the resident was last provided with an incontinence care. CNA #203 stated CNA's were informed by nurses not to place two briefs on residents.

On 11/05/24 at 7:08 A.M. interview with Licensed Practical Nurse (LPN) #301 revealed she was unaware Resident #2 was placed in two incontinence briefs and was unaware when the resident was last provided repositioning or observed for incontinence episodes.

On 11/05/24 at 8:40 A.M., telephone interview with CNA #204 confirmed providing care to Resident #2 between 11/04/24 at 10:30 P.M. and 11/05/24 at approximately 12:30 A.M. CNA #204 stated she turned care over to CNA #205 at that time. CNA #204 also confirmed oncoming staff was not at the facility at the end of the shift and no report was provided. CNA #204 ended the shift on 11/05/24 at 6:30 A.M.

On 11/05/24 at 8:46 A.M., telephone interview with CNA #205 denied assuming care of Resident #2 during the shift on 11/05/24. CNA #205 verified she did not check Resident #2 for incontinence or provide turning with repositioning during her shift on 11/05/24 between 12:30 A.M. and 6:30 A.M.

On 11/05/24 at 7:45 A.M., interview with the Director of Nursing (DON) revealed residents are not to be double briefed due to creating a increased potential for skin breakdown and infections. CNA's are to document incontinence checks and repositioning in the medical record under task. The DON also stated resident skin breakdown interventions are contained in the nursing plan of care and also included incontinence frequency checks for the specific resident.

3. Resident #3 admitted to the facility on 06/09/23 with diagnoses including, cerebral infarction, type 2 diabetes mellitus, protein calorie malnutrition, hypertension, anemia, dysphagia, acute kidney failure, and muscle disorder.

According to the most current MDS assessment dated 09/16/24 revealed Resident #3 with the inability to make needs known, severe cognitive impairment, dependent on staff for the completion of ADLs including bed mobility, always incontinent of bowel and bladder, and at risk for pressure ulcer development with no current skin breakdown.

Review of nursing plans of care revealed on 05/18/24 a plan of care was developed to address Resident #3's ADL self-care performance deficit related to disease process. Interventions included the following; for bed mobility, the resident is able to complete task with limited to extensive assist of one to two staff members, for toilet use, the resident is able to complete task with extensive to total assist of one to two staff members, for transfers, the resident is able to complete task with extensive to total assist of one to two staff members, monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, and declines in function. No turning or repositioning frequency was indicated in the nursing plans of care.

On 09/03/24 a Braden scale for predicting pressure sore risk scored Resident #3 at high risk for pressure sore development.

On 09/03/24 a Bladder Incontinence Data Collection Tool was completed and noted resident is incontinent of bladder all or most of the time.

A physician order was initiated on 10/10/24 to provide additional ADL assistance related to diagnosis of Hemiplegia and Cerebral Infarction. Please refer to plan of care.

On 11/04/24, weekly skin observation documentation noted risk factors for impaired skin integrity were due to impaired mobility and incontinence of bowel and bladder. Interventions to preserve skin integrity included weekly skin assessment and two hour turns per facility protocol.

Observation on 11/05/24 at 7:13 A.M.. with Certified Nurse Aide (CNA) #201 discovered Resident #3 in bed with two incontinence briefs applied. Resident #3 was unable to indicate when last checked for incontinence and was observed to require total dependence of care from CNA #201. CNA #201 stated she assumed care of Resident #3 at 7:00 A.M. and the observation was her first observation of the resident. CNA #201 went on to state the previous CNA identified to provide care to Resident #3 left the facility before giving report regarding the last turning and repositioning or incontinence check for Resident #3. CNA #201 stated Resident #3 required two hour incontinence episode checks with repositioning.

According to task bowel and bladder monitoring documentation Resident #3 was documented to be checked and found incontinent on 11/04/24 at 8:22 A.M. No further bowel and bladder tracking or documentation of incontinence monitoring was documented in the medical record. Review of repositioning documentation noted on 11/04/24 at 11:57 P.M. Resident #3 was provided with repositioning. No further repositioning was noted in the medical record.

On 11/05/24 at 7:45 A.M. interview with the Director of Nursing (DON) revealed residents are not to be double briefed due to creating a increased potential for skin breakdown and infections. CNA's are to document incontinence checks and repositioning in the medical record under task. The DON also stated resident skin breakdown interventions are contained in the nursing plan of care and also included incontinence frequency checks for the specific resident.

Review of facility undated Pressure Injury Prevention and Management policy revealed the facility shall establish and utilize a systematic approach for pressure injury prevention and management. The approach will include prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors: monitoring the impact of the interventions; modifying the interventions as appropriate. Interventions for prevention and to promote healing included the development of a care plan to include measurable goals with appropriate interventions. Basic or routine care interventions include redistribution of pressure, minimize exposure to moisture.

Review of facility undated Turing and Repositioning policy instructed that all residents at risk of or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to a medical condition. Turning and repositioning is a primary responsibility of nursing assistants. The frequency of turning and repositioning will be documented in the residents plan of care. Repositioning while in the chair directed every one hour repositioning for a resident unable to reposition or make position changes.

Based on observation, medical record review, and staff interview, the facility failed to ensure incontinence interventions were implemented in a timely manner and in accordance with nursing plans of care. This affected three (#1, #2, #3) of three sampled residents reviewed for incontinence care and treatment. Facility census was 69.

Findings include:

1. Resident #1 admitted to the facility on 05/23/22 with diagnoses including, polyosteoarthritis, anemia, chronic fatigue, polyneuropathy, congestive heart failure, peripheral vascular disease, spondylosis, absence right leg above knee, and covid-19.

According to the most current Minimum Data Set (MDS) assessment dated 09/01/24 revealed Resident #1 with severe cognitive impairment, dependent on staff for the completion of activities of daily living including bed mobility, always incontinent of bowel and bladder, and at risk for pressure ulcer development with no skin breakdown.

On 09/20/24, a Bladder Incontinence Data Collection Tool was completed and noted resident was incontinent of bladder requiring staff to complete incontinence care. Resident does wet through brief and pants when urinating. Resident does not verbalize the need to use the toilet.

Review of Resident #1's nursing plan of care dated 01/24/23 revealed Resident #1 had bladder incontinence. Interventions included, clean peri-area with each incontinence episode. No documentation indicated a frequency to monitor Resident #1 for urinary incontinence. On 01/24/23 a plan of care was implemented to address Resident #1 bowel incontinence related to immobility with interventions including; check resident every two hours and assist with toileting as needed.

Observation on 11/05/24 at 7:34 A.M. with Certified Nurse Aide (CNA) #201 discovered Resident #1 in bed with two incontinence briefs applied. Resident #1 was unable to indicate when last checked for incontinence. CNA #201 stated she assumed care of Resident #1 at 7:00 A.M. and this was her first observation of the resident. CNA #201 went on to state CNA #202 provided care for the resident on the previous shift and had left the facility before CNA #201 received a report regarding the last incontinence check for Resident #1.

According to task bowel and bladder monitoring documentation Resident #1 was documented as incontinent on 11/04/24 at 9:23 P.M. with repositioning documented as taking place at 9:24 P.M. No further bowel and bladder tracking was documented in the medical record.

On 11/05/24 at 7:45 A.M. interview with the Director of Nursing (DON) revealed residents are not to be double briefed due to creating a increased potential for skin breakdown and infections. CNAs are to document incontinence checks in the medical record under task and resident incontinence frequency checks are indicated in the nursing plan of care.

2. Resident #2 admitted to the facility on 11/28/18 with diagnoses including, rheumatoid arthritis, major depressive disorder, dysphagia, congestive heart failure, muscle wasting and atrophy, protein calorie malnutrition, anxiety disorder, hypertension, atrial fibrillation, type 2 diabetes mellitus, right eye blindness and atrioventricular septal defect.

According to the most current MDS assessment dated 10/09/24 assessed Resident #2 with severe cognitive impairment, dependent on staff for the completion of activities of daily living including bed mobility, always incontinent of bowel and bladder, at risk for pressure ulcer development with no current skin breakdown.

On 09/21/24 a Bladder Incontinence Data Collection Tool was completed and Resident #2 was assessed as incontinent of bladder requiring staff to complete incontinence care. Resident does not verbalize the need to use toilet.

A nursing plan of care was developed on 09/23/24 to address Resident #2's potential alteration in elimination frequently incontinent of bowel and bladder. Interventions included the following: monitor for skin redness and irritation and provide incontinent care as needed (PRN). No frequency was indicating related to checking the resident for incontinence episodes.

According to task bowel and bladder monitoring documentation Resident #2 was documented as incontinent on 11/04/24 at 11:48 P.M. No further bowel and bladder tracking was documented in the medical record.

Observation on 11/05/24 at 7:02 A.M. noted Resident #2 in bed. Certified Nurse Aide (CNA) #203 entered the room and proceeded to complete an incontinence check. CNA #203 discovered Resident #2 had two adult incontinence briefs applied and the resident was soiled of a moderate amount of urine. CNA #203 indicated she had just assumed the shift at 7:00 A.M. and was unaware when the resident was last provided with an incontinence observation. CNA #203 stated CNA's were informed by nurses not to place two briefs on residents.

On 11/05/24 at 7:08 A.M. interview with Licensed Practical Nurse #301 revealed she was unaware Resident #2 was placed into two incontinence briefs and was unaware when the resident was last observed for incontinence episode.

On 11/05/24 at 8:40 A.M. telephone interview with CNA #204 confirmed providing care to Resident #2 between 11/04/24 at 10:30 P.M. and 11/05/24 at approximately 12:30 A.M. CNA #204 stated she turned care over to CNA #205 at that time. CNA #204 also confirmed oncoming staff was not at the facility at the end of the shift and no report was provided. CNA #204 ended the shift on 11/05/24 at 6:30 A.M.

On 11/05/24 at 8:46 A.M. telephone interview with CNA #205 denied assuming care of Resident #2 during the shift on 11/05/24. CNA #205 verified she did not check Resident #2 for incontinence or provide turning with repositioning during her shift between 11/05/24 at 12:30 A.M. and 6:30 A.M.

According to task bowel and bladder monitoring documentation Resident #2 was documented to be checked and found incontinent on 11/04/24 at 11:48 P.M. No further bowel and bladder tracking or documentation of incontinence monitoring was documented in the medical record.

On 11/05/24 at 7:45 A.M. interview with the Director of Nursing (DON) revealed residents are not to be double brief due to creating a increased potential for skin breakdown and infections. CNAs are to document incontinence checks in the medical record under task and resident incontinence frequency checks are indicated in the nursing plan of care.

3. Resident #3 admitted to the facility on 06/09/23 with diagnoses including, cerebral infarction, type 2 diabetes mellitus, protein calorie malnutrition, hypertension, anemia, dysphagia, acute kidney failure, and muscle disorder.

According to the most current MDS assessment dated 09/16/24 revealed Resident #3 with the inability to make needs known, severe cognitive impairment, dependent on staff for the completion of activities of daily living (ADL) including bed mobility, always incontinent of bowel and bladder, at risk for pressure ulcer development with no current skin breakdown.

Review of nursing plans of care revealed on 05/18/24 a plan of care was developed to address Resident #3's ADL self-care performance deficit related to disease process. Interventions included for toilet use, the resident is able to complete task with extensive to total assist of one to two staff members.

On 09/03/24 a Bladder Incontinence Data Collection Tool was completed and noted resident is incontinent of bladder all or most of the time.

A physician order was initiated on 10/10/24 to provide additional ADL assistance related to diagnoses of Hemiplegia and Cerebral Infarction. Please refer to plan of care.

Observation on 11/05/24 at 7:13 A.M. with Certified Nurse Aide (CNA) #201 discovered Resident #3 in bed with two incontinence briefs applied. Resident #3 was unable to indicate when last checked for incontinence and was observed to require total dependence of care from CNA #201. CNA #201 stated she assumed care of Resident #3 at 7:00 A.M. and the observation was her first observation of the resident. CNA #201 went on to state the previous CNA identified to provide care to Resident #3 left the facility before giving report regarding the last incontinence check for Resident #3. CNA #201 stated Resident #3 required two hour incontinence episode checks with repositioning.

According to task bowel and bladder monitoring documentation Resident #3 was documented to be checked and found incontinent on 11/04/24 at 8:22 A.M. No further bowel and bladder tracking or documentation of incontinence monitoring was documented in the medical record.

On 11/05/24 at 7:45 A.M. interview with the Director of Nursing (DON) revealed residents are not to be double brief due to creating a increased potential for skin breakdown and infections. CNAs are to document incontinence checks in the medical record under task and resident incontinence frequency checks are indicated in the nursing plan of care.

This deficiency represents non-compliance investigated under Complaint Number OH00159047.

The state published no narrative for this citation.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately. This affected two (#47 and #155) of 30 residents reviewed for MDS assessments. The facility census was 61.

Findings include:

1. Review of the medical record for Resident #47 revealed an admission date of 06/30/22 with diagnoses of neoplasm of the brain and anxiety.

Review of the annual MDS assessment dated 07/08/24 revealed Resident #47 had intact cognition and no functional limitations in range of motion to his upper extremity (shoulder, elbow, wrist, hand).

Review of the physical therapy progress report and updated therapy plan dated 07/08/24 through 08/06/24 revealed Resident #47 was assessed on 07/07/24 and 07/08/24 and was found to have left shoulder range of motion from zero to 90 degrees, with standard range of motion defined as zero to 120 degrees.

Interview and observation on 08/12/24 at 2:25 P.M. with Resident #47 revealed he had pain in his left shoulder and demonstrated he could not lift his arm any higher than the level of his shoulder while holding it straight out in front of him.

Interview on 08/15/24 at 3:10 P.M. with Rehabilitation Services Director #404, along with concurrent review of Resident #47's physical therapy progress note, confirmed a range of motion of 90 degrees was considered a limited range of motion to Resident #47's left shoulder.

2. Review of the medical record for Resident #155 revealed an admission date of 07/26/24 with a diagnosis of a wound to the right forearm.

Review of the MDS assessment dated 07/30/24 revealed Resident #155 had intact cognition and had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device.

Review of the weekly wound evaluation dated 07/31/24 revealed Resident #155 was admitted with a trauma injury to her right forearm.

Review of the skin observation tool, dated 08/02/24, revealed Resident #155 had a right forearm trauma/injury.

Interview on 08/15/24 at 4:04 P.M. with the Director of Nursing (DON) confirmed Resident #47's range of motion was documented incorrectly in the MDS assessment dated 07/08/24 and Resident #155's trauma wound was documented incorrectly in the MDS assessment dated 07/30/24.

Based on observation medical record review, resident interview, and staff interview, the facility failed to adequate ensure nail care was provided to residents dependent on staff for care. This affected two (#24 and #44) of three residents reviewed for assistance with activities of daily life (ADLs). The facility census was 61.

Findings include:

1. Review of the medical record for Resident #24 revealed an admission date of 05/28/24 with diagnoses of type II diabetes mellitus and anxiety.

Review of the modified admission Minimum Data Set (MDS) assessment dated 06/03/24 revealed Resident #24 had intact cognition and was dependent for personal hygiene.

Review of the current care plan for Resident #24 revealed she had an ADL self-care performance deficit. Interventions included checking nail length and trimming and cleaning on bath day and as necessary.

Observation and interview on 08/12/24 at 10:33 A.M. with Resident #24 revealed the nails on her left hand were long and had dark debris under them. Resident #24 stated she tried to clean them every day and she wanted her nails trimmed. Resident #24 heard someone came to the facility once a month to do nails.

Observation on 08/13/24 at 3:57 P.M. revealed staff transferred Resident #24 from the chair to the bed. Continued observation when Resident #24 was settled in bed revealed the fingernails on her left hand continued to be long and have dark debris under them.

Interview and observation on 08/14/24 at 3:20 P.M. revealed Resident #24 lying in bed. Her nails on the left hand remained long and had some dark debris under them. Additionally, the thumbnail on her right hand and dark debris under it. Resident #24 stated her sister visited earlier in the day and helped clean under her fingernails.

Interview on 08/14/24 at approximately 3:21 P.M. with State Tested Nurse Aide (STNA) #412 revealed Resident #24's showers were scheduled for Mondays and Thursdays on first shift.

Interview and observation on 08/14/24 at 3:23 P.M. with Licensed Practical Nurse (LPN) #446 confirmed Resident #24's nails on her left and right hands were dirty. LPN #446 stated STNAs were responsible for nail care.

Interview on 08/14/24 at 3:27 P.M. with STNA #469 revealed residents' nails were usually cleaned and trimmed on shower days; however, if she saw dirty nails she would clean them.

2. Resident #44 admitted to the facility on 06/20/24 with the diagnoses including, pervasive developmental disorder, schizoaffective disorder, moderate intellectual disorder, vascular dementia, depression, and obstructive and reflux uropathy.

Review of the most current MDS assessment dated 06/27/24 revealed Resident #44 was assessed with moderately impaired cognition and was dependent on staff for the completion of activities of daily living.

Review of Resident #44's plan of care dated 06/20/24 revealed a focus area was initiated to address Resident #44's ADL self-care performance deficit related to disease process and impaired balance. Interventions included the resident was dependent on one to two staff for bathing, was dependent of one to two staff to assist with dressing, and was dependent on one staff with personal hygiene and oral care.

Observation on 08/12/24 at 9:34 A.M. noted Resident #44 was seated in a wheelchair in his room. The resident was observed with long jagged finger nails with black/brown debris under the nails and heavy facial hair growth.

On 08/13/24 at 9:14 A.M. interview with STNA #450 verified Resident #44 with heavy facial hair growth and jagged fingernails with debris under them.

Based on observation, resident and staff interviews, review of the medical record, review of a bowel protocol, and review of a facility policy, the facility failed to ensure wound dressings were completed per physician orders and failed to implement the facility bowel protocol as indicated. This affected one (#155) of two residents reviewed for wounds and two (#24 and #49) of two residents review for bowel movements. The facility census was 61. Findings include: 1. Review of the medical record for Resident #155 revealed an admission date of 07/26/24 with a diagnosis of a wound to the right forearm. Review of the Minimum Data Set (MDS) assessment dated 07/30/24 revealed Resident #155 had intact cognition. Review of a physician order dated 07/26/24 revealed wound care orders to wash Resident #155's right forearm with normal saline, pat dry, cover the wound bed with collagen, then place adaptic over collagen, cover with foam, and change daily and as needed to be completed every day shift and as needed for wound care. Review of Resident #155's treatment records for August 2024 revealed no wound care documentation dated 08/11/24. Observation and interview on 08/12/24 at 2:47 P.M. with Resident #155 revealed she had a bandage on her right forearm. Resident #155 stated the bandage was not changed since 08/10/24. Observation of the bandage revealed it was dated 08/10/24. Interview on 08/12/24 at 2:53 P.M. with Licensed Practical Nurse (LPN) #426 with concurrent observation of Resident #155's bandage on her right forearm confirmed the bandage was dated 08/10/24. LPN #426 further confirmed the order for Resident #155's dressing change was once daily on day shift. Observation on 08/14/24 at 8:34 A.M. with Wound Specialist Physician (WSP) #503 revealed Resident #155 was not wearing a bandage on her right forearm upon WSP #503's arrival to assess the wound. Resident #155 stated the bandage had peeled off some and she pulled the whole thing off earlier in the morning. WSP #503 stated the wound was improving drastically and she had no concerns with the facility's treatment of Resident #155's wound. Interview on 08/14/24 at 1:18 P.M. with Regional Director of Clinical Reimbursement (RDCR) #501 confirmed Resident #155's August 2024 treatment records contained no evidence her wound dressing was completed to the right forearm on 08/11/24. Review of the policy titled, Clean Dressing ChangeBased on observation, resident and staff interviews, review of the medical record, review of a bowel protocol, and review of a facility policy, the facility failed to ensure wound dressings were completed per physician orders and failed to implement the facility bowel protocol as indicated. This affected one (#155) of two residents reviewed for wounds and two (#24 and #49) of two residents review for bowel movements. The facility census was 61.

Findings include:

1. Review of the medical record for Resident #155 revealed an admission date of 07/26/24 with a diagnosis of a wound to the right forearm.

Review of the Minimum Data Set (MDS) assessment dated 07/30/24 revealed Resident #155 had intact cognition.

Review of a physician order dated 07/26/24 revealed wound care orders to wash Resident #155's right forearm with normal saline, pat dry, cover the wound bed with collagen, then place adaptic over collagen, cover with foam, and change daily and as needed to be completed every day shift and as needed for wound care.

Review of Resident #155's treatment records for August 2024 revealed no wound care documentation dated 08/11/24.

Observation and interview on 08/12/24 at 2:47 P.M. with Resident #155 revealed she had a bandage on her right forearm. Resident #155 stated the bandage was not changed since 08/10/24. Observation of the bandage revealed it was dated 08/10/24.

Interview on 08/12/24 at 2:53 P.M. with Licensed Practical Nurse (LPN) #426 with concurrent observation of Resident #155's bandage on her right forearm confirmed the bandage was dated 08/10/24. LPN #426 further confirmed the order for Resident #155's dressing change was once daily on day shift.

Observation on 08/14/24 at 8:34 A.M. with Wound Specialist Physician (WSP) #503 revealed Resident #155 was not wearing a bandage on her right forearm upon WSP #503's arrival to assess the wound. Resident #155 stated the bandage had peeled off some and she pulled the whole thing off earlier in the morning. WSP #503 stated the wound was improving drastically and she had no concerns with the facility's treatment of Resident #155's wound.

Interview on 08/14/24 at 1:18 P.M. with Regional Director of Clinical Reimbursement (RDCR) #501 confirmed Resident #155's August 2024 treatment records contained no evidence her wound dressing was completed to the right forearm on 08/11/24.

Review of the policy titled, Clean Dressing Change

Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure interventions and treatments were implemented for a resident assessed at risk for pressure ulcers to prevent deterioration of an existing stage four pressure ulcer (full-thickness skin and tissue loss) and the development of additional pressure ulcers and failed to ensure pressure ulcer treatments were applied as ordered by the physician. Actual harm occurred to Resident #31 when the facility failed to initiate an alternative pressure relieving cushion or additional pressure reliving intervention to the resident's wheelchair after an existing cushion was damaged and removed and treatments were not administered as ordered. This resulted in Resident #31 developing two stage three in-house acquired pressure ulcers (full-thickness skin loss) with related worsening and drainage. This affected one (#31) of two sampled residents reviewed for pressure ulcer prevention and care in a facility census of 61.

Findings include:

Review of Resident #31's medical record revealed the resident admitted to the facility on 08/27/19 with diagnoses including, cervical cord syndrome, paraplegia, traumatic brain injury, type II diabetes mellitus, poly neuropathy, atrial fibrillation, venous thrombosis and embolism, respiratory failure, chronic obstructive pulmonary disease, ulcerative pancolitis, and spinal stenosis.

Review of the most current Minimum Data Set (MDS) assessment dated 07/16/24 assessed Resident #31 with intact cognition. The resident was dependent on staff for the completion of activities of daily living (ADLs) including bed mobility and repositioning. The resident utilized an indwelling catheter and colostomy, and was assessed at risk for pressure ulcer development with one or more unhealed pressure ulcers/injuries including a stage three pressure ulcer not present at the time of admission, one stage four present on admission, and one unstageable pressure injury (obscured full-thickness skin and tissue loss) present upon admission.

Review of a nursing plan of care initiated on 10/11/21 revealed Resident #31 had actual impairment to skin integrity related to paraplegia including a stage four pressure ulcer to the right ischium. Interventions included to follow facility protocols for treatment of the injury; identify and document potential causative factors and eliminate and resolve where possible; monitor and document the location, size, and treatment of the skin injury, and report abnormalities, failure to heal, signs or symptoms of infection, or maceration to the physician; and weekly treatment documentation to include measurement of each area of skin breakdown with width, length, depth, type of tissue and exudate, and any other notable changes or observations.

Review of the wound specialist physician evaluation documentation on 05/01/24 revealed a chronic stage four right ischium pressure ulcer present greater than 761 days. Further review revealed the wound evaluation description was noted with moderate serous exudate (drainage) and measured 3.3 centimeters (cm) long by (x) 1.8 cm wide x 1.1 cm deep. The recommended interventions included to off-load the wound, turn side to side and front to back in bed every one to two hours if able when in bed, lay flat in wheelchair for one hour every three hours, reposition per facility protocol, and continue application of specialized cushion (ROHO, pressure-reliving cushion) to the specialized wheelchair.

On 05/02/24 the physician modified a treatment to the right ischium to cleanse Resident #31's wound with wound cleanser (Vashe), pat dry, apply a collagen sheet, then apply calcium alginate/AG to the wound bed, and cover with bordered gauze once daily and as needed every day shift for a pressure injury.

Review of the pressure risk assessment dated 06/22/24 Resident #31 was assessed at moderate risk of pressure ulcer development.

Review of wound specialist physician evaluation documentation on 07/19/24 noted a chronic stage four right ischium pressure ulcer. Further review of the wound evaluation description noted moderate serous exudate and measured 3.0 cm long x 1.9 cm wide x 0.5 cm deep. The recommended interventions included to off-load the wound, turn side to side and front to back in bed every one to two hours if able when in bed, lay flat in wheelchair for one hour every three hours, reposition per facility protocol, and continue application of ROHO cushion to specialized wheelchair. The primary dressing for the wound included the application of a collagen sheet apply once daily for 30 days, and alginate calcium with silver apply once daily for 30 days.

On 07/31/24 a weekly wound evaluation noted Resident #31's stage four right ischium pressure ulcer was documented as worsening due to resident non-compliance with wound care and broken ROHO cushion. The wound description revealed there was moderate serous exudate, and the wound measured 4.2 cm long x 3.0 wide x 0.7 cm deep. No additional intervention was implemented to replace the broken ROHO cushion. In addition, two in-house pressure ulcers were discovered. Documentation indicated wound #1, which was a right buttock stage three pressure ulcer, was noted on 07/30/24 and was described with a small amount of serous exudate and measured 7.5 cm long x 4.0 cm wide x 0.1 cm deep. Treatment of the wound included to cleanse with soap and water apply Triad paste every shift and as needed. Wound #2, which was identified as left ischium moisture associated skin damage (MASD), measured 4.0 cm long x 7.5 cm wide x 0.1 cm deep with no drainage. The same treatment was applied as wound #1.

Review of a wound specialist evaluation dated 07/31/24 noted the physician indicated Resident #31's custom ROHO cushion was taken to see if a repair could be made. The document continued that the resident continued to stay in his chair for 14-plus hours per day without getting up to off-load and had caused a quick breakdown of his skin. Resident #31 was encouraged to get back into bed or at least lay on his side when he got back into bed. The wound specialist documented the facility will also see if physical therapy might have a ROHO cushion available to use until they find out what was happening with the resident's personal ROHO cushion. Resident #31's wound progress was documented as exacerbated due to patient non-compliant with wound care and broken ROHO cushion. Wound measurement to the right ishium was 4.2 cm long x 3.0 cm wide x 0.7 cm deep with moderate serous drainage. Recommendations included to off-load the wound, reposition per facility protocol, and therapy consultation for ROHO cushion options.

On 08/07/24 the wound specialist documented Resident #31's ROHO cushion was being repaired and his wounds and skin are breaking down further. The resident's right ischium was assessed with moderate serous drainage and measured 4.0 cm long x 2.7 cm wide x 1.0 cm deep with a new treatment to apply Methylene blue foam once daily for 30 days. The right buttock was assessed with moderate serous exudate and measured 3.5 cm long x 4.5 cm wide x 0.2 cm deep with wound treatment to apply Methylene blue foam apply once daily for 30 days. The left ischium MASD measured 0.5 cm long x 1.0 cm wide x 0.1 cm deep with continued application of Triad paste apply twice daily. In addition, a third in-house acquired wound was discovered to the posterior scrotum described as a stage three pressure wound measuring 2.0 cm long x 5.0 cm wide x 0.1 cm deep with no drainage. Treatment for this wound included application of Triad paste to be applied twice daily. Review of the medical record lacked documentation of additional interventions to address pressure relief while the resident was in the wheelchair, or a therapy evaluation related to temporary replacement of the ROHO cushion.

Review of Resident #31's wound treatment orders dated 08/07/24 included, for the right buttock, right ischium, and left ischium, to cleanse with wound cleanser (Vashe), pat dry, apply Methylene Blue (Hydrofera Blue) to the wound bed, and cover with bordered gauze once daily and as needed every day shift for the pressure injuries. The treatment order for the posterior scrotal wound was to cleanse with soap and water and apply Triad paste every shift and as needed.

Observation on 08/12/24 at 10:49 A.M. with State Tested Nurse Aide (STNA) #409 noted Resident #31 in his room after being transferred with a mechanical lift. Resident #31 was placed in a specialized electric wheelchair, dressed, and groomed. Interview with Resident #31 at the time of the observation stated he was waiting on repair of his ROHO cushion for four weeks. STNA #409 stated Resident #31 developed an open area to his buttock with no treatment applied for two weeks. Observation at that time revealed Resident #31's wheelchair was noted without a pressure relief cushion to the seat.

On 08/13/24 at 10:38 A.M. observation with STNA #409 and STNA #450, during morning activities of daily living with Resident #31, noted the resident was positioned to the left side and revealed exposed wounds to the bilateral ischium, right buttock, and posterior scrotum. There was no dressing or treatment applied to the wounds and blood-tinge drainage was identified contained in the incontinence brief under the resident. Interview with STNA #409 at the time of the observation verified no dressing was in place since assuming care of Resident #31 at 7:00 A.M.

Interview on 08/13/24 at 10:43 A.M. with Licensed Practical Nurse (LPN) #422 revealed she was unaware Resident #31 required a dressing application to wounds on the ischium or buttock. LPN #422 indicated she thought a wound barrier cream was to be applied. Observation at that time revealed LPN #422 proceeded to obtain dressing treatment supplies following review of Resident #31's medical record and went to Resident #31's room. Interview with LPN #422 during observation of the resident confirmed no treatment was applied to the resident's wounds. Further observation revealed LPN #422 cleansed the resident's right ischium, right buttock, posterior scrotum, and left ischium with wound cleanser (Vashe) and patted them dry. LPN #422 applied Methylene Blue (Hydrofera Blue) to the wound bed of the bilateral ischium and right buttock, applied barrier cream to the posterior scrotum and peri-wounds, and covered all of the wounds with two absorbent dressings (ABD).

Observations on 08/13/24 at 11:00 A.M., 12:20 P.M., 1:03 P.M., 08/14/24 at 12:10 P.M., and 2:00 P.M. noted Resident #31 seated in the wheelchair without a pressure relieving cushion to the seat.

On 08/14/24 at 6:45 A.M. interview with the Director of Nursing (DON), during a review of the medical record, confirmed Resident #31 specialized pressure relief cushion (ROHO) to the wheelchair was removed approximately two weeks ago and no intervention was implemented in place of the cushion. The DON verified Resident #31 remained in the wheelchair for extended periods and was unable to reposition himself.

Interview on 08/14/24 at 7:20 A.M. with Wound Specialist Physician (WSP) #503 confirmed Resident #31 had a ROHO cushion in place until a couple weeks ago when the cushion was broken, and no current intervention was placed in the chair to replace the missing cushion while being repaired. WSP #503 stated since the cushion had been removed the resident had developed new skin breakdown and deterioration of an existing wound.

Observation on 08/14/24 at 9:08 A.M. with WSP #503 and LPN #500 noted Resident #31 in bed. LPN #500 positioned Resident #31 to the left and exposed the dressings. WSP #503 removed the dressings and noted a moderate amount of serous drainage. WSP #503 obtained wound descriptions with measurements to the right ischium wound as measuring 5.0 cm long x 2.0 cm wide x 1.4 cm deep, measurements to the right buttock wound were 5.0 cm long x 3.6 cm wide x 0.1 cm deep, the wound to the left buttock was noted as healed, and the wound to the posterior scrotum measured 5.0 cm long x 1.5 cm wide x 0.2 cm deep. Observation noted Resident #31 to exhibit verbal pain with evaluation of the right ischium wound and indicated the pain was a level of eight on a 10-point scale, with 10 being the worse pain. WSP #503 stated Resident #31 did not express pain when this wound was evaluated previously and indicated the wound appeared more tender and sensitive.

Review of the undated pressure injury prevention and management policy revealed interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment. Evidence-based interventions for prevention will be implemented for all residents at risk or who have pressure injury present. Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have pressure injury present.

Review of the undated clean dressing change policy revealed the facility will provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes.

Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were adequately supervised while smoking and failed to ensure smoking materials were maintained in a safe manner. This affected two (#21 and #156) of two residents reviewed for smoking. The facility census was 61. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 04/09/24 with diagnoses of bipolar disorder, dementia, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/19/24, revealed Resident #21 had impaired cognition. Review of the smoking safety screen document, dated 04/10/24, revealed Resident #21 required supervision while smoking. Observation on 08/13/24 at 10:43 A.M. revealed five residents in the smoking area, including Resident #21, and no facility staff. Resident #21 was smoking two cigarettes at the same time, with one in each hand. Resident #21 was sitting in a wheelchair wearing shorts and a t-shirt. Continued observation revealed Resident #21 dropped a finished cigarette on the concrete and continued to smoke the other cigarette. Further observation revealed Resident #21 had cigarette ashes on his shorts. No burn holes were observed. Observation and interview on 08/13/24 at 10:51 A.M. with MDS Coordinator #456 confirmed Resident #21 had ashes on his shorts and confirmed cigarette butts were on the concrete, in the grass, and in the rocks around the ash trays. Further interview with MDS Coordinator #456 confirmed no facility staff was present in the smoking area while Resident #21 was outside. Interview on 08/13/24 at 11:08 A.M. with Licensed Practical Nurse (LPN) #480 confirmed Resident #21 should be supervised while he smoked. Interview on 08/15/24 at 9:45 A.M. with the Director of Nursing (DON) verified Resident #21 required supervision while smoking. 2. Review of the medical record for Resident #156 revealed an admission date of 07/20/24 with diagnoses of chronic obstructive pulmonary disease and hypertension. Review of the comprehensive admission MDS assessment dated 07/27/24 revealed Resident #156 had intact cognition and used tobacco. Review of the smoking safety screen document, dated 07/26/24, revealed Resident #156 was safe to smoke without supervision. Observation on 08/12/24 at 11:21 A.M. revealed Resident #156 was not in his room. Further observation revealed a half-smoked extinguished cigarette sitting on top of a cardboard pizza box on Resident #156's overbed table. An unopened pack of cigarettes was also on the table. Interview on 08/12/24 at 11:22 A.M. with LPN #426 revealed Resident #156 was out of the facility at a doctor's appointment. During the continued interview and concurrent observation of Resident #156's room, LPN #426 confirmed the half-smoked, extinguished cigarette was lying on top of a cardboard pizza box. Review of the policy titled, Resident SmokingBased on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were adequately supervised while smoking and failed to ensure smoking materials were maintained in a safe manner. This affected two (#21 and #156) of two residents reviewed for smoking. The facility census was 61.

Findings include:

1. Review of the medical record for Resident #21 revealed an admission date of 04/09/24 with diagnoses of bipolar disorder, dementia, and schizophrenia.

Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/19/24, revealed Resident #21 had impaired cognition.

Review of the smoking safety screen document, dated 04/10/24, revealed Resident #21 required supervision while smoking.

Observation on 08/13/24 at 10:43 A.M. revealed five residents in the smoking area, including Resident #21, and no facility staff. Resident #21 was smoking two cigarettes at the same time, with one in each hand. Resident #21 was sitting in a wheelchair wearing shorts and a t-shirt. Continued observation revealed Resident #21 dropped a finished cigarette on the concrete and continued to smoke the other cigarette. Further observation revealed Resident #21 had cigarette ashes on his shorts. No burn holes were observed.

Observation and interview on 08/13/24 at 10:51 A.M. with MDS Coordinator #456 confirmed Resident #21 had ashes on his shorts and confirmed cigarette butts were on the concrete, in the grass, and in the rocks around the ash trays. Further interview with MDS Coordinator #456 confirmed no facility staff was present in the smoking area while Resident #21 was outside.

Interview on 08/13/24 at 11:08 A.M. with Licensed Practical Nurse (LPN) #480 confirmed Resident #21 should be supervised while he smoked.

Interview on 08/15/24 at 9:45 A.M. with the Director of Nursing (DON) verified Resident #21 required supervision while smoking.

2. Review of the medical record for Resident #156 revealed an admission date of 07/20/24 with diagnoses of chronic obstructive pulmonary disease and hypertension.

Review of the comprehensive admission MDS assessment dated 07/27/24 revealed Resident #156 had intact cognition and used tobacco.

Review of the smoking safety screen document, dated 07/26/24, revealed Resident #156 was safe to smoke without supervision.

Observation on 08/12/24 at 11:21 A.M. revealed Resident #156 was not in his room. Further observation revealed a half-smoked extinguished cigarette sitting on top of a cardboard pizza box on Resident #156's overbed table. An unopened pack of cigarettes was also on the table.

Interview on 08/12/24 at 11:22 A.M. with LPN #426 revealed Resident #156 was out of the facility at a doctor's appointment. During the continued interview and concurrent observation of Resident #156's room, LPN #426 confirmed the half-smoked, extinguished cigarette was lying on top of a cardboard pizza box.

Review of the policy titled, Resident Smoking

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure timely incontinence care and interventions were provided following an episode of urinary incontinence. This affected one (#36) of three residents reviewed for urinary tract infections in a facility census of 61.

Findings include:

Review of the medical record noted Resident #36 admitted to the facility on 09/15/20 with diagnoses including, epilepsy, extended spectrum beta lactamase resistance, type II diabetes mellitus, hypertension, acute kidney failure, anxiety disorder, hypothyroidism, muscle wasting and atrophy, and dysphagia.

Review of the most current Minimum Data Set (MDS) assessment dated 07/02/24 revealed Resident #36 was assessed with moderately impaired cognition, required partial to moderate assist with activities of daily living (ADLs) including toileting, and was frequently incontinent of bowel and bladder.

Review of Resident #36's care plan revealed on 09/10/21 a nursing plan of care was revised to address the resident's risk for alteration in elimination related to being occasionally incontinent of bowel and bladder, and acute kidney injury. Interventions included to administer medications as ordered, monitor for signs and symptoms of urinary tract infections (UTIs) including elevated temperature, dysuria, flank pain, hematuria, foul smelling urine, and report to a physician to seek diagnosis and treatment promptly, monitor for skin redness and irritation, and provide incontinent care as needed.

Review of an additional nursing plan of care dated 05/05/23 was initiated to address Resident #36's risk for an ADL self-care performance deficit related to dementia, impaired balance, limited mobility, and pain. The care plan identified ADL support may fluctuate related to the resident's cognition. Interventions included the resident required limited assistance by one staff with bathing/showering as necessary, required limited to extensive assistance by one to two staff to turn and reposition in bed as necessary, required limited assistance by one staff to dress, required limited assistance by one staff with personal hygiene and oral care, required skin inspection with care to observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse, required limited to extensive assistance by one to two staff for toileting, and required limited assistance by one staff to move between surfaces as necessary.

On 08/15/24 at 6:16 A.M. interview with State Tested Nurse Aide (STNA) #405 stated she assumed care of Resident #36 during the night shift from 10:30 P.M. on 08/14/24 to 6:30 A.M. on 08/15/24. During the shift STNA #405 went into Resident #36's room to ask if the resident needed to use the restroom and she would not wake. STNA #405 was unaware Resident #36 had a history of urinary incontinence, and also stated she did not check under the resident's sheets to determine if the resident was soiled of urine.

Observation on 08/15/24 at 6:20 A.M. with STNA #405 noted Resident #36 in bed and covered with sheets. STNA #405 woke Resident #405 and observed the resident to be incontinent of a heavy amount of urine. The resident was assisted out of bed and it was noted the resident's pants and lift pad (cloth chux) bed linen were also saturated with urine with a strong urinary odor. STNA #405 assisted the resident to the restroom and placed the resident on the toilet. Resident #36 indicated she was done using the restroom and STNA #405 obtained a clean brief (pull-up) and pair of pants. STNA #405 reminded the resident to use a portion of toilet tissue to wipe herself and proceeded to assist the resident with placing the clean brief and pants on. No opportunity was provided to cleanse the resident of the residual urine on the resident's perineum or buttock. No perineal care was provided.

On 08/15/24 at 6:34 A.M. interview with STNA #405 confirmed Resident #36 was heavily soiled of urine and was not observed for urinary incontinence during the night shift (10:30 P.M. to 6:30 P.M.). STNA #405 was unaware the resident was incontinent and indicated she thought the resident would take herself to the restroom when needed. STNA #405 also verified the resident was not cleansed of the soiled urine following the incontinence episode, and placed into a clean incontinence brief and pants.

Interview with the Director of Nursing (DON) on 08/15/24 at 6:50 A.M. confirmed Resident #36 was identified as incontinent of bladder and required assistance with incontinence needs, and stated following an incontinence episode residents are to be thoroughly cleansed of urinary soiling. The DON stated a resident's bowel and bladder status are assessed on admission and quarterly.

On 08/15/24 at 7:18 A.M. additional interview with the DON revealed the facility lacks a policy of procedure to assess resident bowel and bladder needs.

Review of the facility perineal care policy, implemented 2022, revealed the facility practice was to provide perineal care to all incontinence residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and prevent and assess for skin breakdown.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure hand hygiene was practiced during meal service. This affected six (#24, #155, #160, #161, #162, and #154) of six residents observed during meal service. The facility census was 61. Findings include: Observation on 08/12/24 at 12:17 P.M. revealed a cart with lunch trays was delivered to the 300 hall. Observation on 08/12/24 at approximately 12:18 P.M. revealed Licensed Practical Nurse (LPN) #426 pushing Resident #40 in a wheelchair to the scale in the lounge. LPN #426 assisted Resident #40 by touching his sleeve while he stood on the scale and she obtained his weight. LPN #426 then assisted Resident #40 back into his wheelchair and pushed him back to his room. LPN #426 did not practice hand hygiene before opening the meal cart and removing Resident #24's meal tray. LPN #426 entered Resident #24's room, moved items from her overbed table, and set down Resident #24's meal on the table. Interview on 08/12/24 at 12:24 P.M. with LPN #426 confirmed she did not clean her hands after assisting Resident #40 and providing Resident #24's meal. Continuous observation on 08/12/24 beginning at 12:24 P.M. revealed State Tested Nurse Aide (STNA) #469 entered Resident #155's room and came out with her dirty breakfast tray. STNA #469 placed the dirty tray on top of the tray cart, then, without cleaning her hands, reached inside the cart and picked up Resident #155's lunch tray and delivered it. STNA #469 returned to the cart and picked up Resident #160's tray and delivered it to her. STNA #469 moved Resident #160's wheelchair and overbed table to make Resident #160 more comfortable to eat her meal. STNA #469 then closed Resident #155's door, then picked up and provided Resident #161's tray. STNA #469 returned to the tray cart and picked up Resident #162's tray and upon entering his room, picked up his fall mat from the floor, moved his tray table, set the tray down and removed the lid from his tray. STNA #469 did not clean her hands after touching Resident #162's personal items. Continued observation revealed Resident #160 asked for some salt and STNA #469 reached into the tray cart, found a salt packet and attempted to hand it to Resident #160. The salt packet fell on the floor and STNA #160 picked the salt packet up off the floor and handed it to Resident #160 who proceeded to open it and sprinkle salt on her meal. STNA #469 then returned to the tray cart to get Resident #154's lunch tray and provided it to him. At no time during this continuous observation was STNA #469 observed to perform hand hygiene. Interview on 08/12/24 at 12:31 P.M. with STNA #469 confirmed she touched several personal items and picked items up from the floor while delivering meal trays to multiple residents. STNA #469 confirmed she did not perform hand hygiene at any time while she was passing meal trays. STNA #469 believed she was expected to perform hand hygiene before she passed the first meal tray, and after she passed the final meal tray. Concurrent interview with LPN #426, who interjected into the interview, advised STNA #469 hand hygiene should be performed after contact with each resident. Review of the policy titled, Hand HygieneBased on observation, staff interview, and review of the facility policy, the facility failed to ensure hand hygiene was practiced during meal service. This affected six (#24, #155, #160, #161, #162, and #154) of six residents observed during meal service. The facility census was 61.

Findings include:

Observation on 08/12/24 at 12:17 P.M. revealed a cart with lunch trays was delivered to the 300 hall.

Observation on 08/12/24 at approximately 12:18 P.M. revealed Licensed Practical Nurse (LPN) #426 pushing Resident #40 in a wheelchair to the scale in the lounge. LPN #426 assisted Resident #40 by touching his sleeve while he stood on the scale and she obtained his weight. LPN #426 then assisted Resident #40 back into his wheelchair and pushed him back to his room. LPN #426 did not practice hand hygiene before opening the meal cart and removing Resident #24's meal tray. LPN #426 entered Resident #24's room, moved items from her overbed table, and set down Resident #24's meal on the table.

Interview on 08/12/24 at 12:24 P.M. with LPN #426 confirmed she did not clean her hands after assisting Resident #40 and providing Resident #24's meal.

Continuous observation on 08/12/24 beginning at 12:24 P.M. revealed State Tested Nurse Aide (STNA) #469 entered Resident #155's room and came out with her dirty breakfast tray. STNA #469 placed the dirty tray on top of the tray cart, then, without cleaning her hands, reached inside the cart and picked up Resident #155's lunch tray and delivered it. STNA #469 returned to the cart and picked up Resident #160's tray and delivered it to her. STNA #469 moved Resident #160's wheelchair and overbed table to make Resident #160 more comfortable to eat her meal. STNA #469 then closed Resident #155's door, then picked up and provided Resident #161's tray. STNA #469 returned to the tray cart and picked up Resident #162's tray and upon entering his room, picked up his fall mat from the floor, moved his tray table, set the tray down and removed the lid from his tray. STNA #469 did not clean her hands after touching Resident #162's personal items.

Continued observation revealed Resident #160 asked for some salt and STNA #469 reached into the tray cart, found a salt packet and attempted to hand it to Resident #160. The salt packet fell on the floor and STNA #160 picked the salt packet up off the floor and handed it to Resident #160 who proceeded to open it and sprinkle salt on her meal. STNA #469 then returned to the tray cart to get Resident #154's lunch tray and provided it to him. At no time during this continuous observation was STNA #469 observed to perform hand hygiene.

Interview on 08/12/24 at 12:31 P.M. with STNA #469 confirmed she touched several personal items and picked items up from the floor while delivering meal trays to multiple residents. STNA #469 confirmed she did not perform hand hygiene at any time while she was passing meal trays. STNA #469 believed she was expected to perform hand hygiene before she passed the first meal tray, and after she passed the final meal tray. Concurrent interview with LPN #426, who interjected into the interview, advised STNA #469 hand hygiene should be performed after contact with each resident.

Review of the policy titled, Hand Hygiene

Based on staff interview, record review, and review of the Certification and Survey Provider Enhanced Reporting system (CASPER) Report, the facility failed to have an effective quality assurance program to address repeated quality concerns identified during three consecutive annual surveys. This affected all 61 residents in the facility. The census was 61. Findings include: Review of the CASPER Report dated 08/02/24 revealed the facility received deficiencies for failing to provide activities of daily life (ADL) care to dependent residents during the annual surveys conducted in August 2019 and August 2022. 1. Review of the medical record for Resident #24, during the current annual survey, revealed an admission date of 05/28/24. Review of the Minimum Data Set (MDS) assessment dated 06/03/24 revealed Resident #24 had intact cognition and was dependent on staff for personal hygiene. Observations on 08/12/24 at 10:33 A.M., 08/13/24 at 3:57 P.M. and 08/14/24 at 3:20 P.M. revealed Resident #24's fingernails and thumbnails on her right and left hands had dark debris under them. Interview and observation on 08/14/24 at 3:23 P.M. with Licensed Practical Nurse (LPN) #446 confirmed Resident #24's nails on her left and right hands were dirty. 2. Review of Resident #44's medical record, during the current annual survey, revealed the resident admitted to the facility on 06/20/24 with a diagnosis of vascular dementia. Review of the MDS assessment dated 06/27/24 revealed Resident #44 had moderately impaired cognition, and was dependent on staff for the completion of activities of daily living. Observation on 08/12/24 at 9:34 A.M. noted Resident #44 seated in a wheelchair in his room. The resident was observed with long, jagged finger nails with black/brown debris under the nails, and heavy facial hair growth. On 08/13/24 at 9:14 A.M. interview with State Tested Nurse Aide (STNA) #450 verified the resident with heavy facial hair growth and fingernails jagged with debris. Review of the policy titled, Quality Assurance and Performance Improvement (QAPI)Based on staff interview, record review, and review of the Certification and Survey Provider Enhanced Reporting system (CASPER) Report, the facility failed to have an effective quality assurance program to address repeated quality concerns identified during three consecutive annual surveys. This affected all 61 residents in the facility. The census was 61.

Findings include:

Review of the CASPER Report dated 08/02/24 revealed the facility received deficiencies for failing to provide activities of daily life (ADL) care to dependent residents during the annual surveys conducted in August 2019 and August 2022.

1. Review of the medical record for Resident #24, during the current annual survey, revealed an admission date of 05/28/24. Review of the Minimum Data Set (MDS) assessment dated 06/03/24 revealed Resident #24 had intact cognition and was dependent on staff for personal hygiene.

Observations on 08/12/24 at 10:33 A.M., 08/13/24 at 3:57 P.M. and 08/14/24 at 3:20 P.M. revealed Resident #24's fingernails and thumbnails on her right and left hands had dark debris under them.

Interview and observation on 08/14/24 at 3:23 P.M. with Licensed Practical Nurse (LPN) #446 confirmed Resident #24's nails on her left and right hands were dirty.

2. Review of Resident #44's medical record, during the current annual survey, revealed the resident admitted to the facility on 06/20/24 with a diagnosis of vascular dementia. Review of the MDS assessment dated 06/27/24 revealed Resident #44 had moderately impaired cognition, and was dependent on staff for the completion of activities of daily living.

Observation on 08/12/24 at 9:34 A.M. noted Resident #44 seated in a wheelchair in his room. The resident was observed with long, jagged finger nails with black/brown debris under the nails, and heavy facial hair growth.

On 08/13/24 at 9:14 A.M. interview with State Tested Nurse Aide (STNA) #450 verified the resident with heavy facial hair growth and fingernails jagged with debris.

Review of the policy titled, Quality Assurance and Performance Improvement (QAPI)

Based on observation, staff interview, medical record review, and review of the facility policy, the facility failed to ensure enhanced barrier precautions (EBP) were followed during personal care and failed to ensure appropriate infection control procedures were practiced. This affected one (#24) of one residents reviewed for enhanced barrier precautions. The facility census was 61. Findings include: Review of the medical record for Resident #24 revealed an admission date of 05/28/24 with diagnoses of type II diabetes mellitus and anxiety. Review of the modified admission Minimum Data Set (MDS) assessment dated 06/03/24 revealed Resident #24 had intact cognition and was always continent of bowel and bladder and was dependent for toileting and personal hygiene. Review of the current care plan for Resident #24 revealed she had an activities of daily living (ADL) self-care performance deficit and was dependent on staff for toileting and personal hygiene. Review of Resident #24's care plan dated 05/30/24, and current at the time of the survey, indicated Resident #24 had a stage four pressure ulcer (full-thickness skin and tissue loss) to the coccyx. Review of the physician order initiated 07/02/24 revealed Resident #24 had EBP ordered and directed staff to wear gown and gloves during high contact activities. Observation on 08/12/24 at 10:33 A.M., on 08/13/24 at 3:57 P.M., and on 08/14/24 at 3:18 P.M. revealed Resident #24 had an orange sign on her door indicating to, See Nurse Before EnteringBased on observation, staff interview, medical record review, and review of the facility policy, the facility failed to ensure enhanced barrier precautions (EBP) were followed during personal care and failed to ensure appropriate infection control procedures were practiced. This affected one (#24) of one residents reviewed for enhanced barrier precautions. The facility census was 61.

Findings include:

Review of the medical record for Resident #24 revealed an admission date of 05/28/24 with diagnoses of type II diabetes mellitus and anxiety.

Review of the modified admission Minimum Data Set (MDS) assessment dated 06/03/24 revealed Resident #24 had intact cognition and was always continent of bowel and bladder and was dependent for toileting and personal hygiene.

Review of the current care plan for Resident #24 revealed she had an activities of daily living (ADL) self-care performance deficit and was dependent on staff for toileting and personal hygiene.

Review of Resident #24's care plan dated 05/30/24, and current at the time of the survey, indicated Resident #24 had a stage four pressure ulcer (full-thickness skin and tissue loss) to the coccyx.

Review of the physician order initiated 07/02/24 revealed Resident #24 had EBP ordered and directed staff to wear gown and gloves during high contact activities.

Observation on 08/12/24 at 10:33 A.M., on 08/13/24 at 3:57 P.M., and on 08/14/24 at 3:18 P.M. revealed Resident #24 had an orange sign on her door indicating to, See Nurse Before Entering

Based on medical record review of vaccinations, staff interview, review of a facility policy, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to offer COVID-19 booster vaccines for residents as indicated. This affected three (#12, #15, and #34) of five reviewed for COVID-19 vaccinations. The facility census was 61. Findings include: 1. Review of the medical record for Resident #12 revealed the last administration of COVID-19 vaccination was 08/19/22. Review of the immunization record for Resident #12 revealed no education or consent for acceptance or refusal of a COVID-19 booster vaccine following the administration in 2022. 2. Review of the medical record for Resident #15 revealed the last administration of COVID-19 vaccination was 08/19/22. Review of the immunization record for Resident #15 revealed no education or consent for acceptance or refusal of a COVID-19 booster vaccine following the administration in 2022. 3. Review of the medical record for Resident #34 revealed the last administration of COVID-19 vaccination was 08/19/22. Review of the immunization record for Resident #34 revealed no education or consent for acceptance or refusal of a COVID-19 booster vaccine following the administration in 2022. Interview on 08/13/24 at 4:46 P.M. with the Director of Nursing (DON) verified Resident #12, Resident #15, and Resident #34 were not offered COVID-19 vaccinations since 2022. Review of the facility policy titled, Infection Prevention and Control ProgramBased on medical record review of vaccinations, staff interview, review of a facility policy, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to offer COVID-19 booster vaccines for residents as indicated. This affected three (#12, #15, and #34) of five reviewed for COVID-19 vaccinations. The facility census was 61.

Findings include:

1. Review of the medical record for Resident #12 revealed the last administration of COVID-19 vaccination was 08/19/22. Review of the immunization record for Resident #12 revealed no education or consent for acceptance or refusal of a COVID-19 booster vaccine following the administration in 2022.

2. Review of the medical record for Resident #15 revealed the last administration of COVID-19 vaccination was 08/19/22. Review of the immunization record for Resident #15 revealed no education or consent for acceptance or refusal of a COVID-19 booster vaccine following the administration in 2022.

3. Review of the medical record for Resident #34 revealed the last administration of COVID-19 vaccination was 08/19/22. Review of the immunization record for Resident #34 revealed no education or consent for acceptance or refusal of a COVID-19 booster vaccine following the administration in 2022.

Interview on 08/13/24 at 4:46 P.M. with the Director of Nursing (DON) verified Resident #12, Resident #15, and Resident #34 were not offered COVID-19 vaccinations since 2022.

Review of the facility policy titled, Infection Prevention and Control Program

Based on observation, medical record review, and staff interview, the facility failed to ensure the facility had an effective pest control program to promote an environment that was free from pests. This affected one (#36) of five residents reviewed for the environment. The census was 61.

Findings include:

Review of the medical record noted Resident #36 was admitted to the facility on 09/15/20 with diagnoses including, epilepsy, extended spectrum beta lactamase resistance, type II diabetes mellitus, hypertension, acute kidney failure, anxiety disorder, hypothyroidism, muscle wasting and atrophy, and dysphagia.

Review of the most current Minimum Data Set (MDS) assessment dated 07/02/24 assessed Resident #36 with moderately impaired cognition, required partial to moderate assist with activities of daily living including toileting, and was frequently incontinent of bowel and bladder.

Observation on 08/12/24 at 11:15 A.M. noted Resident #36's room with a lift pad (cloth chux) bed linen with 16 gnats on the surface with multiple house flies in the room.

On 08/12/24 at 11:20 A.M. observation and interview with Licensed Practical Nurse (LPN) #446 verified Resident #36's room condition.

Observation on 08/15/24 at 6:20 A.M. with State Tested Nurse Aide (STNA) #405 noted Resident #36 in bed and covered with sheets. STNA #405 woke Resident #405 and observed the resident to be incontinent of a heavy amount of urine. Multiple gnats and house flies were observed in the room and restroom. STNA #405 was noted to swat at the insects while interacting with the resident.

On 08/15/24 at 6:34 A.M. interview with STNA #405 confirmed the presence of gnats and house flies in Resident #36's room.

Observation and interview on 08/15/24 at 8:42 A.M. with Maintenance Director (MD) #406 confirmed the gnats with house flies throughout Resident #36's room. MD #406 indicated he was unaware of the insects and was unable to provide documentation of house fly/gnat prevention treatments.

Based on review of personnel files and staff interviews, the facility failed to ensure state tested nurse aides (STNAs) completed training on dementia care and completed 12 hours of continuing education annually. This had the potential to affect all 61 residents in the facility. The census was 61.

Findings include:

1. Review of the personnel file for STNA #409 revealed a hire date of 09/20/18. Review of STNA #409's continuing education revealed all documents were on paper and the facility could not provide evidence of 12 hours of continuing education was conducted for STNA #409. Additionally, the file contained no evidence STNA #409 received training on caring for residents with dementia.

2. Review of the personnel file for STNA #479 revealed a hire date of 02/24/23. Review of STNA #479's new hire paperwork and continuing education revealed no evidence STNA #479 received training on caring for residents with dementia.

3. Review of the personnel file for STNA #419 revealed a hire date of 08/02/23. Review of STNA #419's new hire paperwork revealed no evidence STNA #419 received training on caring for residents with dementia.

4. Review of the personnel file for STNA #449 revealed a hire date of 08/23/23. Review of STNA #449's new hire paperwork revealed no evidence STNA #449 received training on caring for residents with dementia.

Interview on 08/15/24 at 11:05 A.M. with Human Resources Director (HRD) #489 confirmed the facility could not provide evidence STNA #409 received 12 hours annually of continuing education. HRD #489 confirmed the facility did not provide dementia training to staff because the facility did not have a designated dementia unit.

Interview on 08/15/24 at 11:10 A.M. with STNA #454 confirmed she had not received dementia education.