Mulberry Gardens Senior Living

Based on record review and interview the facility failed to provide adequate staffing levels to provide timely care and services for the residents and timely incontinence care for Resident #47. This affected one out of three residents reviewed for incontinence care and all the residents in the facility. The facility census was 79.

Findings include:

Review of Resident #47's medical records revealed an admission date of 03/22/23 with diagnoses including but not limited to acute kidney failure, left heel pressure ulcer, spinal stenosis of the lumbar region and history of falls.

Review of the Slums cognition assessment dated 04/01/24 revealed Resident #47 had moderately impaired cognition.

Review of service plan dated 09/13/24 revealed Resident #47 was incontinent and required total assistance. Intervention included staff to change brief and clean up as needed (PRN).

Review of physician orders for September 2024 and October 2024 revealed no orders regarding incontinence care.

Interview on 10/16/24 at 7:04 A.M. with Caregiver (CG) #121 revealed Resident #47 was always saturated with urine, blood and strong urine odor due to night shift staff not checking or changing her.

Observation on 10/16/24 at 7:09 A.M. of incontinence care for Resident #47 revealed upon entrance to the room there was a very strong pungent urine odor. CG # 121 and CG #117 assisted Resident #47 to a standing position from her recliner. Resident #47 held onto her wheeled walker. The cloth pad Resident #47 was seated on had dried and fresh blood on it. CG #121 removed her incontinence brief which was saturated with urine and there was a very pungent urine odor. CG #121 took wipes and from behind resident wiped several times to reveal bright red blood. Further observation revealed a dressing to buttocks which was intact with bloody drainage noted. CG #117 applied a new brief and assisted Resident #47 back to a seated position on the recliner.

Observation on 10/16/24 at 11:37 A.M. of wound care revealed Licensed Practical Nurse (LPN) #107 gathered supplies, performed hand hygiene, donned gloves and removed Resident #47's incontinence brief. Resident #47 had been incontinent of large amount of urine and a strong urine odor was noted.

Interview on 10/17/24 at 11:44 A.M. with Resident #47's family revealed she visited often, at least once a week, and Resident #47 smelled strongly of urine.

Observation on 10/17/24 at 11:55 A.M. of Resident #47's bed with Resident #47's family revealed a top cloth pad which was saturated with urine and blood, underneath the pad the sheet was saturated with urine and blood, and underneath the sheet was another cloth pad saturated with urine and blood, and her mattress was soaked with urine and bloody drainage. There was a strong urine odor present.

Interview and observation on 10/17/24 at 12:12 P.M. with Health Services Director (HSD) confirmed Resident #47's bedding was saturated with urine and blood, and there strong urine odor present.

An interview with CG #118 on 11/07/24 at 7:11 A.M. revealed the facility needed to hire additional staff to meet the needs of the residents. CG #118 stated the facility had several residents who needed checked for incontinence every two hours and assisted with incontinence care when necessary. CG #118 stated routinely she had to complete duties left over from the night shift because they did not have time to complete their duties. They tried to work as a team to help each other but she found herself running from task to task all day long. During the interview CG #118's pager was ringing nonstop to alert her of residents pressing their call pendent for assistance.

An interview with Resident Care Coordinator (RCC) #101 on 11/07/24 at 9:47 A.M. revealed on 11/02/24 during the night shift hours from 10:00 P.M. to 4:00 A.M. there was one Licensed Practical Nurse (LPN), LPN #150, and one Caregiver, CG #151, to care for the residents. RCC #101 stated she had notified the HSD on 10/28/24 of the need to study for a test she was scheduled to complete for her Medical Technician certification on 11/03/24. RCC #101 stated she usually was on-call to provide direct care when the facility had a caregiver call off for their shift. RCC #101 stated HSD agreed to take the on-call duties for 11/02/24 during the night shift hours from 10:00 P.M. to 6:00 A.M. RCC #101 turned her cellular phone alert off on 11/02/24 so she could sleep uninterrupted during the night. RCC #101 stated HSD refused to assume the on-call duties for 11/02/24 when the staff alerted HSD of a caregiver call-off and the need to work in the facility from 10:00 P.M. to 6:30 A.M. on 11/02/24 to provide direct care to the residents. RCC #101 stated HSD's mother was in the hospital, and she refused to leave the hospital to work in the facility. RCC #101 did not see a text message from the staff about a caregiver call-off and the need for help until 11:30 P.M. on 11/02/24. RCC #101 stated LPN #150 and CG #151 worked from 10:00 P.M. to 6:30 A.M. to provide care for the 79 residents. CG #151 was still in orientation to the facility and had not been oriented to the night shift duties. RCC #101 indicated the facility was routinely short staffed. The facility based the staffing level in the number of residents and not the acuity of the residents. Many residents needed two staff members to assist them with activities of daily living and needed to be checked for incontinence every two hours. Staff were burned out and CG #151 resigned after completing her shift on 11/02/24 from 10:00 P.M. to 6:00 A.M.

An interview with HSD on 11/07/24 at 1:47 P.M. revealed she was not informed that RCC #101 would not be able to assume the on-call duties and replace staff who called off for their shift on 11/02/24. RCC #101 stated her mother was in the hospital and she was unable to work from 10:00 P.M. to 6:30 A.M. and it was the responsibility of RCC #101 to provide direct care in the event of a staff member calling off for their shift. HSD verified LPN #150 and CG #151 were the staff working from 10:00 P.M. to 6:30 A.M. on 11/02/24.

Interviews on 11/12/24 between 7:00 A.M. and 10:15 A.M. with Resident #9, Resident #13, Resident #59, and Resident #74 stated the facility needed more staff to ensure their call light was answered in a timely manner to assist them with their care needs. The residents stated the staffing level in the facility was inconsistent and the weekends were often short staffed.

An interview with CG #151 on 11/12/24 at 8:20 A.M. revealed she agreed to work on 11/02/24 from 10:00 P.M. to 6:00 A.M. with a preceptor to orient to the night shift duties. CG #151 stated her preceptor called off for the shift and LPN #150 tried to reach RCC #101 by phone to alert her of the call off. CG #151 stated they were unable to replace the caregiver who had called off for the shift. CG #151 stated LPN #150 and herself ran from one call light to the next all night long trying to provide care for the residents. CG #151 stated many of the residents needed two staff members to assist them with their care needs and it took a long time to provide the care. CG #151 stated she was unable to check on any residents who were unable to use their call light. CG #151 stated at the end of her shift she notified the facility she would not be returning and resigned

An interview with LPN #150 on 11/12/24 at 11:19 A.M. revealed she worked from 10:00 P.M. to 6:30 A.M. on 11/02/24. LPN #15 stated it was her second day off orientation, and she assisted CG #151 to check the residents for incontinence and provide care as needed. LPN #150 stated she had medications to administer to the residents as well as assisting with answering the call lights. LPN #150 stated there were residents who needed supervision to prevent falls, and they were unable to provide that supervision. LPN #15 stated they were lucky there was no emergency or residents who fell during the night. LPN #150 stated they were not able to complete all their assigned duties; they could only answer call-lights all night long.

This violation represents non-compliance investigated under Master Complaint Number OH00159582.

Based on observation, interview and facility policy review the facility failed to ensure Resident #47 received proper and timely incontinence care. This affected one resident (Resident #47) of three residents reviewed for incontinence care. The facility census was 73.

Findings include:

Review of Resident #47's medical records revealed an admission date of 03/22/23 with diagnoses including but not limited to acute kidney failure, left heel pressure ulcer, spinal stenosis of the lumbar region and history of falls.

Review of the Slums cognition assessment dated 04/01/24 revealed Resident #47 had moderately impaired cognition.

Review of service plan dated 09/13/24 revealed Resident #47 was incontinent and required total assistance. Intervention included staff to change brief and clean up as needed (PRN).

Review of physician orders for September 2024 and October 2024 revealed no orders regarding incontinence care.

Interview on 10/16/24 at 7:04 A.M. with Caregiver (CG) #121 revealed Resident #47 was always saturated with urine, blood and strong urine odor due to night shift staff not checking or changing her.

Observation on 10/16/24 at 7:09 A.M. of incontinence care for Resident #47 revealed upon entrance to the room there was a very strong pungent urine odor. CG # 121 and CG #117 assisted Resident #47 to a standing position from her recliner. Resident #47 held onto the wheeled walker. The cloth pad Resident #47 was seated on had dried and fresh blood on it. CG #121 removed Resident #47's incontinence brief which was saturated with urine and there was a very pungent urine odor. CG #121 took wipes and from behind the resident wiped several times to reveal bright red blood. Further observation revealed a dressing to Resident #47's buttocks that was intact with bloody drainage noted. CG #117 applied a new brief and assisted Resident #47 back to a seated position on the recliner with same cloth pad on recliner. CG #121 did not provide peri care to the perineal area (the area of the body between the anus and the vulva).

Observation on 10/16/24 at 11:37 A.M. of wound care revealed Licensed Practical Nurse (LPN) #107 gathered supplies, performed hand hygiene, donned gloves and removed Resident #47's incontinence brief. Resident #47 had been incontinent of large amount of urine and strong urine odor was noted. Her buttocks was cleaned but the peri area was not. Interview on 10/16/24 at 12:04 P.M. with LPN #107 confirmed she had not provided incontinence care to Resident #47's peri area and she placed Resident #47 back in bed after wound care was completed.

Interview on 10/17/24 at 7:44 A.M. with CG #121 verified she only provided incontinence care to the buttocks and not the peri area.

Interview on 10/17/24 at 11:44 A.M. with Resident #47's family revealed she visited often, at least once a week, and Resident #47 smelled strongly of urine.

Observation on 10/17/24 at 11:55 A.M. of Resident #47's bed with Resident #47's family revealed a top cloth pad which was saturated with urine and blood, underneath the pad sheet was saturated with urine and blood, and underneath the sheet was another cloth pad saturated with urine and blood, and her mattress soaked with urine and bloody drainage. There was a strong urine odor present.

Interview and observation on 10/17/24 at 12:12 P.M. with Health Services Director (HSD) confirmed Resident #47's bedding was saturated with urine and blood, and there strong urine odor present.

Review of facility policy titled Resident Personal Care Standards, dated 11/01/24, revealed the perineal and buttocks area was to be cleaned as necessary and staff were to ensure perineal hygiene occurred following every episode of incontinence.

This violation represents non-compliance investigated under Complaint Number OH00158527 and OH00158340.

Based on observation, record review, interview, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff maintained infection control practices to prevent possible cross contamination of germs during wound treatment. This affected one out of three residents reviewed for wounds, Resident #47. The facility census was 79.

Findings include:

Review of Resident #47's medical records revealed an admission date of 03/22/23 with diagnoses including but not limited to acute kidney failure, left heel pressure ulcer, spinal stenosis of the lumbar region and history of falls.

Review of the Slums cognition assessment dated 04/01/24 revealed Resident #47 had moderately impaired cognition.

Review of service plan dated 09/13/24 revealed Resident #47 was incontinent and required total assistance. Intervention included staff to change brief and clean up as needed (PRN).

Review of Resident #47's home care skilled documentation dated 09/16/24 indicated the presence of a deep tissue injury of the left heel (no measurements provided) and contact dermatitis due to friction or contact with body fluids (no location or description provided).

Review of Resident #47's physician order dated 11/05/24 indicated to apply a nickel sized amount of Santyl (enzymatic debrider) ointment to the left heel wound bed and cover with gauze. Wrap the entire heel with gauze to secure the dressing to the left heel once a day and as needed. Facility staff would perform the wound treatment daily except on Wednesdays when the skilled home care staff would perform the wound treatment. The physician order dated 11/05/24 indicated to cleanse the left and right buttock wounds with soap and water, pat dry, apply a small amount of Santyl ointment, apply calcium alginate, cover with large absorbent island dressing once a day except Wednesdays when the skilled home care staff would perform the wound treatment. Replace the wound treatment as needed if dislodged and/or soiled.

An observation on 11/07/24 at 8:15 A.M. of Licensed Practical Nurse (LPN) #107 perform Resident #47's wound treatment assisted by Care Giver (CG) #121 revealed a failure to maintain infection control practices during the task. LPN #107 and CG #121 entered Resident #47's room and did not perform hand hygiene. LPN #107 obtained supplies for the wound treatment. LPN #107 and CG #121 assisted Resident #47 to transfer from the recliner to her bed. Prior to assisting Resident #47 on the bed, CG #121 removed Resident #47's incontinence brief. CG #121 placed the soiled incontinence brief on a chair next to the bed. The wound dressing was dislodged. CG #121 removed the soiled wound dressing with her bare hand and placed the wound dressing on the bed. The wound dressing was saturated with bloody wound drainage and had a foul odor. CG #121 then donned a pair of gloves without performing hand hygiene. Resident #47 was assisted with turning on her side and LPN #107 proceeded to perform the wound treatment. CG #121 removed her gloves and left the room without performing hand hygiene. Resident #47's left and right buttock area was excoriated with several open wounds draining moderate amounts of bloody drainage. LPN #107 cleaned the buttock and thigh wounds with soap and water, applied the Santyl ointment to the right/left buttock and inner thigh areas and removed her gloves and donned another pair of gloves without performing hand hygiene. LPN #107 then cut the calcium alginate dressing and placed it over the open areas on the right/left buttock region. LPN #107 then obtained four large absorbent dressings covering the calcium alginate dressings and securing the covering to the wounds. LPN #107 removed her gloves and did not perform hand hygiene and assisted Resident #47 on her side with her feet dangling over the end of the bed. LPN #107 then obtained additional supplies to perform a wound treatment to the left heel. LPN #107 donned a pair of gloves and cleaned the left heel wound with soap and water. LPN #107 removed her gloves, washed her hands with soap and water and donned another pair of gloves. LPN #107 applied Santyl ointment to the left heel wound bed and removed her gloves and donned another pair of gloves without performing hand hygiene. LPN #107 applied large gauze pads covering the heel wound and wrapped the left heel and ankle, securing the wound treatment with gauze wrap. LPN #107 removed her gloves and donned another pair of gloves without performing hand hygiene and proceeded to apply lotion to both of Resident #47's legs. LPN #107 then removed her gloves and donned another pair of gloves without performing hand hygiene and placed the unused clean supplies with the other supplies located on a table in Resident #47's room. LPN #107 removed the soiled wound dressing/supplies from the room and discarded them in the soled utility room. LPN #107 left the soiled incontinence brief lying on the chair in Resident #47's room.

An interview with LPN #107 following the observation on 11/07/24 at 9:15 A.M. verified the above findings.

A review of the CDC guidelines dated 02/27/24 indicated clinical safety: Hand Hygiene for Healthcare Workers. The purpose of the guidelines was to protect yourself and your patients from deadly germs by cleaning your hands. All healthcare personnel should understand how to care for and clean their hands.

Hand hygiene protected both healthcare personnel and patients. Hand hygiene meant cleaning your hands with:

-Handwashing with water and soap (e.g., plain soap or with an antiseptic).

-Antiseptic hand rub (alcohol-based foam or gel hand sanitizer).

-Surgical hand antisepsis.

Cleaning your hands reduced:

-The potential spread of deadly germs to patients.

-The spread of germs, including those resistant to antibiotics.

-The risk of healthcare personnel colonization or infection caused by germs received from the patient.

CDC recommended performing hand hygiene as indicated below:

-Immediately before touching a patient.

-Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices.

-Before moving from work on a soiled body site to a clean body site on the same patient.

-After touching a patient or patient's surroundings.

-After contact with blood, body fluids, or contaminated surfaces.

-Immediately after glove removal.

Based on observation, record review, policy review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program for Resident #47 to ensure timely and accurate assessment/monitoring and treatment for a pressure ulcer, to prevent the deterioration of the pressure ulcer, adequately coordinate the resident's overall pressure ulcer wound care with the home health agency, and to prevent the development of moisture associated skin damage (MASD).

Actual harm occurred beginning on 09/14/24 when Resident #47, who had moderately impaired cognition and was dependent on staff for incontinence care needs and repositioning was re-admitted with a left heel pressure ulcer without appropriate assessment of the wound, physician orders for wound care, and the development of a comprehensive service plan regarding monitoring and treatment of the pressure wound. Upon acquiring the services of a home health agency to provide the wound care, the facility failed to ensure coordination of care and service. On 10/16/24 it was noted the heel ulcer deteriorated from a deep tissue injury to an unstageable pressure ulcer. In addition, on 09/16/24 the home health staff identified MASD to the bilateral buttocks and thigh which had not been previously identified or treated by facility staff. This affected one resident (#47) of three residents reviewed for wound care.

Findings include:

Review of Resident #47's medical record revealed the resident was admitted to the facility on 03/22/23 with diagnoses including acute kidney failure, left heel pressure ulcer, spinal stenos of the lumbar region and history of falls. Resident #47's was discharged from the facility to the hospital on 08/26/24 for acute kidney failure. Resident #47 was transferred to a long-term care skilled nursing facility upon discharge from the hospital on 08/30/24. On 09/14/24 Resident #47 was re-admitted to the facility with a Stage II pressure ulcer (partial -thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) of the left heel.

Review of a cognition (SLUMS) assessment dated 04/01/24 revealed Resident #47 had moderately impaired cognition.

Review of Resident #47's service plan dated 09/13/24 revealed Resident #47 had a pressure ulcer to the left heel and staff were to report to supervisor if the dressing fell off or redness worsened. Resident #47 had interventions including assisting into bed in a side lying position for 30 minutes and to place a pillow between the knees. The service plan revealed Resident #47 required repositioning assistance - total assist and the goal was for resident to be assisted with repositioning to optimize mobility and skin integrity. Resident #47 also had a service plan for incontinence care that included Resident #47 required total assistance with care. The goal was for Resident #47 to be dry, hygienic and odor free with intervention of staff to change brief and clean up as needed.

Resident #47's medical record contained no additional information regarding the listed left heel pressure ulcer until the resident was seen by a home health agency on 09/16/24.

Review of an observation note dated 09/14/24 at 10:15 A.M. authored by Licensed Practical Nurse (LPN) #111 revealed Resident #47 returned to facility that morning. There was no evidence LPN #111 completed a head-to-toe evaluation or skin assessment.

Review of the Medication Administration Report (MAR) dated 09/13/24 to 09/30/24 revealed orders for the nurse to place Resident #47 on her side with pillow between her legs twice a day at 9:00 A.M. and 4:00 P.M. There were no wound treatments included on the MAR.

Review of home health skilled service record revealed on 09/16/24 Resident #47 had pressure ulcer wounds to the bilateral buttocks, left heel, and bilateral posterior thigh. There was no assessment or measurements of the wounds and no indication wound treatments were initiated. The documentation indicated at least one unhealed pressure injury at Stage II or higher and an unstageable pressure injury (full- thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar [dead tissue]). The documentation was not clear where the Stage II pressure area and unstageable pressure injury were located. Under Wound Care Worksheet it listed left heel, present on admission and no other information about the wound. Under skilled intervention it listed skin was compromised due to urine presence and pressure on buttock area. The buttock area was documented as being red and excoriated with an open area. However, there were no measurements, description, or staging of the buttock open area. The documentation did not identify any treatments in place.

A review of Resident #47's wound documentation completed by the Home Health LPN #148 and Home Health Registered Nurse (RN) #146 between 09/20/24 to 10/11/24 revealed inconsistent staging, and descriptions of Resident #47's wounds and inconsistent documentation regarding the location of Resident #47's left heel pressure ulcer.

Review of Home Health Nurse Practitioner (NP) #147's notes revealed on 09/27/24 Resident #47 was seen for an initial visit. Wound #1, bilateral buttocks, was identified as MASD. The area measured 11 centimeters (cm) x 10 cm x 0.2 cm. The tissue was 100 percent pink with moderate serosanguinous (pink watery) drainage. Wound #2 was located on the left heel and classified as a deep tissue injury (intact skin with localized area of persistent non-bleachable deep red, maroon, or purple discoloration due to damage of underlying soft tissue) measuring 3 cm x 2.5 cm x 0 cm. The wound was purple, closed with no drainage. The note indicated a new treatment order was provided for the resident's buttocks which included cleansing with normal saline (NS), patting dry, applying calcium alginate to wound bed, covering with a foam, and changing the dressing three times a week and as needed (PRN). Treatment for left heel included cleansing with breadline, covering with foam, and changing three times a week and PRN.

Review of Home Health NP #147's notes dated 10/09/24 revealed Resident #47 was seen for a follow up visit. The notes reflected Wound #1 to the bilateral buttocks, MASD, which measured 10 cm x 9 cm x 0.2 cm. The tissue was 100 percent, with moderate serosanguinous drainage and perinea area was intact. Wound #2, left heel, deep tissue injury, measured 2.4 cm x 2.8 cm x 0 cm, the tissue was 100 percent purple, no drainage and peri wound was intact.

Review of Home Health NP #147's notes dated 10/16/24 revealed Resident #47 seen for follow up visit. Wound #1, left buttock MASD, identified to be improved, measured 7 cm x 6.5 cm x 0.2 cm, tissue was 100 percent pink, with moderate serosanguinous drainage. Wound #2, right buttock MASD, identified to be improved, measured 8 cm x 7 cm x 0.2 cm (intact skin bridge). Resident #47 was found to have two new areas of MASD to the posterior thighs. Wound #3 to the left posterior thigh measured 1.5 cm x 5 cm x 0.1 cm (intact skin bridge), tissue was 100 percent pink, moderate serosanguinous drainage and peri-wound intact with no odor, erythema or sign of infection noted. Wound #4 to right posterior thigh measured 4 cm x 8 cm x 0.1 cm (intact skin bridge), tissue was 100 percent pink, moderate serosanguinous drainage, and peri-wound intact with no odor, erythema or sign of infection noted. Wound #5, left heel, progress had declined, and was now identified as an unstageable pressure injury (full-thickness tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) measured 2 cm x 3 cm x undetermined depth, peri wound was intact with no odor, erythema or sign of infection noted. Treatments to left and right buttocks included cleansing with normal saline (NS), patting dry, applying silver alginate to wound bed, covering with foam, and changing dressing three times per week and PRN. Treatment to left and right posterior thigh included cleansing with NS, patting dry, applying silver alginate to wound bed, covering with silicone composite and changing the thigh dressings three times a week and as needed. The left heel wound treatment included cleaning with normal saline, applying silver alginate, covering with a foam dressing three times a week and PRN.

Review of a Home Health Communication Form dated 10/21/24 timed 7:16 A.M. for Resident #47 revealed recommendations to continue to monitor, keep resident off area (did not specify what area), keep dressing dry and intact, change position every two hours, and float heels. There was no evidence of other communication forms completed between the home health agency and the facility and there was no documented evidence of these interventions being completed.

Interview on 10/16/24 at 7:04 A.M. with Care Giver (CG) #121 revealed Resident #47 was not provided incontinence care at night and was always saturated with urine in the morning when she provided care and was bleeding from her buttocks wound. CG #121 reported Resident #47 always had a strong urine smell in her room.

Observation on 10/16/24 at 7:05 A.M. of Resident #47 revealed she was in her recliner in her room covered with a blanket. The room had strong pungent urine odor.

Interview with the Health Services Director (HSD) on 10/16/24 at 8:55 A.M. confirmed there were no physician orders related to wound care and a skin evaluation/assessment was not completed at the time of Resident #47's readmission on 09/13/24.

Observation of Resident #47's incontinence care on 10/16/24 at 11:46 A.M. revealed LPN #107 gathered supplies, knocked on door, greeted resident, performed hand hygiene, and donned gloves. Resident #47's room had a very strong pungent urine odor. Resident #47 was assisted to turn to her left side. LPN #107 removed Resident #47's soiled incontinence brief which had serosanguinous drainage noted and strong pungent urine odor. LPN #107 cleansed Resident #47's buttocks. LPN #107 indicated the red areas to Resident #47's upper posterior thighs must be new. LPN #107 removed her gloves, performed hand hygiene, donned gloves and began to perform the dressing change for Resident #47's buttocks. LPN #107 cleansed the buttocks with NS, patted the areas dry, applied calcium alginate and foam border dressing, applied a new incontinence brief, and positioned resident on her back in bed. There was a sign on the headboard of Resident #47's bed stating to position the resident on her side when in bed.

Interview on 10/16/24 at 12:04 P.M. with LPN #107 confirmed she cleansed Resident #47's buttocks but did not provide incontinence care and she positioned Resident #47 on her back.

Interview with Home Health Registered Nurse (RN) #146 on 10/16/24 at 4:22 P.M. and on 10/17/24 at 9:47 A.M. revealed he saw Resident #47 for the first time on 09/16/24. Home Health RN #146 reported Resident #47 had a Stage II or III to her glutei area and deep tissue injury, but not sure, to her left heel. Home Health RN #146 said he did not complete facility communication forms but he spoke to the nurse (could not identify specific nurse). Home Health RN #146 reported he and his staff needed to get better at completing facility communication documents for wound care. Home Health RN #146 reported he completed Resident #47's wound treatments, and orders should have been in place for facility staff to complete dressing changes PRN. Home Health RN #146 did not measure the wounds.

Interview on 10/16/24 at 4:40 P.M. via phone with LPN #111 confirmed she did not do a skin assessment on Resident #47 upon her readmission to the facility from the nursing home. LPN #111 said she did not complete the assessment because Resident #47 was too weak but said she would have asked the oncoming shift to do the skin assessment. LPN #111 explained staff had 24 hours to complete a skin assessment following a resident's admission/re-admission.

Interview on 10/17/24 at 6:53 A.M. with LPN #108 (nurse who worked night shift on day Resident #47 was readmitted) revealed skin assessments were to be completed on all residents upon readmission. LPN #108 confirmed she did not complete a skin assessment on Resident #47 and denied being told LPN #111 did not complete the skin assessment and she (LPN #108) needed to complete.

On 10/17/24 observation at 8:16 A.M., 9:50 A.M., 10:30 A.M., 11:13 A.M., 12:00 P.M., 12:33 P.M., and 1:30 P.M. of Resident #47 revealed she was in her room seated in a recliner. Resident #47's room had a very strong pungent urine odor. At the time of the observations, interview with Resident #47 revealed staff had not offered to lie her down in bed.

Interview on 10/17/24 at 11:55 A.M. with Resident #47's family member revealed the family member visited the resident often, at least once a week and had never observed Resident #47 on her side while she was in bed. Resident #47's family member said she put a handwritten note on the headboard of Resident #47's bed indicating to place the resident on her side when in bed. Observation of Resident #47's bed at the time of the interview revealed there was a cloth pad which was saturated with urine and blood, underneath the pad the sheet was saturated with urine and blood, underneath the sheet was another cloth pad saturated with urine and blood, and her mattress was soaked with urine and bloody drainage. A strong urine odor was noted.

Interview and observation on 10/17/24 at 12:12 P.M. with the HSD confirmed Resident #47's bedding was saturated with urine/blood which had soaked through to the mattress and the room had and strong urine odor. soaked The HSD notified housekeeping at 12:18 P.M. to change the bed linens.

Interview on 10/17/24 at 1:38 P.M. with Home Health NP #147 via phone revealed Resident #47 was seen on 09/27/24 for a wound care consult initial visit. During the visit it was determined Resident #47 had MASD to her buttocks and a deep tissue injury to her left heel. The treatment to the buttocks included calcium alginate and foam dressing and the treatment to left heel included breadline and foam dressing. Both treatments were to be completed three times a week and PRN. Home Health NP #147 reported Home Health RN #146 and Home Health LPN #148 visited during the week and they were supposed to measure the wounds. On 10/16/24 Home Health NP #147 saw Resident #47 and the MASD to bilateral buttocks was healing and the left heel had deteriorated to an unstageable pressure ulcer. Two new areas of MASD were noted to the resident's posterior thighs. Home Health NP #147 reported Home Health RN #146 and Home Health LPN #148 sent her pictures of the wounds.

Interview on 10/21/24 at 7:16 A.M. revealed the HSD had communication forms for home health visits for 09/20/24, 09/27/24, 09/30/24, 10/11/24, 10/13/24, and 10/18/24 from Home Health LPN #148. HSD revealed the communication forms were not included in the medical record.

Observation of Resident #47 on 10/21/24 at 7:48 A.M., 9:30 A.M., 10:12 A.M., 10:34 A.M., 11:03 A.M., and 11:37 A.M. revealed the resident was in her room in her recliner. Resident #47's room had a very strong pungent urine odor. Interview with Resident #47 at the times of the observation revealed staff had not offered to lie her down in bed.

Interview on 10/22/24 at 9:59 A.M. with Physician #149 revealed he was notified Resident #47 had wounds and sent an order to the facility for consultation at a wound clinic. Physician #149 reported he wanted to send the resident to an outside wound clinic for care, but the facility reported they dealt with another company.

Interview on 10/22/24 at 10:21 A.M. with the Administrator confirmed there were no physician orders for Resident #47's wounds upon readmission, no skin assessment was completed on readmission, there was no documented evidence to support all treatments were completed as ordered, and there was a lack of communication between the home health agency and the facility regarding Resident #47's wound care.

An observation of Resident #47's wounds on 11/07/24 at 8:15 A.M. revealed the wounds to the buttocks, thighs and left heel were consistent with the Home Health NP #147's assessments.

Review of facility policy, Skin Care Oversight Guidelines, revised 06/19/24, revealed skin assessment were to be done by nurse prior to moving into community, every 6 months, and after a significant change in condition. The form was to be stored in the resident health care record in the resident assessment/evaluation section. The nurse will document wound. The nurse would notify the attending physician and family of any findings. Additionally, home health may be requested to provide comprehensive wound care oversight. The nurse would document wound management orders obtained and or review orders to ensure orders are in place to manage the wound/skin concerns. Within 24 hours of the resident moving into the community, the nurse or designee will document a head-to-toe skin review/observation and document any skin concerns on the skin check for. Any skin concerns noted will require the development of an incident report and care plan/service plan to address interventions to manage the identified skin concern.

This violation represents non-compliance investigated under Complaint Number OH00158527 and OH00158340.

Based on observation, interview, record review the facility failed to ensure sufficient staffing to meet the needs of the residents. This affected two residents (Resident's #75 and #76) and had the potential to affect all 72 residents residing in the facility.

Findings include:

1. Review of Resident #76's medical record revealed an admission date of 11/20/17 and diagnoses included hypertension, history of dizziness and history of DVT (deep vein thrombosis) of the RLE (right lower extremity). Resident #76 was transported to the hospital on 02/03/24 and discharged from the facility.

Review of Resident #76's physician orders dated 08/23/23 revealed to complete skin checks on Wednesdays at noon and evaluate Resident #76's skin, chart skin issues and notify the primary physician.

Review of Resident #76's SLUMS (Saint Louis University Mental Status) Cognitive Evaluation undated revealed Resident #76 had moderate cognitive impairment.

Review of Resident #76's Individual Service Plan dated 12/22/23 included Resident #76 was deaf in the left ear, had a hearing aid, was ambulatory and used a wheeled walker. Resident #76 needed assistance with dressing to present a clean and neat appearance and to promote independence. Staff provided partial assistance to Resident #76 for bathing to optimize hygiene and appearance. Resident #76 was incontinent, her family provided incontinence supplies, and Resident #76 changed her own incontinence brief. Resident #76 would have vital signs monitored per physician orders and staff would monitor and record vital signs per physician orders. Resident #76 would be monitored for skin issues to maintain optimal skin integrity. Staff would monitor skin for issues. Resident #76 had edema and weeping of her RLE (right lower extremity) and had venous ulcers. Staff to report to supervisor any redness or new skin issues noted on skin.

Review of Resident #76's Skin Check Form dated 11/22/23 revealed Resident #76 had elevated skin tags and a big red area on her back.

Review of Resident #76's Skin Check Form dated 11/29/23 revealed Resident #76 had no skin issues or open areas.

Review of Resident #76's Skin Check Form dated 12/06/23 revealed Resident #76 had an old scab on her back.

Review of Resident #76's Skin Check Form dated 12/13/23 revealed Resident 376 had mild redness to her bottom and barrier cream was applied, her feet were swollen and she was encouraged to elevate her legs, ted hose applied, and lotion was applied to dry skin on legs.

Review of pictures of Resident #76 taken on 01/09/24 (date provided by Resident #76's family) revealed Resident #76 had a dark red scabbed area about the size of a nickel by her right ear. Further review revealed Resident #76's left forearm had a circular open area about two inches in diameter, was red around the edges, had a small open area around a scab noted in the middle of the circular area and the scab was greenish-yellow in color. Resident #76's bilateral lower legs were dark reddish-purple and discolored over almost the entire lower legs and dry, peeling skin could be seen. Resident #76's right lower leg had a bandaid covering an open area and some edema was noted. Resident #76's left lower leg had a sickle-shaped area which was covered with a dark red scab.

Review of Resident #76's Skin Check Form dated 01/10/24 revealed Resident #76 had no skin issues or open areas.

Review of Resident #76's Skin Check Form dated 01/17/24 revealed discoloration was noted on legs and hands during shower. Resident #76 also had little cuts on her nose that were scabbed over.

Review of Resident #76's Observation notes from 11/22/23 through 01/28/23 revealed on 11/22/23 documentation included Resident #76 had elevated skin tags and a big red area on her back. There was no follow-up note regarding the big red area on her back. Further review revealed no follow-up notes regarding the old scab on Resident #76's back, and no mention of redness to bottom, discoloration of legs and hands, or swollen legs. There was no documentation Resident #76's physician was contacted regarding skin issues or wounds.

Interview on 03/05/24 at 10:41 A.M. with Licensed Practical Nurse (LPN) #314 revealed she was shown pictures taken on 01/09/24 of Resident #76's skin and wounds. LPN #314 stated if she had seen Resident #76's skin she would have cleaned the wounds and put a bandaid on open areas, and would have contacted her family and physician for new orders. LPN #314 stated she did not remember if she saw Resident #76's skin on 01/10/24 when she documented Resident #76 did not have skin issues. LPN #314 stated she tried to do head-to-toe skin assessments on residents when it was their shower day and she completed the Skin Check Form, but sometimes she was super busy and did not have time to look at the skin herself. LPN #314 indicated on the super busy days she used the Resident Assistant (RA) shower sheets for her documentation because the RA's saw the skin while they were showering residents. LPN #314 stated the facility nurses requested to have a third nurse on day shift because of the heavy workload, and requested a third nurse for day shift during the nurse meetings with the management team.

2. Review of Resident #75's medical record revealed an admission date of 10/02/18 and diagnoses included CHF (congestive heart failure), a-fib (atrial fibrillation), and Parkinson's disease. Resident #75 passed away at the facility on 02/06/24.

Review of Resident #75's physician orders dated 08/18/22 revealed check weights three times a week, give Lasix (Furosemide) as needed (give Lasix 20 mg for a weight gain of three pounds in two days, or five pounds in a seven day period). Notify physician if weights exceed this amount also.

Review of Resident #75's physician orders dated 11/21/23 revealed update weight checks to once daily every morning. Weigh with same scale at the same time of day and preferably by the same nurse. Notify Medical Doctor #355 if a weight gain of greater than three pounds in 24 hours or greater than five pounds in one week. Continue daily weights for two weeks, then resume three times per week on Monday, Wednesday and Friday for a diagnosis of atrial fibrillation and heart failure.

Review of Resident #75's Individual Service Plan dated 12/20/23 revealed Resident #75 was incontinent and was ambulatory. Resident #75 to remain free from falls. Staff to monitor Resident #75 during waking hours to help prevent falls as needed. Staff to keep walker or assistive device in sight to provide visual reminder to use. Resident #75 would be assisted with dressing to present a clean and neat appearance and promote independence. Staff would assist Resident #75 with dressing to maintain proper hygiene and a neat appearance. Resident #75's living space would be cared for and maintained to ensure a safe and clean living space. Staff would assist with housework as needed to maintain a safe living space for Resident #75. Resident #75 to take medications correctly, timely and per physician's orders. Staff to assist with Resident #75's medication administration needs routinely and as needed. Resident #75 would have his vitals monitored per physicians orders to maintain and monitor health. Staff would monitor and record Resident #75's vitals per physicians orders. Resident #75 to be dry, hygienic, and odor free. Staff to change Resident #75's brief and clean up.

Review of Resident #75's Observation notes dated 01/03/24 included per MD #355's strict orders to weigh around the same time in the morning on Monday, Wednesday and Friday mornings with approximately the same amount of clothing, with the same scale, and if possible by the same nurse. Notify the physician is there was a weight gain of greater than three pounds in two days, or greater than five pounds in a seven day period, and if having increased work of breathing, and oxygen saturation less than 90 percent or respirations greater than 24, or increased peripheral edema was noted.

Review of Resident #75's MAR on 01/24/24 revealed check weights three times a week, give Lasix (Furosemide) as needed (give Lasix 20 mg for a weight gain of three pounds in two days, or five pounds in a seven day period). Notify physician if weights exceed this amount also. Resident #75's MAR dated 01/22/24 revealed Resident #75's weight was scheduled to be checked at 5:00 A.M., the recorded time was 4:32 A.M. and the weight was 202.8 pounds. Review of Resident #75's MAR dated 01/24/24 revealed Resident #75's weight was scheduled to be checked at 5:00 A.M., the recorded time was 10:43 A.M., and the weight was 210.4. There was no evidence Resident #75 was administered Lasix 20 mg or Resident #75's physician (MD #355) was notified of the weight gain.

Interview on 02/22/24 at 2:45 P.M. with Health Services Director (HSD) #300 confirmed Medical Doctor (MD) #355 was not notified on 01/24/24 of Resident #75's weight gain of 7.6 pounds or given Furosemide 20 mg as ordered. HSD #300 indicated three days of weights popped up when the weight was entered on the MAR.

Interview on 02/22/24 at 2:12 P.M. with Licensed Practical Nurse (LPN) #320 revealed it was hard to remember details of Resident #75's medication administration on 01/24/24 because it was awhile ago. When shown Resident #75's MAR, LPN #320 confirmed on 01/24/24 she documented Resident #75's weight of 210.4 pounds and was not sure why she did not notice the 7.6 pound weight gain from 01/22/24. LPN #320 stated she did not remember giving extra Lasix due to Resident #75's weight gain, and she was probably so busy, and trying to get medications passed that she didn't notice the weight gain when it popped up on the MAR after she recorded the weight. LPN #320 indicated she did not remember what time the weight was checked, but confirmed it was scheduled to be checked at 5:00 A.M. and was not recorded until 10:43 A.M. LPN #320 stated Resident #75 should have been reweighed. LPN confirmed MD #355 was not notified of Resident #75's weight gain and Resident #75 did not receive Lasix for the weight gain as ordered.

3. Review of Charge Nurse Meeting minutes dated 10/11/23 at 6:00 P.M. included nurses stated the facility needed another full time day shift nurse.

Interview on 03/05/24 at 11:29 A.M. with LPN #380 revealed a third nurse on day shift would be helpful and if the nurse worked 7:00 A.M. until 3:00 P.M. the nurse could help with things like lab follow up, skin checks and physician orders. LPN #380 stated the morning med pass was super heavy and LPN #380 stated nurses were so busy passing medications and meeting the needs of the residents that they ran out of time to get everything completed.

Interview on 03/06/24 at 9:48 A.M. with LPN #311 revealed things fall through the cracks and she thought part of the reason was because the nurses did not consistently have the same assignment, they worked where they were needed and continuity of care was rough. LPN #311 stated not having the same assignment and knowing the residents definitely affected follow up for things like skin issues, lab work, and problems residents were having. LPN #311 indicated report was recorded and was not conducted with the nurse from the previous shift and sometimes the recordings did not have important information about residents recorded. LPN #311 stated she definitely thought a third nurse would be helpful, at least Monday through Friday for phone calls, follow up on resident issues, lab work etcetera. LPN #311 stated medications took hours to administer, sometimes there was not enough hours in a day to complete everything, and the nurses were so busy, follow up on issues did not always happen. LPN #311 revealed the need for a third nurse was brought up in nurses meetings with the management staff, a nurse was interested in working Monday through Friday from 7:00 A.M. until 3:00 P.M. but the nurses were never told why it was not possible.

Observation on 03/07/23 at 12:35 P.M. revealed LPN #320 hurriedly walking in the hall, her face was red and she had a stressed look on her face.

Interview on 03/07/24 at 12:35 P.M. with LPN #320 revealed the facility could use one more nurse on day shift, and the need for a third day shift nurse was brought up in nurse meetings with the facility management team. LPN #320 stated she was running around like a chicken today, and if there was a third nurse there would be help with the resident admission, skin checks, physician orders and labwork follow up she needed to complete in addition to all the medications she had to pass. LPN #320 stated sometimes she was just too busy to follow up with everything and that was why there were gaps in the charting and follow up in the resident records. LPN #320 stated when she had a crazy day something might be missed, and most of the time she did not have time to sit and listen to the recorder. LPN #320 stated if she took the time to listen to the recorder she was behind passing medications because the med pass was so heavy. LPN #320 stated having a third nurse on day shift would be very helpful. LPN #320 stated the Resident Assistant probably gave her the weight for Resident #75 on 01/24/24 but she was so busy she did not add it right away, and when she did add it she was so busy she didn't even think about checking the last three days of weights. LPN #320 stated she should have noticed Resident #75's weight difference .

Interview on 03/07/24 at 1:00 P.M. with HSD #300 confirmed the nurses asked to have a third nurse scheduled to work the day shift because they did not have time to complete everything that needed to be done during their shift. HSD #300 stated the nurses brought up the need for a third nurse during conversations and the nurses' brought up the need to have a third nurse scheduled to work the day shift in nurse meetings. When asked if there were plans to have a third nurse scheduled to work the day-shift, HSD #300 stated the facility had a nurse interested in working Monday through Friday 7:00 A.M. until 3:30 P.M., Regional Director of Nursing (RDN) #356 was aware the nurses requested a third nurse to work day shift, but the facility did not have approval at this time to have a third nurse work day shift. HSD #300 confirmed only two nurses were assigned daily from 7:00 A.M. until 7:30 P.M. to work on the nursing units, and Today's Nurse Schedule only had two nurses' spots recorded on the document for nurses to work 7:00 A.M. until 7:30 P.M.

Review of Today's Nurse Schedule dated 12/15/23, 12/15/23, 12/20/23, 12/24/23, 12/25/23, 01/21/24, 01/22/24, 01/23/24, 01/24/24, 01/25/24, 01/26/24, 01/27/24, 01/28/24, 01/29/24, 02/05/24, 02/06/24 and 03/06/24 revealed two nurses were assigned to work on the nursing units from 7:00 A.M. until 7:30 P.M. and only two spots for nurses to work day-shift from 7:00 A.M. until 7:30 P.M. was recorded on the Schedule.

Review of Today's Nurse Schedule dated 01/24/24 at 7:00 A.M. until 7:30 P.M. revealed LPN #320 was assigned to the first-floor nursing unit and LPN #323 was assigned to the second-floor nursing unit, but did not arrive at 7:00 A.M. AHSD #301 worked on the second floor nursing unit until LPN #323 arrived at the facility.

This violation represents non-compliance investigated under Complaint Number OH00151029.

Based on observation, interview, record review, and review of the facility policy the facility failed to provided proper evaluation, treatment, and intervention for Resident #76's skin impairments, and failed to ensure Resident #60 and #75 had post fall documentation and assessments completed. This affected one resident (Resident #76) out of three residents reviewed for wounds and two residents (Resident #60 and #75) out of three reviewed for falls. The facility census was 72.

Findings include:

1. Review of Resident #76's medical record revealed an admission date of 11/20/17 and diagnoses included hypertension, history of dizziness and history of DVT (deep vein thrombosis) of the RLE (right lower extremity). Resident #76 was transported to the hospital on 02/03/24 and discharged from the facility.

Review of Resident #76's physician orders dated 08/23/23 revealed to complete skin checks on Wednesdays at noon and evaluate Resident #76's skin, chart skin issues and notify the primary physician.

Review of Resident #76's SLUMS (Saint Louis University Mental Status) Cognitive Evaluation undated revealed Resident #76 had moderate cognitive impairment.

Review of Resident #76's Individual Service Plan dated 12/22/23 included Resident #76 was deaf in the left ear, had a hearing aid, was ambulatory and used a wheeled walker. Resident #76 needed assistance with dressing to present a clean and neat appearance and to promote independence. Staff provided partial assistance to Resident #76 for bathing to optimize hygiene and appearance. Resident #76 was incontinent, her family provided incontinence supplies, and Resident #76 changed her own incontinence brief. Resident #76 would have vital signs monitored per physician orders and staff would monitor and record vital signs per physician orders. Resident #76 would be monitored for skin issues to maintain optimal skin integrity. Staff would monitor skin for issues. Resident #76 had edema and weeping of her RLE (right lower extremity) and had venous ulcers. Staff to report to supervisor any redness or new skin issues noted on skin.

Review of Resident #76's Skin Check Form dated 11/22/23 revealed Resident #76 had elevated skin tags and a big red area on her back.

Review of Resident #76's Skin Check Form dated 11/29/23 revealed Resident #76 had no skin issues or open areas.

Review of Resident #76's Skin Check Form dated 12/06/23 revealed Resident #76 had an old scab on her back.

Review of Resident #76's Skin Check Form dated 12/13/23 revealed Resident 376 had mild redness to her bottom and barrier cream was applied, her feet were swollen and she was encouraged to elevate her legs, ted hose applied, and lotion was applied to dry skin on legs.

Review of pictures of Resident #76 taken on 01/09/24 (date provided by Resident #76's family) revealed Resident #76 had a dark red scabbed area about the size of a nickel by her right ear. Further review revealed Resident #76's left forearm had a circular open area about two inches in diameter, was red around the edges, had a small open area around a scab noted in the middle of the circular area and the scab was greenish-yellow in color. Resident #76's bilateral lower legs were dark reddish-purple and discolored over almost the entire lower legs and dry, peeling skin could be seen. Resident #76's right lower leg had a bandaid covering an open area and some edema was noted. Resident #76's left lower leg had a sickle-shaped area which was covered with a dark red scab.

Review of Resident #76's Skin Check Form dated 01/10/24 revealed Resident #76 had no skin issues or open areas.

Review of Resident #76's Skin Check Form dated 01/17/24 revealed discoloration was noted on legs and hands during shower. Resident #76 also had little cuts on her nose that were scabbed over.

Review of Resident #76's Observation notes from 11/22/23 through 01/28/23 revealed on 11/22/23 documentation included Resident #76 had elevated skin tags and a big red area on her back. There was no follow-up note regarding the big red area on her back. Further review revealed no follow-up notes regarding the old scab on Resident #76's back, and no mention of redness to bottom, discoloration of legs and hands, or swollen legs. There was no documentation Resident #76's physician was contacted regarding skin issues or wounds.

Interview on 02/20/24 at 1:07 P.M. with Family Member (FM) #362 revealed he stuck his head in Executive Director (ED) #357's office and told both HSD #300 and ED #357 they needed to check Resident #76's skin. FM #362 stated staff did not look at Resident #76's legs, and he did not remember Medical Doctor (MD) #355 evaluating Resident #76's legs, and there was no referral for Resident #76's legs to be looked at. FM #362 stated he cleaned Resident #76's wounds and put dressings on them. FM #362 stated he told ED #357 and HSD #300 Resident #76 had open areas on her arms and legs at different times.

Interview on 02/21/24 at 11:15 A.M. with Health Services Director (HSD) #300 revealed if a new area was found by the nurses during resident skin checks there would be an Observation note in the residents record stating the resident's PCP (primary care provider) was contacted for new orders. HSD #300 stated a new process was recently started for skin issues and now along with an Observation note in the resident record an incident report would be created. HSD #300 stated Resident #76 did not have skilled nursing for wound care and was seen regularly by Certified Nurse Practitioner (CNP) #354. HSD #300 indicated she could not provide Resident #76's shower sheets because they were shredded.

Interview on 02/26/24 at 9:01 A.M. with Resident Assistant (RA) #319 revealed she assisted Resident #76 with showers and she had a scab on her back for awhile, had open areas on her arms and legs, and her arms were constantly covered in bruises. RA #319 stated she told the nurses when she noticed any skin issues and the nurses were supposed to document it.

Interview on 02/26/24 at 9:03 A.M. with RA #325 revealed Resident #76 sometimes had open areas on her arms and legs, and the open areas looked like bruises. RA #325 stated Resident #76 had discoloration on her legs and little skin tears at times. RA #325 stated when Resident #76 had any skin issues she verbally told the nurses about the skin issues, filled out a shower sheet and marked the areas with skin issues and would give the shower sheet to the nurses.

Interview on 02/26/24 at 3:21 P.M. with MD #355 revealed she was not aware Resident #76 had open areas on her arms and legs. MD #355 stated she was not contacted and notified of the condition of Resident #76's skin.

Observation on 02/27/24 at 11:10 A.M. with Executive Director (ED) #357, Regional Director of Nursing (RDN) #356 and Health Services Director (HSD) #300 of pictures of Resident #76 taken on 01/09/24 revealed they confirmed Resident #76 had a dark, red scabbed area about the size of a nickel by her right ear. Further review revealed Resident #76's left forearm had a circular open area about two inches in diameter, was red around the edges, had a small open area around a scab noted in the middle of the circular area and the scab was greenish-yellow in color. Resident #76's bilateral lower legs were dark reddish-purple and discolored over almost the entire lower legs and dry, peeling skin could be seen. Resident #76's right lower leg had a bandaid covering an open area and some edema was noted. Resident #76's left lower leg had a sickle-shaped area which was covered with a dark red scab. ED #357, RDN #356 and HSD #300 stated there should have been follow-up of Resident #76's wounds and nurse's were supposed to lay eyes on residents when doing their skin checks.

Interview on 03/05/24 with 10:41 A.M. of Licensed Practical Nurse (LPN) #314 revealed she was shown pictures taken on 01/09/24 of Resident #76's skin and wounds. LPN #314 stated if she had seen Resident #76's skin she would have cleaned the wounds and put a bandaid on open areas, and would have contacted her family and physician for new orders. LPN #314 stated she did not remember if she saw Resident #76's skin on 01/10/24 when she documented Resident #76 did not have skin issues. LPN #314 stated she tried to do head-to-toe skin assessments on residents when it was their shower day and she completed the Skin Check Form, but sometimes she was super busy and did not have time to look at the skin herself. LPN #314 indicated on the super busy days she used the Resident Assistant (RA) shower sheets for her documentation because the RA's saw the skin while they were showering residents. LPN #314 stated the facility nurses requested to have a third nurse on day shift because of the heavy workload, and requested a third nurse for day shift during the nurse meetings with the management team.

Review of the facility policy titled Skin Care Oversight Guidelines dated 11/24/22 included the purpose of the policy was to develop a system to monitor skin concerns and ensure proper skin care was provided to all residents. Weekly routines included the HSD or nurse would review the Skin Risk Evaluation Tool and any skin concerns identified by the direct care staff must be assessed by th nurse and any concerns noted documented on the Skin Bath Review Worksheet Form was then documented on the Skin Check Form. New skin concerns must be reported to the physician, family, or responsible, and if required request assistance from third party providers. An Incident Report must be reported and the resident placed in Alert Charting for oversight. Update the resident individualized service plan or care plan to address wound care interventions and place the resident new skin concern on the 24-hour communication report. Any resident with a skin concern should have a weekly skin evaluation completed by the nurse using the Skin Care Check Form.

2. Review of Resident #75's medical record revealed an admission date of 10/02/18 and diagnoses included CHF (congestive heart failure), a-fib (atrial fibrillation), and Parkinson's disease. Resident #75 passed away at the facility on 02/06/24.

Review of Resident #75's Fall Risk Evaluation dated 10/01/23 revealed Resident #75 was a moderate fall risk.

Review of Resident #75's Fall Investigation dated 12/16/23 included Resident #75 was going to the bathroom, wearing socks and had a fall on 12/16/23 at 9:10 A.M. Licensed Practical Nurse (LPN) #314 was called to his room and found Resident lying on the floor outside his bathroom. Resident #75 had blood on his neck and a cut on the left side of the back of his head and 9-1-1 was called to transport Resident #75 to the local hospital Emergency Department. Resident #75's POA (Power of Attorney) was notified , Health Services Director (HSD) #300 was notified, and Medical Doctor (MD) #355 was notified on 12/16/23 at 9:04 A.M.

Review of Resident #75's Observation notes dated 12/16/23 at 4:14 P.M. included Resident #75 returned from the hospital on 12/15/23 and had a fall in the morning on 12/16/23. Resident #75 hit his head, had a cut on the top of his head, was taking blood thinners (anticoagulant) and was transported to the local hospital for evaluation. Resident #75 did not have a brain bleed or fractures and was safe to return to the facility. Resident #75 was currently at the facility and his after visit assessment included Resident #75 was baseline confused, he had many skin tears and discoloration on both arms, he had an area of extravasation (leakage of fluid into surrounding tissue) by his right elbow. Per Family Member (FM) #367 the extravasation was caused by many attempts to start an intravenous (IV), but all attempts for an IV were blown. FM #367 told the nurse Resident #75 had a large bruise on his right thigh. Medical Doctor (MD) #355 or Certified Nurse Practitioner (CNP) #354 was scheduled to visit Resident #75 on 12/16/23.

Review of Resident #75's Observation notes dated 12/16/23 through 12/22/23 did not reveal evidence follow up assessments were completed for Resident #75's fall on 12/16/23. There was no documentation of Resident #75's cut on his head, skin tears, bruising of arms, extravasation area by his right elbow, large bruise on his right thigh or mental status.

Review of Resident #75's Fall Risk Evaluations revealed there was no Fall Risk Evaluation completed after Resident #75's fall on 12/16/23 and a Fall Risk Evaluation was not completed until 01/24/24.

Review of Resident #75's Individual Service Plan dated 12/20/23 revealed Resident #75 was incontinent, and was ambulatory. Resident #75 to remain free from falls. Staff to monitor Resident #75 during waking hours to help prevent falls as needed. Staff to keep walker or assistive device in sight to provide visual reminder to use. Resident #75 would be assisted with dressing to present a clean and neat appearance and promote independence. Staff would assist Resident #75 with dressing to maintain proper hygiene and a neat appearance. Resident #75's living space would be cared for and maintained to ensure a safe and clean living space. Staff would assist with housework as needed to maintain a safe living space for Resident #75. Resident #75 to take medications correctly, timely and per physician's orders. Staff to assist with Resident #75's medication administration needs routinely and as needed. Resident #75 would have his vitals monitored per physicians orders to maintain and monitor health. Staff would monitor and record Resident #75's vitals per physicians orders. Resident #75 to be dry, hygienic, and odor free. Staff to change Resident #75's brief and clean up.

Review of Resident #75's Observation notes dated 01/26/24 at 11:03 A.M. written by Licensed Practical Nurse (LPN) #320 included LPN #320 was called into Resident #75's room on 01/26/24 at 10:10 A.M. after a Resident Assistant found Resident #75 lying on his left side with his head resting on his walker and he was on the floor to the right of his recliner. Resident #75 was assisted to his feet by three staff members. Resident #75 ambulated normally and sat down on bed. FM #366 reviewed Resident #75's room camera footage and voiced to LPN #320 that the Resident #75 was coming out of bathroom with his walker backwards, and was holding on to the foam part of walker and stopped by the filing cabinet. FM #366 then noted Resident #75 fell backwards. Resident #75 stated he hit his head, however there were no bumps or bleeding noted on his head at this time. Resident #75 appeared to be bleeding from his back. LPN #320 noted a skin tear below Resident #75's left shoulder blade. LPN #320 cleaned and applied a dressing to the area. Resident #75 complained of left arm and back pain, Resident #75 stated he was having some pain in the head. Due to Resident #75 hitting head, LPN #320 called EMT (Emergency Medical Technician) at 10:07 A.M. EMTs arrived at facility around 10:12 A.M. LPN #320 called FM #366 and informed her Resident #75 needed evaluated. FM #366 declined to have EMTs transport Resident #75 to the hospital because he received hospice services. The EMT's noted a deformity of Resident #75's left elbow. FM #366 stated the hospice nurse would determine if Resident #75 needed X-rays.

Review of Resident #75's Fall Risk Evaluations did not reveal an evaluation was done after his fall on 01/26/24.

Interview on 02/15/24 at 3:22 P.M. with Family Member (FM) #366 revealed Resident #75 had a fall on 12/16/23 and after he returned from the hospital Family Member (FM) #367 stayed two nights at the facility because they were concerned the facility would not follow up on his care. FM #366 indicated Resident #26 had a fall on 01/26/24 at 9:35 A.M. and the family was concerned about his care after the fall. FM #366 indicated Resident #75 received hospice services and she requested he not be sent to the hospital, but to wait for the hospice nurse's evaluation. FM #366 stated nurses administered Resident #75 medications after the fall on 01/26/24, but did not take vital signs or complete assessments. FM #366 stated the nurses did not visit with Resident #75 any other time during the day other than medication administration times.

Interview on 02/26/24 at 9:13 A.M. with LPN #314 revealed she could not remember details about Resident #75's fall on 12/16/23. LPN #314 remembered Resident #75 received blood thinners and she might have completed the incident report after she talked to Medical Doctor (MD) #355, and completed the progress note before she talked to MD #355.

Interview on 02/26/24 at 3:21 P.M. with MD #355 revealed she was Resident #75's PCP (primary care provider) and she was not notified by the facility Resident #75 had a fall on 12/16/23 and was transported to the Emergency Department. MD #355 stated she just happened to see Resident #75 had a fall on 12/18/23 when it popped up in the hospital electronic information. MD #355 stated she was trying to schedule a transitional care visit from Resident #75's hospital stay 12/10/23 through 12/15/23 when the fall popped up on the computer screen. MD #355 stated her fellow (finished medical school and residency and has chosen to further study in a subspecialty in medicine) had no call documented either. MD #355 stated she had access to the facility electronic records and the electronic record stated the facility nurse notified MD #355 on 12/16/23 at 9:04 A.M. and that did not happen. MD #355 indicated the call center did not have a record of the call.

Interview on 02/27/24 at 2:26 P.M. with LPN #314 revealed she did not remember if she notified MD #355 on 12/16/23 of Resident #75's fall. LPN #314 stated if she wrote that MD #355 was notified she would have attempted a phone call, there would be an answering service and should be a record of the call.

Interview on 02/27/24 at 7:33 A.M. with LPN #314 revealed she talked to MD #355 and told her about Resident #75's fall on 12/16/23.

Interview on 03/07/24 at 9:26 A.M. with Health Services Director (HSD) #300 and Executive Director (ED) #357 revealed when a resident had a fall they pressed the call pendant if they were able and when a caregiver responded, the caregiver stayed with the resident and a nurse would be called on a walkie talkie. HSD #300 stated the caregiver did not attempt to move the resident until a nurse arrived, did an assessment, and called 9-1-1 if needed. HSD #300 indicated if a resident hit their head, or had an unwitnessed fall EMS would be called. If the resident did not appear to have an injury the nurse would complete an assessment to make sure it was appropriate for the resident to move. HSD #300 stated depending on the situation EMS could be called. HSD #300 stated vital signs were situational and if EMS was called the nurse did not always obtain vital signs, but most of the time the nurse would check vital signs and at the very least check the blood pressure. HSD #300 indicated if a resident had a fall with an injury they would be transported to the hospital and when they returned they were on Alert Charting. HSD #300 indicated alert charting meant the nurse laid eyes on the resident every shift, and checked for signs and symptoms of changes, not necessarily mental status, no formal assessments were completed, and no neuro checks or vital signs were checked. HSD #300 stated the facility was an assisted living and they did not have to do vital signs or neuro checks. HSD #300 stated nursing judgement was used and if the nurse felt it was necessary vital signs could be taken. HSD #300 and ED #357 stated if a resident had a fall they were placed on 72 hour alert charting and longer if needed. ED #357 stated if a resident received a wound during a fall the would should be documented in the 72 hour monitoring. HSD #300 stated when a resident was monitored for falls there was no specific charting, the nurse went more frequently to the resident room to check on their status and the charting should include orientation, how they feel, general observations. HSD #300 stated the residents primary care physician and family were notified of falls. When told Medical Doctor (MD) #355 stated she was not notified of Resident #75's fall on 12/16/23, and it was documented she was notified on the fall investigation HSD #300 stated was not aware MD #355 was not notified. HSD #300 indicated there should be a note on the investigation if the nurse spoke to someone at the call center or left a message.

Interview on 03/07/24 at 3:00 P.M. with HSD #300 confirmed there were no Fall Risk Evaluations documented in Resident #75's medical record after his falls on 12/16/23 and 01/26/24. HSD #300 stated Resident #75 had a Fall Risk Evaluation completed on 01/09/24 which was after the fall (24 days after the fall), but it was not included in his medical record because it was completed with QAPI.

Review of the facility policy titled Fall Management and Post Fall Investigations dated 05/15/23 included the resident's responsible party and physicians were notified of falls. A Fall Risk Evaluation was performed on all residents prior to move-in, every six months and after a significant change of condition. The resident would be placed on Alert Charting. Post fall QAPI tool and Fall Risk Evaluation tool is completed after each fall.

3. Review of Resident #60's medical record revealed an admission date of 02/10/23 and diagnoses included dementia, macular degeneration and hypothyroidism.

Review of Resident #60's Individual Service Plan dated 09/15/23 included Resident #60 was incontinent, was ambulatory and used a walker and a wheelchair. Resident #60 was a high risk for falls and Resident #60 would remain free of serious injury from falls. Staff to actively implement interventions to prevent falls daily, in the morning, evening and night shift.

Review of Resident #60's Fall Risk Evaluation dated 10/25/23 revealed Resident #60 was a high fall risk. Further review of Resident #60's medical record from 10/25/23 through 01/31/23 including Fall Risk Evaluations did not reveal another Fall Risk Evaluation was completed.

Review of the Incident Log dated 12/25/23 revealed Resident #60 had a fall at 3:00 P.M. and an intervention was to increase Safety Checks. Further review of the log revealed Resident #60 had another fall on 12/25/23 at 5:46 P.M. and Resident #60 should be sent to the hospital Emergency Department per family request.

Review of Resident #60's Incident Report Fall dated 12/25/23 at 3:00 P.M. included Resident #60 had an unwitnessed fall in his room in the kitchen area. There was clutter in walkway, his wheelchair was unlocked and he was not using it, he was walking and wearing rubber sole dress shoes, and his call light was in reach when the fall occurred. The nurse was called to Resident #60's room and found Resident #60 lying flat on his back, fully clothed. The nurse asked what happened and he stated he was preparing himself a cup of ice water and lost his balance and fell backwards. Resident #60 stated he did not hit his head, was not hurt or in pain and refused to go to the hospital. Resident #60 was assisted off floor and cleaned up. Resident #60 was reminded to use his wheelchair or rollator when ambulating in his apartment. The POA, HSD #300 and Resident #60's primary care physician were notified.

Review of Resident #60's Incident Report Fall dated 12/25/23 at 5:46 P.M. included Resident #60 had an unwitnessed fall, had gripper socks on. The nurse was called to Resident #60's room and found him lying on the floor in front of his rollator and refrigerator. When asked what happened Resident #60 stated he hit his head and he was not going to the hospital. The nurse told Resident #60 due to hitting his head paramedics needed to be called to examine him. Vital signs were taken, paramedics arrived, and Resident #60 again said he did not want to go to the hospital. Resident #60 was reminded to use his call pendant to call for help. Resident #60 was assisted to his recliner. The POA, HSD #300 and Resident #60's primary care physician were notified.

Review of Resident #60's Observation notes dated 12/25/23 through 12/30/23 revealed only Resident #60's fall on 12/25/23 at 3:00 P.M. was documented in the notes. Resident #60's fall on 12/25/23 at 5:46 P.M. was not documented. Further review from 12/25/23 through 12/30/23 did not reveal any Observation notes were documented including Alert Charting which was supposed to be documented every shift for 72 hours and no documentation regarding Resident #60 hitting his head on a fall 12/25/23.

Review of Resident #60's medical record from 12/25/23 at 3:00 P.M. through 12/20/23 including Observation notes and Individual Service Plan did not reveal evidence Safety Checks were completed.

Interview on 03/07/24 at 9:26 A.M. with Health Services Director (HSD) #300 and Executive Director (ED) #357 revealed when a resident had a fall they pressed the call pendant if they were able and when a caregiver responded, the caregiver stayed with the resident and a nurse would be called on a walkie talkie. HSD #300 stated the caregiver did not attempt to move the resident until a nurse arrived, did an assessment, and called 9-1-1 if needed. HSD #300 indicated if a resident hit their head, or had an unwitnessed fall EMS would be called. If the resident did not appear to have an injury the nurse would complete an assessment to make sure it was appropriate for the resident to move. HSD #300 stated depending on the situation EMS could be called. HSD #300 stated vital signs were situational and if EMS was called the nurse did not always obtain vital signs, but most of the time the nurse would check vital signs and at the very least check the blood pressure. HSD #300 indicated if a resident had a fall with an injury they would be transported to the hospital and when they returned they were on Alert Charting. HSD #300 indicated Alert Charting meant the nurse laid eyes on the resident every shift, and checked for signs and symptoms of changes, not necessarily mental status, no formal assessments were completed, and no neuro checks or vital signs were checked. HSD #300 stated the facility was an assisted living and they did not have to do vital signs or neuro checks. HSD #300 stated nursing judgement was used and if the nurse felt it was necessary vital signs could be taken. HSD #300 and ED #357 stated if a resident had a fall they were placed on 72 hour Alert Charting and longer if needed. ED #357 stated if a resident received a wound during a fall the would should be documented in the 72 hour monitoring. HSD #300 stated when a resident was monitored for falls there was no specific charting, the nurse went more frequently to the resident room to check on their status and the charting should include orientation, how they feel, general observations. HSD #300 stated the residents primary care physician and family were notified of falls. When told Medical Doctor (MD) #355 stated she was not notified of Resident #75's fall on 12/16/23, and it was documented she was notified on the fall investigation HSD #300 stated was not aware MD #355 was not notified. HSD #300 indicated there should be a note on the investigation if the nurse spoke to someone at the call center or left a message.

Interview on 03/07/24 at 9:26 A.M. with HSD #300 and ED #357 revealed Safety Checks were documented on a paper form and completed by Resident Assistants. HSD #300 stated the Safety Check forms were not part of the medical record and unable to be provided by the facility.

Interview on 03/07/24 at 3:00 P.M. with HSD #300 confirmed there were no Fall Risk Evaluations documented in Resident #60's medical record after his two falls on 12/25/23. HSD #300 stated Resident #60 had a Fall Risk Evaluation completed on 01/10/24 which was after the fall (16 days after the fall), but it was not included in his medical record because it was completed with QAPI.

Review of the facility policy titled Fall Management and Post Fall Investigations dated 05/15/23 included the resident's responsible party and physicians were notified of falls. A Fall Risk Evaluation was performed on all residents prior to move-in, every six months and after a significant change of condition. The resident would be placed on Alert Charting. Post fall QAPI tool and Fall Risk Evaluation tool is completed after each fall.

This violation represents non-compliance investigated under Complaint Number OH00151303, Complaint Number OH00151029, and Complaint Number OH00149761.

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #21 was assisted with toileting timely. This affected one resident (Resident #21) out of three residents reviewed for toileting. The facility census was 72.

Findings include:

Review of Resident #21's medical record revealed an admission date of 07/11/22 and diagnoses included acute right anterior CVA (cerebrovascular accident) with left hemiplegia (paralysis), bipolar disorder, and anxiety.

Review of Resident #21's Individual Service Plan dated 01/09/24 included Resident #21 was incontinent. Resident #21 would be assisted with transfers with stand-by assistance to optimize her level of functioning. Resident #21 would be assisted by Resident Assistant's at the facility as needed. Resident #21 would be assisted with toileting to optimize hygiene and promote good perineal hygiene. One staff member would provide assistance to ensure successful toileting and maintain hygiene and health.

Review of Resident #21's SLUMS (Saint Louis University Mental Status) Cognitive Evaluation dated 02/01/24 revealed Resident #21 had no cognitive impairment.

Review of assignment sheets dated 03/06/24 included State Tested Nursing Assistant (STNA)'s #313, #317, #319 and #325 were assigned to work 6:00 A.M. until 2:00 P.M.

Interviews on 03/06/24 between 1:20 P.M. through 1:30 P.M. with STNA #313 and #319 revealed none of the resident's they were assigned to needed incontinence care right now, they were going home at 2:00 P.M. and it would be up to the aides arriving for work at 2:00 P.M. to provide resident's incontinence care if it needed done.

Interview on 03/06/24 at 2:08 P.M. with STNA #328 revealed she arrived for work and her shift started at 2:00 P.M., Resident #21's pendant call light was showing it was activated on her pager, and she was going to her room to see what Resident #21 needed. STNA #328 stated Resident #21 would probably need incontinence care completed.

Observation on 03/06/24 at 2:20 P.M. of STNA #328 revealed she entered Resident #21's room and found her sitting on the toilet. Resident #21 stated she needed assistance changing her incontinence brief and STNA #328 proceeded to provide incontinence care following appropriate technique. STNA #328 assisted Resident #21 to stand up to finish helping her put her clean incontinence brief on, and when Resident #21 stood up a dark red ring and circular impression could be seen on her bottom. Resident #21 stated she had been waiting quite a while for a resident assistant to come in to help her. When asked how long she had been waiting Resident #21 looked at her wrist at what appeared to be a watch and said she had been waiting over a half hour. Resident #21 stated she was just sitting and waiting for someone to come and help her. STNA #328 confirmed Resident #21 had a dark red ring with a circular impression on her bottom and said it looked like Resident #21 had been sitting quite awhile. STNA #328 stated she saw Resident Assistants #313 and #317 standing at the time clock when she came to work, and she thought one of them should have answered Resident #21's call light. STNA #328 stated when she left work when her shift was over she made rounds right before she left and all the residents call lights were answered.

Interview on 03/06/24 at 2:55 P.M. with Health Services Director (HSD) #300 revealed when a resident activated their call light or pendant it was expected the light would be answered within ten minutes. HSD #300 stated if a resident activated their call pendant the signal showed up on the resident assistant pagers and a monitor at the front desk. HSD #300 stated the receptionist checked the monitor often to see if a call light pendant was activated, and when the Receptionist saw a call pendant activated the Receptionist communicated by walkie talkie with the Resident Assistants. HSD #300 stated the last few pendants that were activated should show up on the monitor. HSD #300 checked the monitor at the front desk to see if it showed Resident #21's call pendant was activated, it did not show Resident #21's call light was activated recently, and the receptionist stated she did not notice the monitor had a call pendant activated recently. Observation of HSD #300 revealed she walked to Resident #21's room and checked to see if her call pendant was working properly and showed up at the monitor at the front desk. HSD #300 confirmed Resident #21's call light activated the monitor at the front desk and the resident assistant pagers, and could not explain why the call pendant did not show up at the receptionist desk monitor. HSD #300 stated the resident assistant pagers did not show how long they were activated by a call pendant before being answered and were unable be checked to see how long a call pendant was activated. HSD #300 stated Resident Assistant's #313 and #317 should not have been standing at the time clock if Resident #21's call pendant was activated.

Review of the facility policy titled Resident Personal Care Standards dated 11/01/14 included the facility would make every reasonable effort to ensure each resident received the appropriate personal care assistance necessary to support their health and well-being and to maintain their personal dignity. Personal care included toileting hygiene. The residents would be encouraged to perform as much of their toileting hygiene as they were able. Caregivers would supervise and, or assist as necessary to ensure adequate cleansing took place.

This violation represents non-compliance investigated under Complaint Number OH00151029 and Complaint Number OH00149761.

Based on record review, interview and review of the facility policy the facility failed to ensure licensed nursing staff administered Resident #75's medications. This affected one resident (Resident #75) out of four residents reviewed for medication administration. The facility census was 72.

Findings include:

Review of Resident #75's medical record revealed an admission date of 10/02/18 and diagnoses included CHF (congestive heart failure), a-fib (atrial fibrillation), and Parkinson's disease. Resident #75 passed away at the facility on 02/06/24.

Review of Resident #75's Individual Service Plan dated 12/20/23 revealed Resident #75 was incontinent and was ambulatory. Resident #75 to remain free from falls. Staff were to monitor Resident #75 during waking hours to help prevent falls as needed. Staff to keep walker or assistive device in sight to provide visual reminder to use. Resident #75 would be assisted with dressing to present a clean and neat appearance and promote independence. Staff would assist Resident #75 with dressing to maintain proper hygiene and a neat appearance. Resident #75's living space would be cared for and maintained to ensure a safe and clean-living space. Staff would assist with housework as needed to maintain a safe living space for Resident #75. Resident #75 to take medications correctly, timely and per physician's orders. Staff to assist with Resident #75's medication administration routinely and as needed. Resident #75 would have his vitals monitored per physician's orders to maintain and monitor health. Staff would monitor and record Resident #75's vitals per physician's orders. Resident #75's goal was to be dry, hygienic, and odor free. Staff to change Resident #75's brief and clean up.

Review of Resident #75's Medication Administration Record (MAR) dated 12/18/23 revealed Nystatin Powder 100,000 units per Gram, apply topically to the left breast two times a day until healed was due at 6:00 A.M. Assistant Health Services Director (AHSD) #301 documented on 12/18/23 at 6:00 A.M. she did not apply Resident #75's powder to his left breast, but instead gave the Nystatin Powder to a resident assistant, and when Resident #75 went to the restroom the resident assistant was to apply the Nystatin Powder due to Resident #75 was up all night.

Interview on 02/29/24 at 11:47 A.M. of Family Member (FM) #367 revealed the nurses brought Resident #75's Nystatin Powder into his room in a small plastic cup, did not apply the Nystatin as ordered, but left it sitting in the cup in his room. FM #367 stated Resident #75 could accidentally pick the Nystatin up and do something with it. FM #367 stated the nurses should put the Nystatin powder on themselves because they should assess the area on his left breast to determine if it was healing.

Interview on 02/29/24 at 12:51 P.M. of AHSD #301 confirmed she put Resident #75's Nystatin Powder in a small plastic cup and gave it to the resident assistants (who were not licensed nursing staff) to apply. AHSD #301 stated sometimes she would leave Resident #75's Nystatin Powder by the sink for the resident assistants to apply. AHSD #301 stated she gave Resident #75's Nystatin Powder to the resident assistants or would leave the powder by the sink if the resident assistants were assisting Resident #75 with bathing.

Interview on 03/07/24 at 2:01 P.M. of Health Services Director (HSD) #300 revealed she thought it was alright if AHSD #301 gave Resident #75's Nystatin Powder to the resident assistants to apply. HSD #300 indicated if the resident assistants demonstrated they knew how to apply the powder they were allowed to apply it. HSD #300 was unable to provide a policy stating medications ordered by a physician could be administered by resident assistants.

Review of the facility policy titled Medication Management revised 12/19/22 included residents who received assistance with the administration of their medications by facility staff must have their medications stored in a designated locked facility storage area that was not accessible to persons other than employees responsible for the supervision of centrally stored medications. Facility staff would document each time they provided medication administration assistance on the MAR. Each resident's medication must comply with the facility medication packaging policies. No medications should be transferred between containers. Medication assistance would occur according to the prescribed times and methods as indicated by the resident's physician and as indicated on the medication container's label. When a staff member failed to dispense or administer a medication as prescribed the incident would be investigated.

This violation represents non-compliance investigated under Complaint Number OH00151029.

Based on interview, record review and review of the facility policy the facility failed to ensure Resident #76 and Resident #75's physician orders were followed and service planned interventions were implemented to ensure medications were administered timely. This affected two residents (Resident's #75 and #76) out of three residents reviewed for medications. The facility census was 72.

Findings include

1. Review of Resident #76's medical record revealed an admission date of 11/20/17 and diagnoses included hypertension, history of dizziness and history of DVT (deep vein thrombosis) of the RLE (right lower extremity). Resident #76's allergies included sulfa and penicillins Resident #76 was transported to the hospital on 02/03/24 and discharged from the facility.

Review of Resident #76's SLUMS (Saint Louis University Mental Status) Cognitive Evaluation undated revealed Resident #76 had moderate cognitive impairment.

Review of Resident #76's Individual Service Plan dated 12/22/23 included Resident #76 was deaf in the left ear, had a hearing aid, was ambulatory and used a wheeled walker. Resident #76 needed assistance with dressing to present a clean and neat appearance and to promote independence. Staff provided partial assistance to Resident #76 for bathing to optimize hygiene and appearance. Resident #76 was incontinent, her family provided incontinence supplies, and Resident #76 changed her own incontinence brief. Resident #76 would have vital signs monitored per physician orders and staff would monitor and record vital signs per physician orders. Resident #76 would be monitored for skin issues to maintain optimal skin integrity. Resident #76 would receive medications timely and safely per the physician's orders. Staff would assist Resident #76 with medication administration as needed per physicians orders.

Review of Resident #76's Observation notes dated 02/02/24 at 1:49 P.M. included Resident #76 had a hoarse cough over her sternum. New orders were received from Certified Nurse Practitioner (CNP) #354 for a STAT (immediately) chest X-ray and a mucous relief medication.

Review of Resident #76's physician orders dated 02/02/24 with no time documented revealed orders for Cefdinir (antibiotic) 300 milligram (mg) tablets, give two times a day for five days. A second antibiotic was ordered Azithromycin 500 mg the first day, then 250 mg every day for four days then stop. The orders stated to send the medications ASAP (as soon as possible).

Review of Resident #76's Observation notes dated 02/02/24 at 7:53 P.M. included Resident #76's X-ray results returned and Medical Doctor (MD) #364 who was on call for MD #355 gave new orders for Cefdinir 300 mg twice a day for five days, and Azithromycin 500 mg tablet the first day, then 250 mg every day for four days. (FM) #362 was notified.

Review of Resident #76's Observation notes from 02/02/24 through 02/03/24 at 2:00 P.M. did not reveal evidence the pharmacy was contacted about Resident #76's missing antibiotics.

Review of Resident #76's Medication Administration Record (MAR) from 02/02/24 through 02/04/24 revealed Azithromycin tablet 500 mg for the first day, and 250 mg every day for four days was not administered. Further review revealed a mucous relief extended relief tablet 600 mg was administered in the morning of 02/03/24.

Review of Resident #76's failed fax (telephonic transmission of scanned printed material) documented as failed on 02/02/24 at 8:10 P.M. revealed orders for two antibiotics, the first was Cefdinir 300 milligram (mg) tablets, give two times a day for five days. The second antibiotic ordered was Azithromycin 500 mg the first day, then 250 mg every day for four days then stop. Send medications ASAP (as soon as possible).

Review of Resident #76's fax for two antibiotics (Cefdinir and Azithromycin) which failed on 02/02/24 at 8:10 P.M. was received by the pharmacy on 02/03/24 at 4:15 A.M.

Review of Resident #76's fax for two antibiotics (Cefdinir and Azithromycin) was received by the pharmacy on 02/03/24 at 4:15 A.M., and was resent and received by the pharmacy on 02/03/24 at 12:07 P.M.

Review of Resident #76's Observation notes dated 02/03/24 at 2:00 P.M. included Resident #76's family was upset Resident #76 did not receive antibiotics for pneumonia. Resident #76's family transported her to the local hospital Emergency Department for evaluation and treatment.

Review of Resident #76's Observation notes dated 02/04/24 at 12:25 A.M. included Resident #76's hospital nurse stated Resident #76 was admitted to the hospital with pneumonia and a urinary tract infection.

Review of Resident #76's pharmacy delivery invoice revealed Azithromycin pack 250 mg tablets (quantity was six) was delivered to the facility and the invoice was signed as delivered on 02/04/24 at 2:01 A.M by Health Services Director (HSD) #300.

Interview on 02/20/24 at 11:52 A.M. with Executive Director (ED) #357 revealed if a physician gave an order for medications to be given ASAP (as soon as possible) the meds were drop shipped to the facility by the pharmacy within four hours. ED #357 indicated the pharmacy delivered medications to the facility nightly. ED #357 stated antibiotics would be drop shipped or would come in the nightly delivery which was between 2:00 A.M. to 4:00 A.M.

Interview on 02/20/24 at 12:18 P.M. with ED #357 and HSD #300 revealed an order needed to be placed by 4:00 P.M. for the medications to arrive in the nightly shipment. HSD #300 stated Resident #76's orders were given on 02/02/24 at around 7:00 P.M., the orders stated to send the medications ASAP, and the antibiotics should have been drop shipped or arrived in a separate delivery from the pharmacy. HSD #300 indicated the nurses looked through the delivery on 02/03/24, did not find Resident #76's antibiotics, and contacted the pharmacy to find out why the antibiotics had not arrived. HSD #300 stated before the antibiotics could be delivered by the pharmacy Resident #76's son arrived, was upset the antibiotics were not started, and took Resident #76 to the hospital. ED #357 stated the facility did not have on hand medications.

Interview on 02/20/24 at 1:07 P.M. with Family Member (FM) #362 revealed he was out of town for a few weeks in 01/2024 and when he returned Resident #76 had a hoarse cough and did not look like she felt well. The nurses told him Medical Doctor (MD) #355 would be called and he was waiting to hear back from the facility. FM #362 stated he did not hear from the facility, called MD #355 to inform her of Resident #76's condition, and MD #355 called the facility and ordered a chest X-ray and a mucous relief medication. FM #362 indicated antibiotics were ordered after Resident #76 had a chest X-ray. FM #362 stated when he arrived at the facility on 02/03/24 in the afternoon he found out Resident #76 had not received any antibiotics and he was very upset.

Interview on 02/22/24 at 11:32 A.M. of Pharmacy Representative (PR) #365 revealed the pharmacy received Resident #76's antibiotic order on 02/03/24 at 4:15 A.M. which was the failed fax from 02/02/24 at 8:10 P.M. and it was sent back to the facility for clarification because Resident #76 had an allergy to sulfa and penicillins. PR #365 indicated the pharmacy received a fax from the facility on 02/03/24 at 12:07 P.M. for Resident #76's antibiotics, it did not clarify the antibiotic order and was sent back for clarification because Resident #76 had an allergy to sulfa and penicillins. PR #365 indicated when the facility replied they sent a copy of the failed fax but did not clarify the antibiotic orders related to the sulfa and penicillin allergy. PR #365 stated the pharmacy staff contacted the facility a couple times to clarify the order, then was told by the facility to hold the STAT delivery on 02/03/24 at 2:33 P.M. because Resident #76 was being transported to the hospital. PR #365 stated Resident #76's antibiotics were sent to the facility on 02/04/24 in the nightly shipment.

Interview on 02/22/24 at 4:31 P.M. of HSD #300 revealed the facility did not receive confirmation faxes from the pharmacy because the pharmacy set the facility printer up and confirmation faxes were not needed.

Review of the facility policy titled Medication Management revised 12/19/22 included medication assistance would occur according to the prescribed times and methods as indicated by the Resident's physician and as indicated on the medication container's label.

2. Review of Resident #75's medical record revealed an admission date of 10/02/18 and diagnoses included CHF (congestive heart failure), a-fib (atrial fibrillation), and Parkinson's disease. Resident #75 passed away at the facility on 02/06/24.

Review of Resident #75's hospital After Visit Summary revealed his hospital stay was 12/10/23 through 12/15/23 and included Carbidopa/Levodopa 25/100 mg (Sinemet), take two tablets by mouth in the morning, at noon, and at bedtime. Resident #75 last received Sinemet 25/100 mg, on 12/15/23 at 2:34 P.M. Further review of Resident #75's After Visit Summary included acetaminophen (Tylenol) 500 mg tablet, take 1000 mg by mouth three times daily, and Furosemide (Lasix) 40 mg tablet, take 40 mg by mouth daily.

Review of Resident #75's Observation notes dated 12/15/23 at 5:09 P.M. included Resident #75 returned to the facility from the hospital.

Review of Resident #75's Medication Administration Record (MAR) dated 12/2023 revealed Acetaminophen Capsules 500 mg, give two capsules by mouth three times a day was due on 12/15/23 in the evening and was not administered, and was due on 12/18/23 in the evening, was not administered, and no reason was given why it was not administered.

Review of Resident #75's MAR dated 12/2023 revealed Carbidopa/Levodopa (Sinemet) tablet 25/100 mg, give two tablets by mouth, three times a day for Parkinson's disease was due on 12/15/23 at bedtime and was not administered. On 12/17/23 at 6:00 A.M. Sinemet 25/100 mg was not administered and the reason documented was medication not available. Sinemet 25/100 mg was not administered on 12/17/23 at 4:00 P.M. and the reason given was medication not available due to medications have not been recycling since Resident #75 returned from the hospital on 12/15/23, call placed this morning and beginning 12/18/23 Resident #75's medications would be cycled again. Further review revealed Sinemet 25/100 mg tablet was due on 12/18/23 at 6:00 A.M. and was not given and no reason was documented. Sinemet 25/100 mg tablet was due on 12/18/23 at 4:00 P.M. and was not administered due to Resident #75's medications were not cycled, the pharmacy was called to request medications were sent STAT to the facility. Sinemet 25/100 mg tablet was due on 12/18/23 at bedtime, was not administered, and the reason was not documented.

Review of Resident #75's MAR dated 12/2023 revealed Furosemide (Lasix) tablet 40 mg, give one tablet by mouth one time a day was due on 12/17/23 at 6:00 A.M. and was not given due to the medication was not available. Furosemide 40 mg tablet was due on 12/18/23 at 6:00 A.M. , was not administered, and the reason documented was medication not available, Resident #75's medications did not arrive from pharmacy, and the nurse asked for the medication to be delivered STAT.

Review of Resident #75's Individual Service Plan dated 12/20/23 revealed Resident #75 was incontinent and was ambulatory. Resident #75 to remain free from falls. Staff to monitor Resident #75 during waking hours to help prevent falls as needed. Staff to keep walker or assistive device in sight to provide visual reminder to use. Resident #75 would be assisted with dressing to present a clean and neat appearance and promote independence. Staff would assist Resident #75 with dressing to maintain proper hygiene and a neat appearance. Resident #75's living space would be cared for and maintained to ensure a safe and clean living space. Staff would assist with housework as needed to maintain a safe living space for Resident #75. Resident #75 to take medications correctly, timely and per physician's orders. Staff to assist with Resident #75's medication administration needs routinely and as needed. Resident #75 would have his vitals monitored per physicians orders to maintain and monitor health. Staff would monitor and record Resident #75's vitals per physicians orders. Resident #75 to be dry, hygienic, and odor free. Staff to change Resident #75's brief and clean up.

Review of Resident #75's physician Transitional Care Visit note dated 12/19/23 included there were concerns about making sure Resident #75 was able to get his medications since returning to the facility.

Interview on 02/15/24 at 3:22 P.M. with FM #366 revealed when Resident #75 returned from the hospital on 12/15/23 there were problems with his medications. FM #366 stated the pharmacy was not told Resident #75 was admitted to the hospital and to stop his medications until 12/14/23, and he was admitted on 12/10/23. FM #366 indicated Resident #75 returned to the facility from the hospital on 12/15/23 and pharmacy was not notified he returned until 12/18/23. FM #366 stated Resident #75 did not receive important medications like Sinemet and Lasix because of the facilities lack of communication with the pharmacy.

Interview on 02/22/24 at 2:45 P.M. with HSD #300 confirmed Resident #75 was not administered Sinemet, Lasix and acetaminophen as ordered by the physician. HSD #300 stated when a resident returned to the facility a bed hold release needed to be sent and that could take 24 hours.

Interview on 02/26/24 at 3:21 P.M. of Medical Doctor (MD) #355 revealed she had access to the facility electronic medical record. MD #355 indicated on 12/18/23 Licensed Practical Nurse (LPN) #314 called to set up a transitional care visit for Resident #75 from his hospital stay 12/10/23 through 12/15/23 and was questioned why Resident #75 did not receive Sinemet or Lasix the last two days. MD #355 stated LPN #314 confirmed Resident #75 did not receive his medications and they were ordered STAT from the pharmacy. MD #355 stated negative effects from not getting Sinemet could include rigidity, orthostatic hypotension, tremors, unstable gait and he could have falls. MD #355 stated negative effects from not receiving Lasix could include increased edema, increased dyspnea (difficult or labored breathing), opening of skin leading to wounds, lightheadedness, and it was bad for the heart. MD #355 stated Resident #75 not receiving his medications contributed to more confusion, falls, lightheadedness and directly contributed to a more rapid decline.

Interview on 02/27/24 at 10:19 A.M. of Pharmacy Representative (PR) #365 revealed the pharmacy was notified on 12/14/23 that Resident #75 was admitted to the hospital. PR #365 stated on 12/18/23 the facility contacted the pharmacy and notified them Resident #75 was back from the hospital and to start sending his medications. PR #365 stated the pharmacy was not contacted between 12/14/23 and 12/18/23 regarding Resident #75's medications.

Review of the facility policy titled Medication Management revised 12/19/22 included medication assistance would occur according to the prescribed times and methods as indicated by the Resident's physician and as indicated on the medication container's label.

3. Review of Resident #75's medical record revealed an admission date of 10/02/18 and diagnoses included CHF (congestive heart failure), a-fib (atrial fibrillation), and Parkinson's disease. Resident #75 passed away at the facility on 02/06/24.

Review of Resident #75's physician orders dated 08/18/22 revealed check weights three times a week, give Lasix (Furosemide) as needed (give Lasix 20 mg for a weight gain of three pounds in two days, or five pounds in a seven day period). Notify physician if weights exceed this amount also.

Review of Resident #75's physician orders dated 11/21/23 revealed update weight checks to once daily every morning. Weigh with same scale at the same time of day and preferably by the same nurse. Notify Medical Doctor #355 if a weight gain of greater than three pounds in 24 hours or greater than five pounds in one week. Continue daily weights for two weeks, then resume three times per week on Monday, Wednesday and Friday for a diagnosis of atrial fibrillation and heart failure.

Review of Resident #75's Individual Service Plan dated 12/20/23 revealed Resident #75 was incontinent and was ambulatory. Resident #75 to remain free from falls. Staff to monitor Resident #75 during waking hours to help prevent falls as needed. Staff to keep walker or assistive device in sight to provide visual reminder to use. Resident #75 would be assisted with dressing to present a clean and neat appearance and promote independence. Staff would assist Resident #75 with dressing to maintain proper hygiene and a neat appearance. Resident #75's living space would be cared for and maintained to ensure a safe and clean living space. Staff would assist with housework as needed to maintain a safe living space for Resident #75. Resident #75 to take medications correctly, timely and per physician's orders. Staff to assist with Resident #75's medication administration needs routinely and as needed. Resident #75 would have his vitals monitored per physicians orders to maintain and monitor health. Staff would monitor and record Resident #75's vitals per physicians orders. Resident #75 to be dry, hygienic, and odor free. Staff to change Resident #75's brief and clean up.

Review of Resident #75's Observation notes dated 01/03/24 included per MD #355's strict orders to weigh around the same time in the morning on Monday, Wednesday and Friday mornings with approximately the same amount of clothing, with the same scale, and if possible by the same nurse. Notify the physician is there was a weight gain of greater than three pounds in two days, or greater than five pounds in a seven day period, and if having increased work of breathing, and oxygen saturation less than 90 percent or respirations greater than 24, or increased peripheral edema was noted.

Review of Resident #75's MAR on 01/24/24 revealed check weights three times a week, give Lasix (Furosemide) as needed (give Lasix 20 mg for a weight gain of three pounds in two days, or five pounds in a seven day period). Notify physician if weights exceed this amount also. Resident #75's MAR dated 01/22/24 revealed Resident #75's weight was scheduled to be checked at 5:00 A.M., the recorded time was 4:32 A.M. and the weight was 202.8 pounds. Review of Resident #75's MAR dated 01/24/24 revealed Resident #75's weight was scheduled to be checked at 5:00 A.M., the recorded time was 10:43 A.M., and the weight was 210.4. There was no evidence Resident #75 was administered Lasix 20 mg or Resident #75's physician (MD #355) was notified of the weight gain.

Interview on 02/22/24 at 2:45 P.M. with Health Services Director (HSD) #300 confirmed Medical Doctor (MD) #355 was not notified on 01/24/24 of Resident #75's weight gain of 7.6 pounds or given Furosemide 20 mg as ordered. HSD #300 indicated three days of weights popped up when the weight was entered on the MAR.

Interview on 02/22/24 at 2:12 P.M. with Licensed Practical Nurse (LPN) #320 revealed it was hard to remember details of Resident #75's medication administration on 01/24/24 because it was awhile ago. When shown Resident #75's MAR, LPN #320 confirmed on 01/24/24 she documented Resident #75's weight of 210.4 pounds and was not sure why she did not notice the 7.6 pound weight gain from 01/22/24. LPN #320 stated she did not remember giving extra Lasix due to Resident #75's weight gain, and she was probably so busy, and trying to get medications passed that she didn't notice the weight gain when it popped up on the MAR after she recorded the weight. LPN #320 indicated she did not remember what time the weight was checked, but confirmed it was scheduled to be checked at 5:00 A.M. and was not recorded until 10:43 A.M. LPN #320 stated Resident #75 should have been reweighed. LPN confirmed MD #355 was not notified of Resident #75's weight gain and Resident #75 did not receive Lasix for the weight gain as ordered.

Review of the facility policy titled Medication Management revised 12/19/22 included medication assistance would occur according to the prescribed times and methods as indicated by the Resident's physician and as indicated on the medication container's label.

Review of the facility policy titled Weight Monitoring revised 12/14/21 included residents should be weighed at approximately the same time of day and with the same amount of clothing each time. Weights would be recorded on the weight record. If the resident had a five percent or more weight variance, the resident should be weighed again. If the second weight also reflected a five percent or more weight variance the licensed nurse would be notified and the physician and responsible party would be notified.

This violation represents non-compliance investigated under Complaint Number OH00151303, Complaint Number OH00151029, and Complaint Number OH00149761.

Based on interview, record review, and review of the facility policy the facility failed to ensure immediate steps and interventions were properly implemented for a change in health status to Resident #75 and #76. This affected two residents (Resident's #75 and #76) out of three reviewed for a change of condition. The facility census was 72.

Findings include:

1. Review of Resident #76's medical record revealed an admission date of 11/20/17 and diagnoses included hypertension, history of dizziness and history of DVT (deep vein thrombosis) of the RLE (right lower extremity). Resident #76 was transported to the hospital on 02/03/24 and discharged from the facility.

Review of Resident #76's SLUMS (Saint Louis University Mental Status) Cognitive Evaluation undated revealed Resident #76 had moderate cognitive impairment.

Review of Resident #76's Individual Service Plan dated 12/22/23 included Resident #76 was deaf in the left ear, had a hearing aid, was ambulatory and used a wheeled walker. Resident #76 needed assistance with dressing to present a clean and neat appearance and to promote independence. Staff provided partial assistance to Resident #76 for bathing to optimize hygiene and appearance. Resident #76 was incontinent, her family provided incontinence supplies, and Resident #76 changed her own incontinence brief. Resident #76 would have vital signs monitored per physician orders and staff would monitor and record vital signs per physician orders. Further review of the Service Plan did not reveal documentation related to Resident #76 testing positive on 12/24/23 for COVID-19, and did not reveal nursing interventions or physician orders related to COVID-19.

Review of Resident #76's Observation notes dated 12/24/23 at 3:17 P.M. written by Licensed Practical Nurse (LPN) #321 revealed Resident #76 tested positive for COVID-19 and had a dry cough. The note stated Tylenol was given, and Resident #76's temperature was 103 degrees Fahrenheit (F). The note further stated Medical Doctor #355, Family Member #362 and the facility administration were notified. Resident #76 was placed on isolation precautions from 12/24/23 through 01/03/24.

Review of Resident #76's Observation notes dated 12/24/23 at 6:19 P.M. written by LPN #321 revealed new order for labs and vital signs every shift.

Review of Resident #76's Observation notes dated 12/24/23 at 11:36 P.M. written by LPN #324 included Resident #76's temperature was 98.2.

Review of Resident #76's verbal physician orders dated 12/24/23 and unsigned by Medical Doctor #355 revealed LPN #321 took a verbal order from Medical Doctor #355 for vital signs two times a day and BMP (basic metabolic panel to check kidney function) labwork to be drawn on 01/02/04. Medical Doctor #355 stated the BMP labwork was to be drawn on 12/26/23, and Health Services Director (HSD) #300 was unable to provide the signed verbal order.

Review of Resident #76's Medication Administration Record (MAR) from 12/24/23 through 12/28/23 revealed vital signs every shift, two times a day was added to the MAR on 12/26/23 (and not 12/24/23 which was the day the physician gave orders for vital signs to be checked every shift, two times a day). There were no vital signs including blood pressure, pulse, respirations, temperature and oxygen saturation documented on 12/24/23 and 12/25/23. On 12/26/23 vital signs were checked off as completed but there was no documentation what the vital signs values were. On 12/27/23 and 12/28/23 there were no morning vital signs documented.

Review of Resident #76's MAR dated 12/24/23 revealed acetaminophen 325 milligrams (mg) tablets, give two tablets (650 mg) by mouth every four hours as needed for headache, for joint or muscle pain or for temperature greater than 100 F. Further review revealed two acetaminophen 325 mg tablets were given on 12/24/23 at 3:06 P.M. for increased temperature and the outcome was semi-effective. Two acetaminophen 325 mg tablets were given on 12/24/23 at 9:01 P.M. and the outcome was effective. Neither the 3:06 P.M. or the 9:01 P.M. outcome had a temperature documented.

Review of Resident #76's Physician Encounter note dated 12/29/23 written by Certified Nurse Practitioner (CNP) #354 revealed CNP #354 did not see labs at the facility, cannot get Paxlovid now since Resident #76 tested positive for COVID-19 on 12/24/23 and now it was 12/29/23. This was regarding a Telephone Encounter on 12/24/23.

Review of Resident #76's Observation notes dated 12/24/23 through 12/29/23 did not reveal evidence Medical Doctor (MD) #355 and Family Member (FM) #362 were notified Resident #76's labwork was unable to be drawn on 12/26/23 or details regarding Paxlovid orders. The notes did not specify FM #362 would need to make his own arrangements if he wanted Resident #76's labwork drawn in the timeframe needed to have Paxlovid ordered.

Review of Resident #76's Physician note dated 01/02/24 written by MD #355 regarding Resident #76's Telephone Encounter dated 12/24/23 included to please advise family that MD #355 was awaiting bloodwork results to ensure Resident #76 was safe to obtain Paxlovid but Resident #76 was out of the treatment window where it would be safe or effective for Resident #76 to receive Paxlovid so that was why it was not given and instead Resident #76 was put on increased monitoring of vital signs to ensure she was notified if Resident #76's overall breathing status or overall function were worsening for further steps to be taken.

Review of Resident #76's Observation notes dated 01/04/24 at 3:23 P.M. written by LPN #314 included LPN #314 spoke with Medical Doctor #355's office staff and notified them Resident #76's labs were faxed to Medical Doctor #355 and the staff stated they would make sure she reviewed the labs.

Interview on 02/15/24 at 3:37 P.M. with Family Member (FM) #362 revealed Medical Doctor (MD) #355 was Resident #76's Primary Care Physician. FM #362 stated he asked the facility to provide Resident #76's medical record from 12/2023 and there was sloppy stuff at the facility. FM #362 stated on 12/24/23 he stopped in to visit Resident #76, she was coughing, did not seem right and he asked the nurse to check on her. FM #362 revealed an hour later he was called and told Resident #76 tested positive for COVID-19. FM #362 indicated Licensed Practical Nurse (LPN) #321 told him she contacted MD #355 and Resident #76 was supposed to have bloodwork drawn and have Paxlovid (antiviral medication used for the treatment of COVID-19) ordered if her labwork was alright. FM #362 stated LPN #321 told him Resident #76 was given Tylenol for a fever, but he was not told how high her fever was. FM #362 talked to Resident #76 on 12/25/23 and she told him she had not received the antiviral medication. FM #362 stated he called the facility on 12/27/23 to verify if Resident #76 received the antiviral medication, and to get a status report on her fever and symptoms. FM #362 indicated the call went to voicemail, and he did not receive a call back from the facility. FM #362 stated he called two times in the morning on 12/28/23, still had not heard back from the facility at 2:00 P.M., and had another family member call the facility to ask them to call him. FM #362 stated the family member spoke with Health Services Director (HSD) #300, and was questioned why she was calling the facility, and there was no reason the family member should be calling to have the facility call FM #362. FM #362 finally received a call from the facility on 12/28/23 around 2:30 P.M. and was told the antiviral medication was not started. FM #362 stated on 12/29/23 he met with Executive Director (ED) #357 and asked to review Resident #76's care notes and medication administration information from 12/22/23 through 12/29/23. FM #362 revealed he was given Resident #76's MAR (medication administration record), and the MAR showed Resident #76 had a fever of 103 degrees Fahrenheit (F), and there was a note written that stated Resident #76 was given two Tylenol, but no documentation her temperature was rechecked after administration of the Tylenol. FM #362 indicated Resident #76 was given additional Tylenol six hours later. FM #362 stated he was not contacted by the facility and told the bloodwork would not be drawn the week of 12/25/23. FM #362 stated he was not informed he would have to make his own arrangements if he wanted Resident #76 to have her labwork drawn so it could be checked and if it was alright Paxlovid could be ordered and administered.

Interview on 02/20/24 at 5:00 P.M. with Executive Director (ED) #357 and Health Services Director (HSD #300 revealed the facility lab phlebotomist came to the facility on Wednesday and Friday each week to draw blood, and there were no STAT labs drawn at any time. HSD #300 stated if labs were ordered to be drawn for a resident in a holiday week the labs would not be drawn because the lab did not come at all during a holiday week. HSD #300 stated the facility was Assisted Living and if labs needed to be drawn STAT (as soon as possible) the families were responsible to arrange to have the resident's blood drawn. HSD #300 stated the families should be notified by the facility when labwork was not going to be drawn as ordered so they could make the arrangements to have the resident's blood drawn. HSD #300 confirmed Resident #76's medical record including Observation notes did not reveal evidence Resident #76 or FM #362 were notified the labwork ordered for 12/26/23 would not be drawn and they needed to make other arrangements if they wanted the labwork drawn.

Interview on 02/21/24 at 11:15 A.M. with HSD #300 revealed residents' vital signs would be documented on the MAR (medication administration record) or in Observation notes. HSD #300 confirmed Resident #76 did not have vital signs including temperature, pulse, blood pressure, and oxygen saturation documented twice a day from 12/24/23 through 12/28/23. HSD #300 confirmed there were no vital signs documented on Resident #76's MAR on 12/24/23 or 12/25/23. HSD #300 confirmed Resident #76's Observation notes on 12/24/23 had two temperatures documented but no blood pressure, pulse, respirations or oxygen saturations. HSD #300 confirmed Resident #76's MAR on 12/26/23 had vital signs checked off as completed, but there were no vital signs documented on the MAR or the Observation notes. HSD #300 confirmed on 12/27/23 and 12/28/23 Resident #76 did not have vital signs documented in the morning. HSD #300 confirmed Resident #76's order for vital signs to be checked two times a day was discontinued on 01/04/24 and there was no physician order to discontinue checking vital signs twice a day. HSD #300 did not know why Resident #76's vital signs were discontinued.

Interview on 02/21/24 at 2:37 P.M. with LPN #321 revealed when she was asked about verbal orders she took on 12/24/23 for Resident #76's vital signs to be checked two times a day, and bloodwork to be drawn on 01/02/24 (MD #355 stated the bloodwork was to be drawn 12/26/24) LPN #321 stated she sent the orders to the pharmacy and thought pharmacy put the vital sign orders on the MAR. LPN #321 stated nurses had to manually put the lab orders in the system and she did not remember details of Resident #76's verbal orders on 12/24/23. LPN #321 stated she worked 12/24/23 and Resident # 76 was included in her assignment, but she could not remember anything about the situation with Resident #76 on 12/24/23.

Interview on 02/21/24 at 2:50 P.M. with ED #357 and HSD #300 revealed nurses should manually add orders which were not medication orders such as vital signs into the resident's MAR. HSD #300 stated LPN #321 took Resident #76's verbal physician order on 12/24/23 for vital signs but did not put the vital sign orders into the MAR until 12/26/23. HSD #300 indicated LPN #321 knew she had taken the verbal physician order on 12/24/23 for Resident #76 to have vital signs checked twice a day and when she worked on 12/26/23 realized the MAR did not have the vital signs scheduled to be checked twice a day. HSD #300 stated on 12/26/23 LPN #321 added the order for vital signs to be checked two times a day. HSD #300 indicated she could not find Resident #76's signed verbal orders from 12/24/23 and provide them for the survey.

Interview on 02/26/24 at 3:21 P.M. with MD #355 revealed she was the PCP for quite a few residents who resided at the facility, and her office staff had to call and call and call to make sure the facility followed up on and implemented her orders. MD #355 confirmed she was Resident #76's PCP. MD #355 stated Resident #76 did not receive the antiviral medication Paxlovid because the ordered labwork was not completed within five days. MD #355 stated on 12/24/23 orders were given to the nurse to notify her if Resident #76's respiratory rate was greater than 20, if her heart rate was greater than 100, if Resident #76's temperature was above 100 F, and if her oxygen saturation was less than 90 percent. MD #355 stated on 12/24/23 MD #363 gave orders to have Resident #76's vital signs checked two times a day, have labwork drawn for a BMP on 12/26/23, and to fax the labwork back to MD #355 ASAP (as soon as possible). When MD #355 did not receive the labwork which was supposed to be drawn on 12/26/23, she asked her assistant to follow up with the facility. The labwork was not drawn on 12/26/23 as ordered and was not faxed to MD #355 until 01/03/24 which was too late to help. MD #355 stated the labwork needed to be completed within five days of the day Resident #76 tested positive for COVID-19, which was 12/24/23, for her to order Paxlovid. MD #355 stated she was not contacted to let her know Resident #76's labwork was not drawn on 12/26/23 as ordered. MD #355 stated she was not contacted about Resident #76's vital signs, and if they were outside the ordered parameters, and she was not contacted to inform her Resident #76's vital signs were not checked twice a day as ordered. MD #355 indicated if Resident #76 received Paxlovid it could decrease the severity of her symptoms and could decrease the possibility of death.

Review of the facility policy titled Change of Condition dated 11/01/14 included any change in a Resident's condition that was observed or suspected by any staff member would be reported to a licensed nurse. The licensed nurse would ensure appropriate evaluation and follow-up took place and would be responsible for notifying the Resident's family or responsible party and physician if appropriate. The licensed nurse would also determine if the change was potentially life-threatening, significant but not life-threatening, required temporary monitoring and alert charting, or did not require further follow-up. Changes that should be reported included signs of respiratory illness, such as congestion, coughing, wheezing, change in vital signs. The licensed nurse would be responsible for evaluating the Resident for changes noted, in a timely manner. The licensed nurse would determine the type of intervention and follow-up that was indicated, including appropriate notification of the Resident's family or responsible party and physician. Notifications to the Resident's responsible party and primary provider would be noted in the Resident Health Record. The Resident would be placed on alert charting. The noted change of condition, follow-up and outcome would be documented in the Resident Health Record. Any nursing interventions, or new physician orders implemented would be noted on the service plan and all staff members would be informed of the changes.

2. Review of Resident #75's medical record revealed an admission date of 10/02/18 and diagnoses included CHF (congestive heart failure), a-fib (atrial fibrillation), and Parkinson's disease. Resident #75 passed away at the facility on 02/06/24.

Review of Resident #75's Individual Service Plan dated 12/20/23 revealed Resident #75 was incontinent and was ambulatory. Resident #75 to remain free from falls. Staff were to monitor Resident #75 during waking hours to help prevent falls as needed. Staff to keep walker or assistive device in sight to provide visual reminder to use. Resident #75 would be assisted with dressing to present a clean and neat appearance and promote independence. Staff would assist Resident #75 with dressing to maintain proper hygiene and a neat appearance. Resident #75's living space would be cared for and maintained to ensure a safe and clean-living space. Staff would assist with housework as needed to maintain a safe living space for Resident #75. Resident #75 to take medications correctly, timely and per physician's orders. Staff to assist with Resident #75's medication administration routinely and as needed. Resident #75 would have his vitals monitored per physician's orders to maintain and monitor health. Staff would monitor and record Resident #75's vitals per physician's orders. Resident #75's goal was to be dry, hygienic, and odor free. Staff to change Resident #75's brief and clean up.

Review of Resident #75's Observation notes dated 12/02/23 included Licensed Practical Nurse (LPN) #314 was told by Resident #75's aide he had blood in his urine and had painful urination. LPN #314 placed a call to Medical Doctor (MD) #355's office and obtained an order to collect a urine specimen for a urinalysis and culture and sensitivity. LPN #314 placed a hat in Resident #75's room to collect the sample. There was no evidence Resident #75's family or responsible party was contacted about Resident #75's blood in his urine and painful urination.

Review of Resident #75's Observation notes dated 12/02/23 through 12/09/23 did not reveal documentation regarding Resident #75's urine specimen for urinalysis and culture and sensitivity.

Review of Resident #75's urinalysis and culture and sensitivity lab report revealed Resident #75's urine specimen was collected on 12/07/23 and received and reported on 12/08/23. Further review of the report revealed Resident #75 had a urinary tract infection and the medication recommendations were Amoxicillin (antibiotic) 875 mg by mouth two times a day for seven to fourteen days.

Review of Resident #75's Observation notes dated 12/09/23 included Resident #75 was incontinent of urine and did not want to eat in the dining room. Resident #75 was very confused. Further review revealed Resident #75 tested positive for a UTI (urinary tract infection) and Resident #75's physician ordered Amoxicillin which was initiated on 12/09/23.

Review of Resident #75's Observation notes dated 12/22/23 included LPN #314 received new orders for Resident #75 to have a urine specimen sent for urinalysis and culture and sensitivity, and a hat was placed in his room to obtain the urine sample. Further review on 12/22/23 at 6:01 P.M. revealed Resident #75's urine sample was collected, was registered with the lab, and was waiting to be picked up.

Review of Resident #75's Observation notes dated 12/22/23 through 12/29/23 did not reveal documentation regarding Resident #75's urine specimen for urinalysis and culture and sensitivity.

Review of Resident #75's urinalysis and culture and sensitivity lab report revealed the specimen was collected on 12/22/23 and was rejected. Further review revealed the urine specimen was rejected on 12/30/23 because it was collected over seven days ago and was never received by the lab.

Review of Resident #75's Observation notes dated 12/29/23 at 4:30 P.M. included FM #366 and FM #367 were contacted by HSD #300 and informed Resident #75's urine specimen was lost, and FM #366 stated due to holiday weekend to wait and send the specimen on 01/02/24.

Review of Resident #75's Observation notes dated 12/20/23 through 01/03/24 did not reveal documentation regarding Resident #75's urine specimen.

Review of Resident #75's urinalysis and culture and sensitivity lab report revealed Resident #75's urine specimen was collected on 01/03/24 and was received and reported on 01/04/24. Resident #75 had a urinary tract infection and medication recommendations included Cephalexin (antibiotic) give 500 mg two times a day for five to seven days for an uncomplicated urinary tract infection or seven to ten days for a complicated urinary tract infection.

Interview on 02/15/24 at 3:22 P.M. with Family Member (FM) #366 revealed on 12/02/23 the facility notified Medical Doctor (MD) #355 Resident #75 had blood in his urine. FM #366 stated the family was not notified Resident #75 had blood in his urine until 12/04/23. FM #366 indicated MD #355 gave an order to obtain another urine specimen for urinalysis and culture and sensitivity on 12/20/23, but FM #366 was told the urine would go out the next lab day which was 12/22/23. FM #366 stated an email was sent to ED #357 on 12/28/23 asking why Resident #75's urine culture and sensitivity results had not been received. FM #366 stated the family was concerned if Resident #75 had an infection he could be septic with no treatment. FM #366 stated she was told by the nursing staff the lab did not fax results to the facility or residents' physicians, and it was the responsibility of the nurses to go to the lab's website to find the results. FM #366 indicated she received a call on 12/29/23 from Assistant Health Service Director (AHSD) #301 stating the lab did not have the results and they must have been lost by the lab transportation service. FM #366 stated she was told by AHSD #301 another urine specimen would be obtained and sent to the lab and was scheduled to be sent to the lab on 01/02/24. FM #366 stated she told the facility not to send the urine specimen for culture and sensitivity on 12/30/23 because the facility did not know for sure if there would be a pick-up on 12/30/23 and FM #366 wanted the specimen sent when she knew it would be picked up by the lab transportation service. FM #366 stated the urine specimen for urinalysis and culture and sensitivity was not sent to the lab on 01/02/24 but was sent on 01/03/24. FM #366 indicated the facility was unable to explain why Resident #75's urine specimen was not sent on 01/02/24. FM #366 stated the urine results sent to the lab on 01/03/24 identified Resident #75 had a urinary tract infection which was fourteen days after the order was first given to the facility.

Interview on 02/20/24 at 5:00 P.M. with Executive Director (ED) #357 and Health Services Director (HSD) #300 revealed the lab used to analyze urine specimens was located out of state. HSD #300 stated the facility was Assisted Living and there were no STAT blood work or urine specimens collected at the facility. HSD #300 stated if a urine specimen or lab work needed to be collected STAT, the family was notified, and they had to make their own arrangement for it to be collected. HSD #300 stated the lab work and urine specimens were collected two days a week on Wednesdays and Fridays, and if it was a holiday week the lab did not come at all. HSD #300 stated the lab did not fax results to the facility or a resident's physician and it was the responsibility of the nurses to look in the electronic system for blood work and urine results.

Interview on 02/21/24 at 2:50 P.M. with ED #357 and HSD #300 revealed Resident #75 had blood in his urine on 12/02/23 and MD #355 gave orders to have a urine specimen for urinalysis and culture and sensitivity, and it took five days to collect the urine specimen. HSD #300 stated it was difficult to obtain a urine specimen from Resident #75 and confirmed the difficulty obtaining the urine specimen was not documented in Resident #75's Observation notes. HSD #300 confirmed Resident #75 had a urine specimen for urinalysis and culture and sensitivity collected on 12/22/23, the specimen was sent with the lab transportation company, and the specimen was lost by the lab transportation company. HSD #300 stated on Friday, 12/29/23 Resident #75's family said to wait until after the New Year weekend to collect another urine sample. HSD #300 stated she did not know why Resident #75's urine specimen was sent on 01/03/24 and not 01/02/24 documented in Resident #75's Observation notes.

Interview on 02/22/24 at 3:45 P.M. with Assistant Health Services Director (AHSD) #301 revealed she was aware Resident #75's urine specimen for urinalysis and culture and sensitivity ordered on 12/02/23 took awhile to be sent to the lab. AHSD #301 stated it was hard for staff to obtain the urine specimen. AHSD #301 confirmed Resident #75's urine specimen collected on 12/22/23 was lost by the lab transportation company.

Interview on 02/26/24 at 3:21 P.M. with MD #355 revealed it should not take five days from 12/02/23 through 12/07/23 to collect Resident #75's urine for urinalysis and culture and sensitivity and it was not acceptable that it took five days. MD #355 stated one or two days at the maximum was what it should take to collect a urine specimen. MD #355 stated on 12/22/23 Resident #75 was ordered a urine specimen for urinalysis and culture and sensitivity the specimen was lost. MD #355 indicated she was not notified the specimen was lost. MD #355 stated the urine specimen ordered on 12/22/23 was collected and sent to the lab on 01/03/24, it was too long not to be started on antibiotics and was unacceptable. MD #355 stated having a urinary tract infection for a prolonged time could lead to sepsis and death if untreated.

3. Review of Resident #76's medical record revealed an admission date of 11/20/17 and diagnoses included hypertension, history of dizziness and history of DVT (deep vein thrombosis) of the RLE (right lower extremity). Resident #76 was transported to the hospital on 02/03/24 and discharged from the facility.

Review of Resident #76's physician orders dated 08/23/23 revealed to complete skin checks on Wednesdays at noon and evaluate Resident #76's skin, chart skin issues and notify the primary physician.

Review of Resident #76's SLUMS (Saint Louis University Mental Status) Cognitive Evaluation undated revealed Resident #76 had moderate cognitive impairment.

Review of Resident #76's Individual Service Plan dated 12/22/23 included Resident #76 was deaf in the left ear, had a hearing aid, was ambulatory and used a wheeled walker. Resident #76 needed assistance with dressing to present a clean and neat appearance and to promote independence. Staff provided partial assistance to Resident #76 for bathing to optimize hygiene and appearance. Resident #76 was incontinent, her family provided incontinence supplies, and Resident #76 changed her own incontinence brief. Resident #76 would have vital signs monitored per physician orders and staff would monitor and record vital signs per physician orders. Resident #76 would be monitored for skin issues to maintain optimal skin integrity. Staff would monitor skin for issues. Resident #76 had edema and weeping of her RLE (right lower extremity) and had venous ulcers. Staff to report to supervisor any redness or new skin issues noted on skin.

Review of Resident #76's Observation notes dated 01/29/24 at 6:21 P.M. revealed Resident #76 was found sitting on the edge of her bed, blood on the bed, hands, and legs. A scab opened on Resident #76's right leg and was dripping blood. Resident #76's right pointer finger had a significant broken nail that was actively bleeding. Resident #76 was wearing five pairs of pull ups over her pants. Resident #76 was assisted into a new pull up and clean pants. Resident #75's hands were washed and first aid was administered to Resident #76's hand. Resident #76 was unable to remember what happened or what lead to the incident.

Review of Resident #76's Observation notes dated 01/30/24 at 3:05 P.M. included Resident #76 had new orders for a urinalysis and culture and sensitivity due to recent unusual behavior. Further review at 6:54 P.M. revealed Resident #76's urine for urinalysis and culture and sensitivity was collected, registered with the lab and sent out via mail.

Review of Resident #76's Observation notes dated 02/01/24 at 3:01 P.M. included Resident #76's urine specimen was pending.

Review of Resident #76's Observation notes dated 02/01/24 through 02/03/24 did not reveal documentation regarding Resident #76's urine specimen for urinalysis and culture and sensitivity.

Review of Resident #76's Observation notes dated 02/03/24 at 2:00 P.M. revealed Resident #76's family was in and was upset Resident #76's antibiotics for pneumonia had not been administered. Resident #76's family took her to the hospital for evaluation and treatment.

Review of Resident #76's Observation notes dated 02/04/24 at 12:25 A.M. included Resident #76 was admitted to the hospital with pneumonia and a urinary tract infection.

Review of Resident #76's urinalysis and culture and sensitivity lab report revealed Resident #76's urine was collected on 01/30/24 and was rejected. Further review revealed Resident #76's urine specimen was received by the lab on 02/01/24 and was rejected on 02/14/24 because it was on hold for over 14 days and never resolved by the client. Notes stated Resident #76's information on the specimen tube did not match the data in the portal. The date of birth on the specimen tube was 11/31/29 and the portal had Resident #76's date of birth documented as 10/31/29. Please correct the data in the portal if it was incorrect. If the data in the portal was correct, please state the portal was correct.

Interview on 02/22/24 at 9:25 A.M. with HSD #300 revealed Resident #76's urine specimen collected on 01/30/24 had a discrepancy with her birth date in the lab system versus what the nurse wrote on the specimen tube. HSD #300 stated the lab did not contact the facility with discrepancies and it was the responsibility of the nurses to check the system. HSD #300 stated up until today (02/22/24) she did not know why the specimen was rejected. HSD #300 confirmed Resident #76's results for her specimen for urinalysis and culture and sensitivity collected on 01/30/24 was not followed up timely by the nurses.

4. Review of Resident #75's medical record revealed an admission date of 10/02/18 and diagnoses included CHF (congestive heart failure), a-fib (atrial fibrillation), and Parkinson's disease. Resident #75 passed away at the facility on 02/06/24.

Review of Resident #75's Individual Service Plan dated 12/20/23 revealed Resident #75 was incontinent and was ambulatory. Resident #75 to remain free from falls. Staff were to monitor Resident #75 during waking hours to help prevent falls as needed. Staff to keep walker or assistive device in sight to provide visual reminder to use. Resident #75 would be assisted with dressing to present a clean and neat appearance and promote independence. Staff would assist Resident #75 with dressing to maintain proper hygiene and a neat appearance. Resident #75's living space would be cared for and maintained to ensure a safe and clean-living space. Staff would assist with housework as needed to maintain a safe living space for Resident #75. Resident #75 to take medications correctly, timely and per physician's orders. Staff to assist with Resident #75's medication administration routinely and as needed. Resident #75 would have his vitals monitored per physician's orders to maintain and monitor health. Staff would monitor and record Resident #75's vitals per physician's orders. Resident #75's goal was to be dry, hygienic, and odor free. Staff to change Resident #75's brief and clean up.

Review of Resident #75's Medication Administration Record (MAR) revealed on 02/05/24 at 10:17 P.M. Resident #75 had an increased temperature and Licensed Practical Nurse (LPN) #321 administered an acetaminophen suppository 650 mg. There was no follow up documentation regarding the acetaminophen's effectiveness.

Review of Resident #75's Observation notes dated 02/05/24 at 10:27 P.M. included Resident #75 was given a Tylenol (acetaminophen) suppository for a temperature of 101.2 degrees Fahrenheit. Further review of the notes did not reveal documentation of the effectiveness of the acetaminophen suppository or a follow up temperature.

Review of Resident #75's MAR revealed on 02/06/24 at 9:23 A.M. LPN #314 administered Resident #75 an acetaminophen suppository 650 mg because Resident #75's daughter requested it due to Resident #75 having a fever. The follow up outcome stated the acetaminophen was effective, but there was no follow up temperature documented on the MAR.

Review of Resident #75's Observation notes dated 02/06/24 at 9:25 A.M. included Resident #75's daughter stated Resident #75 had a fever and requested a Tylenol suppository. There was no follow up temperature or documentation about the effectiveness of the suppository.

Review of Resident #75's Medication As Needed Administration Report dated 02/06/24 revealed acetaminophen suppository 650 mg was administered by LPN #314 at 9:23 A.M. and the follow up outcome was documented as effective at 7:16 P.M. about ten hours after he was administered the suppository.

Interview on 02/21/24 at 3:48 P.M. with Family Member (FM) #367 revealed FM #366 took Resident #75's temperature, and if he had a fever, FM #366 asked the nurse to give Resident #75 a Tylenol (acetaminophen) suppository. FM #367 stated the nurses gave the suppositories but did not do follow up temperature checks or follow up to see how Resident #75 felt. RM #367 stated the family did not feel the love from the facility.

Interview on 02/29/24 at 10:00 A.M. with HSD #300 revealed after as needed medications such as acetaminophen were administered the nurse was supposed to go back an hour later and check for effectiveness. HSD #300 stated an hour after the as needed medication was administered the system prompted the nurse to check the resident for effectiveness of the medication and the nurse should return to the resident's room to do an evaluation. HSD #300 stated LPN's #314 and #321 should absolutely have checked Resident #75 for the effectiveness of the acetaminophen suppository. HSD #300 confirmed on 02/05/24 after LPN #321 gave Resident #75's suppository at 10:17 P.M. there was no follow up documentation or temperature check regarding the effectiveness of the Tylenol suppository. HSD #300 confirmed on 02/06/23 after Resident #75 was given a Tylenol Suppository at 9:23 A.M. LPN #314 documented it was effective, but there was no follow up temperature documented. HSD #314 confirmed LPN #314 documented the Tylenol suppository was effective on 02/06/24 at 7:16 P.M. which was almost ten hours after the suppository was given. HSD #314 stated LPN #314 should have returned to Resident #75's room in an hour and taken his temperature.

Interview on 02/29/24 at 2:02 P.M. with LPN #314 confirmed she gave Resident #75 a Tylenol suppository on 02/06/24 at 9:23 A.M. because he had a fever, and she did not document a follow up temperature an hour after the suppository was given. LPN #314 confirmed she documented the suppository was effective on 02/06/24 at 7:16 P.M., it was way past the one-hour mark, and since she did not document Resident #75's temperature she could not be sure the suppository was effective. LPN #314 stated she could not remember if she took a follow up temperature.

Interview on 02/29/24 at 2:54 P.M. with LPN #321 revealed she worked on 02/06/24 and remembered giving Resident #75 a Tylenol suppository before she went home. LPN #321 indicated Resident #75's temperature should have been checked an hour after he was given the Tylenol suppository. LPN #321 indicated on 02/06/24 she stayed longer than her scheduled shift to complete the evening medication pass, and she told the next nurse Resident #75 was given a Tylenol suppository and the nurse needed to check up on him and take his temperature.

This violation represents non-compliance investigated under Complaint Number OH00151303, Complaint Number OH00151029, and OH00149761.

Based on observation, interview, record review, and review of the facility policy the facility failed to ensure Resident #75 and #76's room were clean and sanitary. This affected two (Resident's #75 and #76) out of three residents rooms reviewed for cleaning. The facility census was 72.

Findings include:

1. Review of Resident #76's medical record revealed an admission date of 11/20/17 and diagnoses included hypertension, history of dizziness and history of DVT (deep vein thrombosis) of the RLE (right lower extremity). Resident #76 was transported to the hospital on 02/03/24 and discharged from the facility.

Review of facility local discount store receipts dated 12/19/23 and 01/11/24 revealed laundry soap was purchased.

Review of Resident #76's SLUMS (Saint Louis University Mental Status) Cognitive Evaluation undated revealed Resident #76 had moderate cognitive impairment.

Review of Resident #76's Individual Service Plan dated 12/22/23 included Resident #76 was deaf in the left ear, had a hearing aid, was ambulatory and used a wheeled walker. Resident #76 needed assistance with dressing to present a clean and neat appearance and to promote independence. Staff provided partial assistance to Resident #76 for bathing to optimize hygiene and appearance. Resident #76 was incontinent, her family provided incontinence supplies, and Resident #76 changed her own incontinence brief. Resident #76 would have vital signs monitored per physician orders and staff would monitor and record vital signs per physician orders. Resident #76 would be monitored for skin issues to maintain optimal skin integrity. Staff would monitor skin for issues. Resident #76's laundry would be clean and maintained to promote health and a clean appearance. Staff would pull laundry and linens on the evening shift on Tuesdays. Resident #76's linens would be washed to maintain a clean and fresh bed in order to maintain a healthy lifestyle. Staff would strip residents bed and wash linens to promote good health. Linens would be washed on Wednesdays, morning shift. Resident #76's living space would be kept clean and clutter-free daily. Staff would remove Resident #76's trash daily.

Review of Resident #76's Daily Housekeeper Checklist revealed on 12/30/23 Resident #76's room was cleaned, her towels were washed, and strip and make bed was checked off. There was no further cleaning documented until 01/09/24 and on that day her room was cleaned but there was no laundry soap and her towels and bed linens were not washed because there was not laundry soap. On 01/16/24 Resident #76's towels and bed linens were not washed, and a reason was not documented why this was not done. On 01/24/24 the Checklist had Resident #76's room checked off as cleaned but it was not specified what was cleaned or if her towels and bed linens were washed. Resident #76's room had no further cleaning documented in 01/2024.

Interview on 02/15/24 at 3:37 P.M. with Family Member (FM) #362 revealed on 01/02/24 around 6:00 P.M. he visited Resident #76 at the facility and noted her room and bathroom had not been cleaned, her sheets were unchanged, her bathroom was a mess and dirty and her trash can was overflowing. Resident #76 could not recall when her room was last cleaned. FM #362 stated he was told Resident #76's towels and sheets were not washed because the facility was out of laundry detergent. Resident #76 asked an unidentified staff member if her room was going to be cleaned and she was told it would be cleaned when she moved out. FM #362 indicated Resident #76 moved out of the facility in February 2024. FM #362 stated Resident #76's room was empty, had not been cleaned after Resident #76 moved out, and the staff stopped cleaning or washing sheets and linens when they found out she was leaving. FM #362 stated there was still feces on the toilet handle and side of toilet tank, and the floor still had dried urine and feces on it.

Interview on 02/15/24 at 3:37 P.M. with FM #362 confirmed pictures were taken on 01/09/24 of Resident #76's very dirty and stained sheets. Review of the pictures taken on 01/09/24 revealed Resident #76's sheets and pillowcases were very dirty and had multiple white crusty dried areas on them. There were also many areas on the sheets and pillowcases with what appeared to be wet areas that had dried, but the area could still be seen and inside the dried ring the sheets were a darker color than the rest of the sheets.

Observation on 02/21/24 at 2:20 P.M. of Resident #76's former room with Health Services Director (HSD) #300 confirmed the room had not been cleaned since Resident #76 moved out of the facility. Observation of the bathroom revealed dried brown material on the toilet handle and side of the toilet tank and HSD #300 confirmed it was feces. The bathroom floor had dried yellowish-brown material in front of the toilet and the trash can was overflowing. HSD #300 stated Resident #76 was independent for incontinence care and the Resident Assistants probably did not go in the bathroom much. HSD #300 indicated at Resident #76's Service Plan meeting general housekeeping was discussed, but the bathroom was not mentioned. HSD #300 confirmed the carpet needed vacuumed and the trash had not been thrown away.

Interview on 02/27/24 at 11:10 A.M. with Executive Director (ED) #357, Regional Director of Nursing (RDN) #356 and Health Services Director (HSD) #300 revealed the facility was never without laundry soap, and as soon as we knew we were out Maintenance and Housekeeping Supervisor #304 went to the store and purchased it. ED #357, RDN #356 and HSD #300 confirmed Resident #76's pictures taken on 01/09/24 revealed Resident #76's sheets and pillowcases were very dirty and had multiple white crusty dried areas on them. There were also many areas on the sheets and pillowcases with what appeared to be wet areas that had dried, but the area could still be seen and inside the dried ring the sheets were a darker color than the rest of the sheets.

Interview on 02/28/24 at 4:57 P.M. with Maintenance and Housekeeping Supervisor (MHS) #304 revealed the first floor housekeeper quit in the middle of January 2024, he took over cleaning the first floor, but did not do a good job of marking which rooms he cleaned. MHS #304 stated if a room was marked as cleaned on the Checklist then it was definitely cleaned.

Interview on 02/29/24 at 7:57 A.M. with MHS #304 revealed he began working a the facility around the beginning of December 2023 and the facility was in the middle of changing suppliers for laundry soap and there was not enough laundry soap ordered from the new supplier to last the month of December. MHS #304 stated laundry soap was purchased from a local discount store when they ran out of laundry soap in December. MHS #304 stated he placed an order in January 2024 for laundry soap and he did not order enough and laundry soap was again purchased from the local discount store. MHS #304 stated he went out right away and purchased laundry soap when the facility was out. MHS #304 stated there were five laundry rooms in the facility, and the first floor housekeeper would not go to laundry rooms on the second floor to check if she was out of laundry soap in the three downstairs laundry rooms. MHS #304 indicated he would find soap for her to use at the facility or would go to the store to purchase more.

Review of the facility Resident Agreement included under the category of Services Included in Your Monthly Fee it stated laundering of clothing, linens and towels and weekly housekeeping services.

2. Review of Resident #75's medical record revealed an admission date of 10/02/18 and diagnoses included CHF (congestive heart failure), a-fib (atrial fibrillation), and Parkinson's disease. Resident #75 passed away at the facility on 02/06/24.

Review of Resident #75's Individual Service Plan dated 12/20/23 revealed Resident #75 was incontinent, and was ambulatory. Resident #75 to remain free from falls. Staff to monitor Resident #75 during waking hours to help prevent falls as needed. Staff to keep walker or assistive device in sight to provide visual reminder to use. Resident #75 would be assisted with dressing to present a clean and neat appearance and promote independence. Staff would assist Resident #75 with dressing to maintain proper hygiene and a neat appearance. Resident #75's living space would be cared for and maintained to ensure a safe and clean living space. Staff would assist with housework as needed to maintain a safe living space for Resident #75. Staff would strip Resident #75's bed and wash linens to promote good health on Thursdays, evening shift. Resident #75 to take medications correctly, timely and per physician's orders. Staff to assist with Resident #75's medication administration needs routinely and as needed. Resident #75 would have his vitals monitored per physicians orders to maintain and monitor health. Staff would monitor and record Resident #75's vitals per physicians orders. Resident #75 to be dry, hygienic, and odor free. Staff to change Resident #75's brief and clean up.

Review of Resident #75's Observation notes dated 12/10/23 included Resident #75 tested positive for COVID-19 and was transported and admitted to the hospital.

Review of Resident #75's Daily Housekeeping Checklist dated 12/07/23 included Resident #75's room was cleaned, but Resident #75's towels were not washed and strip and make bed was not checked off it was completed. Further review of the Checklist from 12/07/23 through 12/15/23 did not reveal evidence Resident #75's room was cleaned or towels were washed and strip and make bed was completed.

Interview on 02/15/24 at 3:33 P.M. with Family Member (FM) #366 revealed Resident #75 was admitted to the hospital from 12/10/23 through 12/15/23 and upon his return to the facility on 12/15/23 Resident #75's room was found locked and had not been cleaned since he left the facility on 12/10/23. FM #366 stated his television was on, food was rotting in a styrofoam container, there were feces stains in the shower. FM #366 indicated she asked for cleaning supplies and Health Services Director (HSD) supplied them and FM #366 cleaned Resident #75's room herself.

Interview on 02/27/24 at 11:10 A.M. with Executive Director (ED) #357, Health Services Director (HSD) #300 and Regional Director of Nursing (RDN) #356 confirmed Resident #75 was admitted to the hospital on 12/10/23, a styrofoam container was left in his room and on 12/15/23 when Resident #75 returned from the hospital the food inside the styrofoam container was moldy. ED #357 confirmed Resident #75's room was not cleaned when he was at the hospital and his room definitely should have been cleaned.

Review of the facility Resident Agreement included under the category of Services Included in Your Monthly Fee it stated laundering of clothing, linens and towels and weekly housekeeping services.

Review of the facility policy titled Ohio Residential Care Facility Residents' Bill of Rights, Ohio Revised Code Sections 3721.10 through 3721.17 included Resident's Rights included the right to a safe and clean living environment pursuant to the medicare and medicaid programs and applicable state laws and rules adopted by the director of health.

This violation represents non-compliance investigated under Complaint Number OH00151303 and Complaint Number OH00149761.

Based on observation, record review, review of a local fire department report and hospital records, review of facility policy, review of the Ohio Board of Nursing Laws and Rules, review of the American Heart Association CPR Study Guide 2024, review of Rule 4723-4-04 of the Ohio Administrative Code and interview, the facility failed to provide cardiopulmonary resuscitation (CPR) for Resident #78, who had a Full Code advance directive status. This resulted in Real and Present Danger and actual harm/death on 12/15/23 at 11:19 P.M. when Resident #78 was found in his room by Licensed Practical Nurse (LPN) #323 and Resident Assistant (RA) #341 unresponsive, foaming at the mouth and not breathing, but with a faint pulse however, life-sustaining measures, including CPR were not initiated by LPN #323. The LPN did not initiate CPR, begin rescue breathing or recheck Resident #78's pulse while waiting for emergency medical personnel to arrive. EMS was contacted at 11:19 P.M. and upon their arrival at 11:25 P.M., EMS initiated CPR (at 11:26 P.M.), seven minutes after Resident #78 was found unresponsive by facility staff. Resident #78 was subsequently transported by EMS to the nearest local hospital Emergency Department, he remained in asystole (absence of heartbeat) during transportation and passed away en route to the hospital. This affected one resident (#78) and had the potential to affect 21 additional residents (#1, #9, #13, #17, #22, #23, #24, #27, #30, #31, #40, #47, #48, #49, #51, #55, #57, #60, #61, #65 and #66) who resided in the facility and had an advance directive for a full code status as the facility protocol directed staff not to provide CPR to residents. The facility census was 72.

On 02/28/24 at 12:14 P.M. Executive Director (ED) #357 and Health Services Director (HSD) #300 were notified Real and Present Danger began on 12/15/23 at 11:19 P.M. when Resident #78, was found in his room unresponsive, was not breathing, had an advance directive for a full code, and CPR was not initiated by LPN #323. CPR was not initiated until Emergency Medical Services (EMS) arrived at the facility, seven minutes after 911 was called and the operator was notified Resident #78 was found unresponsive and not breathing. Resident #78 passed away while being transported by EMS to the local hospital Emergency Department.

The Real and Present Danger was abated on 03/11/24 when the facility implemented the following corrective action:

On 03/04/24 the Business Office Manager (BOM) conducted a 100% audit of licensed staff CPR status. The audit revealed the facility had 12 licensed staff members, with six (6) being CPR-certified and the remaining six (6) not being CPR-certified. The facility initially implemented a plan for all licensed staff who were not CPR-certified to obtain certification on or before May 31, 2024. A licensed staff member who failed to obtain CPR certification by June 1, 2024, would be removed from the community schedule until they are certified.

On 03/06/24 the Vice President of Clinical Operations completed an incident report audit through the facility's electronic health record system. The audit covered the period from 01/01/23 through 03/06/24 and focused on residents identified as Full Code with search terms that included cardiac arrest

Based on interview, record review and review of facility statements the facility failed to ensure Resident #75's responsible party was fully informed in writing thirty days prior to an increase in fees reflected on her billing statement. This affected on resident (Resident #75) out of three reviewed for basic rate notifications. The facility census was 72.

Findings include:

Review of Resident #75's medical record revealed an admission date of 10/02/18 and diagnoses included CHF (congestive heart failure), a-fib (atrial fibrillation), and Parkinson's disease. Resident #75 passed away at the facility on 02/06/24.

Review of Resident #75's medical record from 03/31/23 through 10/01/23 did not reveal documentation the facility notified Resident #75's Responsible Party there was an error in his statements and he was not being charged the appropriate amount.

Review of Resident #75's facility Statement dated 11/1/23 included the prior statement balance from 10/01/23 was 3713.00 and an additional 900.00 was added for Assisted Living Level 3. The facility received a check on 10/05/23 for 3713.00 which did not include the additional 900.00 for Assisted Living Level 3. Further review on 11/01/23 revealed a Care Income Discount of 150.00. On 11/01/23 Resident #75's Statement reflected the 150.00 discount in the Assisted Living Level 3 charge of 1650.00 for 10/01/23 and 11/01/23 and had an Assisted Living Rent of 3863.00 documented for a total of 5513.00.

Review of Resident #75's Individual Service Plan dated 12/20/23 revealed Resident #75 was incontinent, and was ambulatory. Resident #75 to remain free from falls. Staff to monitor Resident #75 during waking hours to help prevent falls as needed. Staff to keep walker or assistive device in sight to provide visual reminder to use. Resident #75 would be assisted with dressing to present a clean and neat appearance and promote independence. Staff would assist Resident #75 with dressing to maintain proper hygiene and a neat appearance. Resident #75's living space would be cared for and maintained to ensure a safe and clean living space. Staff would assist with housework as needed to maintain a safe living space for Resident #75. Resident #75 to take medications correctly, timely and per physician's orders. Staff to assist with Resident #75's medication administration needs routinely and as needed. Resident #75 would have his vitals monitored per physicians orders to maintain and monitor health. Staff would monitor and record Resident #75's vitals per physicians orders. Resident #75 to be dry, hygienic, and odor free. Staff to change Resident #75's brief and clean up.

Interview on 02/21/24 at 3:38 P.M. of Family Member (FM) #367 revealed the facility added an increased charge on Resident #75's 11/01/23 Statement. FM #367 stated she paid the facility bill monthly by check and FM #366 gave the check to the facility. FM #367 stated the 11/01/23 Statement had 1800.00 dollars added to the Assisted Living Rent, and the family was told there was a billing error when they asked the facility about the increase. FM #367 stated she was told the facility found an error in Resident #75's payment amount, the error was corrected and added to the bill. FM #367 stated the family was not notified either verbally or in writing of the error or that the November 2023 Statement would reflect the error correction.

Interview on 02/28/24 at 3:20 P.M. of Executive Director (ED) #357 and Health Services Director (HSD) #300 revealed Resident #75's Individual Service Plan was updated on 03/31/23 to an Assisted Living Level 3 and was signed by Family Member (FM) #366 and the family was given a copy of the Individual Service Plan. ED #357 indicated Business Office Manager (BOM) #306 was not notified of the increased rent for Assisted Living Level 3 on 03/31/23 and Resident #75 was not charged the increase from 03/31/23 through 10/01/23. Ed #357 stated a facility audit was conducted in 09/2023 and the audit found Resident #75 was not being charged rent for Assisted Living Level 3. ED #357 stated the 10/2023 Statement reflected the increased rent that Resident #75 should have been paying for the Care Level upgrade. ED #357 and HSD #300 confirmed there was no communicating in writing or verbally to Resident #75's family informing them the October 2023 Statement would have the increased amount for a Care Level 3. Ed #357 indicated Resident #75's family disputed the bill and the family continued the Care Level 1 payments, but would not pay the increased amount until they had a meeting with facility staff in December 2023 and the dispute was resolved.

This violation represents non-compliance investigated under Complaint Number OH00151303 and Complaint Number OH00151029.

Based on interview, record review, review of fall investigation and review of the facility policy the facility failed to ensure Resident #75's medical record accurately reflected physician notification after a fall. This affected one resident (Resident #75) out of three reviewed for accurate documentation. The facility census was 72.

Findings include:

Review of Resident #75's medical record revealed an admission date of 10/02/18 and diagnoses included CHF (congestive heart failure), a-fib (atrial fibrillation), and Parkinson's disease. Resident #75 passed away at the facility on 02/06/24.

Review of Resident #75's Fall Risk Evaluation dated 10/01/23 revealed Resident #75 was a moderate fall risk.

Review of Resident #75's Fall Investigation dated 12/16/23 included Resident #75 was going to the bathroom, wearing socks and had a fall on 12/16/23 at 9:10 A.M. Licensed Practical Nurse (LPN) #314 was called to his room and found Resident lying on the floor outside his bathroom. Resident #75 had blood on his neck and a cut on the left side of the back of his head and 9-1-1 was called to transport Resident #75 to the local hospital Emergency Department. Resident #75's POA (Power of Attorney) was notified , Health Services Director (HSD) #300 was notified, and Medical Doctor (MD) #355 was notified on 12/16/23 at 9:04 A.M.

Interview on 02/26/24 at 9:13 A.M. of LPN #314 revealed she could not remember details about Resident #75's fall on 12/16/23. LPN #314 remembered Resident #75 received blood thinners and she might have completed the incident report after she talked to Medical Doctor (MD) #355, and completed the progress note before she talked to MD #355.

Interview on 02/26/24 at 3:21 P.M. with MD #355 revealed she was Resident #75's PCP (primary care provider) and she was not notified by the facility Resident #75 had a fall on 12/16/23 and was transported to the Emergency Department. MD #355 stated she just happened to see Resident #75 had a fall on 12/18/23 when it popped up in the hospital electronic information. MD #355 stated she was trying to schedule a transitional care visit from Resident #75's hospital stay 12/10/23 through 12/15/23 when the fall popped up on the computer screen. MD #355 stated her fellow (finished medical school and residency and has chosen to further study in a subspecialty in medicine) had no call documented either. MD #355 stated she had access to the facility electronic records and the electronic record stated the facility nurse notified MD #355 on 12/16/23 at 9:04 A.M. and that did not happen. MD #355 indicated the call center did not have a record of the call.

Interview on 02/27/24 at 2:26 P.M. with LPN #314 revealed she did not remember if she notified MD #355 on 12/16/23 of Resident #75's fall. LPN #314 stated if she wrote that MD #355 was notified she would have attempted a phone call, there would be an answering service and should be a record of the call.

Interview on 03/07/24 at 9:26 A.M. of Health Services Director (HSD) #300 and Executive Director (ED) #357 revealed when told Medical Doctor (MD) #355 was not notified of Resident #75's fall on 12/16/23, and it was documented she was notified on the fall investigation, HSD #300 stated they were not aware MD #355 was not notified. HSD #300 indicated there should be a note on the investigation if the nurse spoke to someone at the call center or left a message.

Review of the facility policy titled Fall Management and Post Fall Investigations dated 05/15/23 included the resident's responsible party and physicians were notified of falls.

This violation represents non-compliance investigated under Complaint Number OH00151029.