Health inspection·January 11, 2024

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, review of hospital records, staff interview and review of facility policy, the facility failed to ensure physician ordered labs were followed-up on and completed timely to identify a urinary tract infection (UTI) for Resident #110 who had a urinary catheter. Actual harm occurred on 12/07/23 when the facility failed to properly obtain a urine specimen for Resident #110 who was symptomatic of a urinary tract infection. Between 12/07/23 and 12/14/23 no additional testing or interventions to treat a urinary tract infection were provided. On 12/14/23 Resident #110's family transported the resident to the hospital where the resident was admitted and required intravenous (IV) antibiotics for treatment of a urinary tract infection. The resident was hospitalized for four days. This affected one resident (#110) of three residents reviewed for UTIs. The facility census was 105. Findings include: Review of Resident #110's closed medical record revealed an admission date of 10/31/23. Diagnoses included spina bifida with hydrocephalus, anxiety disorder, pseudobulbar affect, and a tongue abscess. Resident #110 had a history of frequent urinary tract infections. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 11/06/23, revealed Resident #110 had moderate cognitive impairment, required maximum assistance for activities of daily living (ADLs), and had an indwelling catheter and a colostomy. Additional review of the discharge MDS, dated [DATE], revealed family notified the facility Resident #110 would not return to the facility due to being admitted to the hospital for a UTI. Review of the care plan, dated 11/07/23, revealed Resident #110 had a suprapubic catheter related to a diagnosis of spina bifida and was at risk for developing UTIs and trauma related to the catheter. Interventions included staff to monitor for signs and symptoms of frequency and discomfort upon urination, pain and discomfort related to the catheter, and monitor/record/report to the physician any signs and symptoms of a UTI, which included pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or a change in eating patterns. Review of a physician's order, dated 12/07/23, revealed Resident #110 was to have a urinalysis with culture and sensitivity completed due to a family concern the resident may have a UTI. Review of Nurse Practitioner (NP) #202's progress note, dated 12/08/23 and timed 8:23 A.M., Page 1 of 15 365830 365830 01/11/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0690 revealed Resident #110 was seen for urinary frequency. Level of Harm - Actual harm Review of the Laboratory Results Report, dated 12/11/23 and timed 1:49 P.M., revealed Resident #110 had urine collected for a urinalysis on 12/07/23 at 5:00 A.M., the urine was received in the laboratory on 12/08/23 at 8:10 A.M. and resulted on 12/11/23 at 2:45 P.M. Further review of the results revealed probable contamination with greater than 100,000 colony forming units per milliliter (CFU/ml), which is the concentration of live, viable growth bacteria cells capable of reproducing when grown on a petri plate, and mixed pathology with greater than or equal to three organisms isolated. Residents Affected - Few Further review of Resident #110's medical record revealed no documentation of the facility acknowledgement of the urinalysis results or physician notification for follow-up on the contaminated urinalysis results. Review of a progress note from NP #202, dated 12/13/23 and signed on 12/14/23 at 7:38 A.M., revealed a diagnosis of urinary frequency. Additionally, it noted results of the urinalysis dated 12/11/23 suggested contamination and the specimen was to be redrawn. Review of the physician order summary, dated 12/13/23, revealed Resident #110 was to have a urinalysis with culture and sensitivity completed, to be collected on 12/14/23. Additional review of Resident #110's medical record revealed no evidence urine was collected on 12/14/23 to complete the urinalysis ordered. Review of an emergency department encounter, dated 12/14/23, revealed Resident #110 had an elevated white blood cell count of 15.5 cells per microliter (normal is four to 11 cells per microliter of blood) and an abnormal urinalysis with the urine having a cloudy appearance (normal is clear or light yellow in color), a trace of ketones (normal is none), a trace of blood (normal is none), protein 1 plus, (normal is none), nitrates were positive (normal is negative) and leukocytes were 3 plus (normal is negative). Resident #110 was admitted to the hospital due to a UTI and was treated with Rocephin (antibiotic) one gram (gm) intravenously daily. Review of the hospital Discharge summary, dated [DATE] and timed 4:49 P.M., revealed Resident #110 had a four-day length of stay and was treated for a UTI with hematuria (blood in urine) and hyponatremia (low sodium). Resident #110 responded well to treatment and discharged to a new facility. Interview on 01/10/24 at 11:30 A.M. of the Administrator revealed on 12/14/23, Resident #110's family transported the resident to an outside appointment. The family took Resident #110 to the hospital due to concerns of the resident having a UTI. Interview on 01/10/24 at 3:45 P.M. with the Director of Nursing (DON) verified the urinalysis ordered for collection on 12/14/23 had not been collected. The DON had no knowledge of why the urine was not collected other than Resident #110 was going out for a scheduled appointment the morning of 12/14/23 and it was not obtained due to getting Resident #110 ready for the appointment. Interview on 11/11/24 at 9:40 A.M. with Corporate Registered Nurse (CRN) #203 verified the medical record for Resident #110 was silent for the urinalysis resulted on 12/11/23 being received and reviewed by the facility and further verified the medical record was silent for physician notification and follow-up on the contaminated specimen. 365830 Page 2 of 15 365830 01/11/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0690 Level of Harm - Actual harm Interview on 01/11/23 at 8:45 A.M. with NP #202 confirmed the facility did not provide notification of the contamination results for the urinalysis collected on 12/07/23 and resulted on 12/11/23. Additionally, NP #202 verified she had discovered the contamination result when seeing Resident #110 on 12/13/23, at which time NP #202 ordered a repeat urinalysis. Residents Affected - Few Review of the facility policy titled Laboratory Testing Process, dated June 2018, revealed it is the responsibility of the facility nurse to process all laboratory orders for each resident in their care. Laboratory results will be reviewed, and appropriate actions taken including physician notification as appropriate. This deficiency represents non-compliance investigated under Complaint Number OH00149314. 365830 Page 3 of 15 365830 01/11/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure timely pharmacy response for medication refill requests. This affected one #40) of seven residents reviewed for medication administration. The facility census was 105. Finding include: Review of the medical record for Resident #40 revealed an admission date of 05/21/23. Diagnoses included diabetes mellitus type II, hypertension, hydronephrosis with renal and ureteral calculous obstruction and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/17/23, revealed Resident #40 had moderate cognitive impairment, was dependent on staff for activities of daily living (ADLs), had a metabolic diagnosis of diabetes mellitus and received insulin on a daily basis. Review of the care plan, revised 11/27/23, revealed Resident #40 had diabetes mellitus. Interventions included for diabetes medication to be provided as ordered, monitor and document side effects and effectiveness of the medications, fasting blood sugar as ordered, and monitor for signs and symptoms of hypoglycemia or hyperglycemia and report to the physician as needed. Review of the current physician orders for Resident #40 revealed an order for Trulicity (medication used to help lower blood sugar) Subcutaneous Solution Pen-Injector three milligrams (mg) per 0.5 milliliter (ml) with 0.5 ml to be administered subcutaneously once weekly on Tuesday at 8:30 A.M. Observation of medication administration on 01/09/24 (Tuesday) at 8:57 A.M. by Registered Nurse (RN) #200 revealed the Trulicity Pen- Injector was unavailable for Resident #40's weekly administration. Concurrent interview with RN #200 at the time of the observation verified the Trulicity Pen-Injector had not been found in either the medication cart or in the refrigerator and would not be able to be administered at the scheduled time. Review of the Medication Administration Record (MAR) for January 2024 revealed Resident #40 had not received the weekly dose of Trulicity on 01/02/24 or 01/09/24 at 8:30 A.M. as ordered. A follow-up interview on 01/09/24 at 11:51 A.M. with RN #200 confirmed Resident #40 did not receive the scheduled dose of Trulicity at 8:30 A.M. on Tuesday, 01/09/24 and further verified the dose scheduled for Tuesday, 01/02/24 at 8:30 A.M. had also not been administered. RN #200 stated a request to refill the Trulicity Pen-Injector had been made to the pharmacy on 12/26/23. Interview on 01/09/24 at 12:00 P.M. with RN #201 revealed nursing had contacted the pharmacy in regard to the Trulicity for Resident #40 and was told there was an error on the pharmacy processing side as to why the Trulicity refill had not been sent to the facility as requested. RN #201 also verified Resident #40 last received the weekly ordered Trulicity on 12/26/23. Review of the facility policy titled Pharmacy Services Provider Agreement, dated 02/21/22, revealed the pharmacy is responsible to provide products in a prompt manner and to provide drug information to the facility regarding products ordered for residents by members of the facility. 365830 Page 4 of 15 365830 01/11/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0755 This deficiency represents non-compliance investigated under Complaint Numbers OH00149303 and OH00149314. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365830 Page 5 of 15 365830 01/11/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview, and review of the pharmacy services provider agreement, the facility failed to ensure medication prescribed to assist with lowering blood sugar was available and administered as ordered. This affected one (#40) of seven residents reviewed for medication administration. The facility census was 105. Residents Affected - Few Findings include: Review of the medical record for Resident #40 revealed an admission date of 05/21/23. Diagnoses included diabetes mellitus type II, hypertension, hydronephrosis with renal and ureteral calculous obstruction and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/17/23, revealed Resident #40 had moderate cognitive impairment, was dependent on staff for activities of daily living (ADLs), had a metabolic diagnosis of diabetes mellitus and received insulin on a daily basis. Review of the care plan, revised 11/27/23, revealed Resident #40 had diabetes mellitus. Interventions included for diabetes medication to be provided as ordered, monitor and document side effects and effectiveness of the medications, fasting blood sugar as ordered, and monitor for signs and symptoms of hypoglycemia or hyperglycemia and report to the physician as needed. Review of the current physician orders for Resident #40 revealed an order for Trulicity (medication used to help lower blood sugar) Subcutaneous Solution Pen-Injector three milligrams (mg) per 0.5 milliliter (ml) with 0.5 ml to be administered subcutaneously once weekly on Tuesday at 8:30 A.M. Observation of medication administration on 01/09/24 (Tuesday) at 8:57 A.M. by Registered Nurse (RN) #200 revealed the Trulicity Pen- Injector was unavailable for Resident #40's weekly administration. Concurrent interview with RN #200 at the time of the observation verified the Trulicity Pen-Injector had not been found in either the medication cart or in the refrigerator and would not be able to be administered at the scheduled time. Review of the Medication Administration Record (MAR) for January 2024 revealed Resident #40 had not received the weekly dose of Trulicity on 01/02/24 or 01/09/24 at 8:30 A.M. as ordered. A follow-up interview on 01/09/24 at 11:51 A.M. with RN #200 confirmed Resident #40 did not receive the scheduled dose of Trulicity at 8:30 A.M. on Tuesday, 01/09/24 and further verified the dose scheduled for Tuesday, 01/02/24 at 8:30 A.M. had also not been administered. RN #200 stated a request to refill the Trulicity Pen-Injector had been made to the pharmacy on 12/26/23. Interview on 01/09/24 at 12:00 P.M. with RN #201 revealed nursing had contacted the pharmacy in regard to the Trulicity for Resident #40 and was told there was an error on the pharmacy processing side as to why the Trulicity refill had not been sent to the facility as requested. RN #201 also verified Resident #40 last received the weekly ordered Trulicity on 12/26/23. Review of the pharmacy services provider agreement, dated 02/21/22, revealed the pharmacy would provide products in a prompt and timely manner. This deficiency represents non-compliance investigated under Complaint Numbers OH00149303 and 365830 Page 6 of 15 365830 01/11/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0760 OH00149314. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365830 Page 7 of 15 365830 01/11/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure medications were kept secure at all times. This affected one (#97) of one residents reviewed for medication storage. The facility census was 105. Findings include: Review of the medical record for Resident #97 revealed an admission date of 11/12/23. Diagnoses included chronic osteomyelitis, diabetes mellitus, type II, chronic obstructive pulmonary disease, hypertension, heart failure and depression. Review of the Minimum Data Set (MDS) assessment, dated 11/16/23, revealed Resident #97 was cognitively intact. Review of the current physician orders revealed Resident #97 had the following medications ordered for morning administration: • Ascorbic Acid 500 milligrams (mg), one tablet • Cholecalciferol 5000 units, one tablet • Daily-Vite multivitamin, 400 micrograms (mcg), one tablet • Lasix 20 mg, one tablet • Metoprolol Succinate extended release 25 mg, one tablet • Sertraline 50 mg, two tablets and Sertraline 180 mg, one tablet • Tamsulosin hydrochloride 0.4 mg, one tablet • 365830 Page 8 of 15 365830 01/11/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0761 Baclofen 5 mg, one tablet Level of Harm - Minimal harm or potential for actual harm • Eliquis 5 mg, one tablet Residents Affected - Few • Lyrica 75 mg, one tablet • Sennosides-docusate sodium 8.6 mg - 50 mg, one tablet Observation on 01/09/24 at 10:15 A.M. of Resident #97's room revealed a medication cup with several pills sitting on the left corner of the over bed table, next to a half full glass of clear fluid. The over bed table was in front of Resident #97, who was lying in bed with his eyes closed. Concurrent interview with Resident #97 revealed the nurse had brought in his morning medications and, because he was not ready to take them, the nurse left them. Review of the Medication Administration Record (MAR) on 01/09/23 at 11:00 A.M. revealed the morning medications had been signed off as administered. Additional observation on 01/09/24 at 12:10 P.M. of Resident #97's room revealed the cup containing several pills remained on the over bed table in front of the resident. Interview on 01/09/24 at 12:35 P.M. with Registered Nurse (RN) #201 verified the cup of medication sitting on the over bed table in front of Resident #97. Additionally, RN #201 confirmed medications should not be left at the bedside and nurses were to observe residents taking all medications provided. Review of a progress note, dated 01/09/24 and timed 1:41 P.M. by RN #201, revealed Resident #97 was educated by RN #201 regarding the importance of taking medications at their scheduled times and medications were not to be left bedside for any reason. RN #201 also provided education to RN #200 that medications were not to be left at bedside and residents had to be observed taking the medications provided. Review of the facility policy titled General Standards for Medication Administration, revised October 2022 stated medications must be kept secure at all times and nurses must give medications directly to each resident and may not leave them at bedside and nurses are responsible for ensuring residents take medications and do not keep or dispose of prescribed medications. This deficiency represents non-compliance investigated under Complaint Numbers OH00149303 and OH00149314. 365830 Page 9 of 15 365830 01/11/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of facility policy the facility failed to ensure physician ordered laboratory services were completed in a timely manner. This affected one (#18) of three residents reviewed for laboratory services. The facility census was 105. Residents Affected - Few Findings include: Review of the medical record for Resident #18 revealed an admission date of 10/06/23. Diagnoses included a displaced bimalleolar fracture of right lower leg, hypertension, osteoarthritis, heart failure, retention of urine, morbid obesity, spinal stenosis, cor pulmonale, dilated cardiomyopathy, and lymphedema. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 10/13/23, revealed Resident #18 was cognitively intact and was dependent for activities of daily living (ADLs). Review of the care plan dated, 10/15/23, revealed Resident #18 was on diuretic therapy related to hypertension and heart failure. Interventions included to administered medications as ordered and report pertinent laboratory results to the physician, especially hematocrit, sodium, and potassium. Review of a nursing progress note, dated 01/04/24 and timed 11:52 P.M., revealed abnormal laboratory results for Resident #18 were called to the physician. The abnormal critical result was a potassium of 2.8 millimoles per liter, (mEq/L) (normal is between 3.5 and 5.3 millimoles per liter). The note indicated the physician ordered three doses of potassium chloride 20 milliequivalent's (mEq) to be administered with the first dose to be given tonight, the second dose the morning of 01/05/24 and the third dose to be administered the afternoon of 01/05/24 and a repeat potassium level to drawn after the administrations. Review of a laboratory results report, dated 01/04/24 and timed 1:53 P.M., confirmed Resident #18 had labs completed on 01/04/24, with a low potassium result of 2.8 mEq/L. Review of physician orders revealed an order dated 01/04/24 for one dose of Potassium Chloride Extended Release 20 mEq to be administered by mouth now for a low potassium and an order dated 01/05/24 for Potassium Chloride Extended Release 20 mEq by mouth two times a day for two doses. Review of the medication administration record (MAR) for January 2024 confirmed Potassium Chloride Extended Release 20 mEq tablet was administered as ordered on 01/04/24 and 01/05/24. Review of the medical record on 01/09/24 remained silent for a repeat potassium for Resident #18 after the three doses of Potassium Chloride had been administered on 01/04/24 and 01/05/24. Review of the laboratory testing book on 01/09/24 at 3:00 P.M. revealed no laboratory requisition for laboratory testing had been printed and no laboratory testing had been completed for Resident #18 from 01/05/24 through 01/09/24. Review of Nurse Practitioner (NP) #202's progress note, dated 01/09/24, revealed Resident #18's potassium was critically low on 01/05/24 and new laboratory testing was to be completed on 01/08/24, but this did not happen. Will obtain potassium level today. 365830 Page 10 of 15 365830 01/11/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Additional review of physician orders revealed an order dated 01/09/24 for a potassium to be drawn stat (immediately). Review of the laboratory testing results for 01/09/24 revealed a stat potassium had not been drawn. Review of a progress note dated 01/09/24 at 9:45 P.M., and created by the Director of Nursing (DON) revealed the stat potassium was unable to be performed and was scheduled to be completed first thing in the morning. The resident, family and doctor were notified. Interview on 01/11/24 at 8:45 A.M. with NP #202 verified a repeat laboratory test for potassium had not been completed on Resident #18 after the three doses of Potassium Chloride had been administered on 01/04/24 and 01/05/24 and a stat order had been entered by NP #202 on 01/09/24. NP #202 verified the 01/09/24 stat potassium lab draw had not been completed on 01/09/24. Review of the laboratory testing results dated 01/10/24 revealed Resident #18 had blood collected for a potassium level at 6:04 A.M Further review revealed Resident #18's potassium level was 2.5 mEq/L and was reported to the facility on [DATE] at 5:21 P.M. Further review of a physician order dated 01/10/24 revealed an order to recheck Resident #18's potassium level on 01/15/23 and an order for 20 mEq of oral potassium to be administered by mouth three times a day. Review of the facility policy titled Laboratory Testing Process, dated June 2018, revealed it is the responsibility of the facility nurse to process all laboratory orders for each resident in their care. When an order is received from the physician, the order is to be placed in the lab portal, a requisition printed off and placed in the laboratory book under the corresponding date for which the laboratory test is to be drawn, laboratory results will be reviewed, and appropriate actions taken to include physician notification of laboratory results with any new orders processed at that time. This was an incidental finding discovered during the investigation of Master Complaint Number OH00149642 and Complaint Numbers OH00149528, OH00149483, OH00149464, OH00149314, and OH00149303. 365830 Page 11 of 15 365830 01/11/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, staff interview and review of facility policy, the facility failed to ensure timely physician notification of laboratory (lab) results. This affected one (#110) of three residents reviewed for physician notification. The facility census was 105. Findings include: Review of the medical record for Resident #110 revealed an admission date of 10/31/23. Diagnoses included spina bifida with hydrocephalus, anxiety disorder, pseudobulbar affect, and a tongue abscess. Resident #110 had a history of frequent urinary tract infections. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 had moderate cognitive impairment and had an indwelling catheter and a colostomy. Review of the care plan for Resident #110, dated 11/06/23, revealed Resident #110' had a suprapubic catheter related to a diagnosis of spina bifida and was at risk for developing urinary tract infections and trauma related to the catheter. Interventions included staff to monitor for signs and symptoms of frequency and discomfort upon urination, pain and discomfort related to the catheter and to monitor/record/report to the physician any signs and symptoms of a urinary tract infection, which included pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or a change in eating patterns. Review of a physician order dated 12/07/23 revealed a urinalysis with culture and sensitivity to be completed once for Resident #110. Review of Nurse Practitioner (NP) #202's progress note dated 12/08/23 revealed Resident #110 was seen for urinary frequency. Review of a Laboratory Results Report, dated 12/11/23, revealed Resident #110 had urine collected for a urinalysis on 12/07/23 at 5:00 A.M. and resulted on 12/11/23 at 2:45 P.M. Further review of the laboratory results revealed probable contamination with greater than 100,000 colony forming units per milliliter (CFU/ml), which is the concentration of live, viable growth bacteria cells capable of reproducing when grown on a petri plate, and mixes pathology with greater than or equal to three organisms isolated. Review of the medical record from 12/11/23 through 12/13/23 revealed no evidence of physician notification of the urinalysis results. Review of an additional NP #202' progress note, dated 12/13/23 and signed on 12/14/23 at 7:38 A.M., revealed a diagnosis of urinary frequency and noted results of the urinalysis resulted on 12/11/23 suggested contamination and the specimen was to be redrawn. Interview on 01/11/24 at 9:40 A.M. with Corporate Registered Nurse (CRN) #203 verified the medical record for Resident #110 was silent for physician notification of the urinalysis results on 12/11/23. 365830 Page 12 of 15 365830 01/11/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 01/11/23 at 8:45 A.M. with NP #202 verified she was not notified of the lab findings, resulted on 12/11/23. NP #202 stated she discovered the the lab results during a visit with Resident #110 on 12/13/23. Review of the facility policy titled Laboratory Testing Process, dated June 2018 revealed it was the responsibility of the facility nurse to process all laboratory orders for each resident in their care. Laboratory results will be reviewed, and appropriate actions taken including physician notification as appropriate. This deficiency was an incidental finding discovered during the investigation of Master Complaint Number OH00149642, OH00149528, OH00149483, OH00149464, OH00149314 and OH00149303. 365830 Page 13 of 15 365830 01/11/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview and review of facility policy, the facility failed to maintain proper infection control practices during wound care. This affected three (#9, #40 and #85) of three residents reviewed for wound care. The facility census was 105. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 04/26/22. Diagnoses included peripheral vascular disease, type II diabetes mellitus, chronic kidney disease, and hypothyroidism. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/20/23, revealed Resident #9 was cognitively intact. Review of the care plan for Resident #9, revised on 10/06/23, revealed a potential for skin impairment related to fragile skin. Interventions included to follow facility protocols for treatment of injury, monitor and document location, size, and treatment for skin injury. Review of Resident #9's current physician orders revealed an order written on 12/29/23 for a skin tear to the left elbow to be cleansed with wound cleaner, have xeroform applied, cover with an abdominal pad, and wrap with rolled gauze daily and as needed. Observation of wound care on 01/09/24 at 2:30 P.M. with Licensed Practical Nurse (LPN) #204 revealed LPN #204 completed hand hygiene, donned gloves, assisted Resident #9 with pulling up the left shirt sleeve, removed the dressing to the left elbow, opened two packages of 4 by 4 gauze pads, sprayed one of the 4 by 4 gauze pads with wound cleanser, cleansed the left elbow wound and used the second 4 by 4 gauze pad to dry the wound. LPN #204 then opened the xeroform, the abdominal gauze pad and the rolled gauze. LPN #204 layered the xeroform dressing onto the abdominal pad. LPN #204 placed the layered dressings onto Resident #9's left elbow, grabbed the rolled gauze and wrapped the left elbow and taped the rolled gauze. LPN #204 removed her gloves and assisted Resident #9 with lowering the left shirt sleeve over the dressing on the left elbow. 2. Review of the medical record for Resident #40 revealed an admission date of 05/21/23. Diagnoses included type II diabetes mellitus, hypertension, spinal stenosis, and anxiety disorder. Review of the quarterly MDS assessment, dated 11/17/23, revealed Resident #40 had moderate cognitive impairment and had wounds to the coccyx. Review of Resident #40's current physician orders revealed an order dated 12/27/23 for the coccyx wound to be cleansed with normal saline, apply collagen, and cover with a dry dressing every other day and as needed. Observation of wound care on 01/10/24 at 8:32 A.M. with LPN #204 revealed LPN #204 completed hand hygiene after removing the soiled dressing from Resident #40's coccyx. LPN #204 donned gloves, opened three 4 by 4 gauze pad packages, sprayed one 4 by 4 gauze pad with normal saline and washed around the wound. Using the second 4 by 4 gauze pad, LPN #204 sprayed the coccyx wound with normal saline and cleansed the wound. LPN #204 patted the wound dry using the third 4 by 4 gauze pad. LPN #204 picked up the collagen and the dry dressing and applied the dressings to the coccyx wound. LPN #204 365830 Page 14 of 15 365830 01/11/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0880 removed the gloves worn throughout the dressing change and assisted Resident #40 with repositioning. Level of Harm - Minimal harm or potential for actual harm 3. Review of the medical record for Resident #85 revealed an admission date of 02/14/23. Diagnoses included type II diabetes mellitus, kidney disease, anxiety disorder, depression, dementia, and morbid obesity. Residents Affected - Few Review of the quarterly MDS assessment, dated 11/28/23, revealed Resident #85 was cognitively impaired and had an unhealed pressure ulcer to the sacrum. Review of the care plan for Resident #85, revised on 12/07/23, revealed Resident #85 had actual and was at risk for impaired skin integrity related to decreased mobility and incontinence. Interventions included for medications and treatments to be provided as ordered, low air loss mattress and for the facility policies and protocols to be followed for skin breakdown. Review of Resident #85's current physician orders revealed an order written on 12/28/23 for the sacrum to be cleansed with normal saline, patted dry and packed with hydrofera blue moistened with sterile water and covered with a dry clean dressing every three days and as needed. Observation on 01/10/24 at 8:52 A.M. of wound care with LPN #204 revealed LPN #204 performed hand hygiene, donned gloves, and rolled Resident #85 onto the left side. Resident #85 was soiled with stool. LPN #204 provided incontinence care and removed the soiled sacral wound dressing. LPN #204 removed her gloves, completed hand hygiene, applied another pair of gloves, opened several packages of 4 by 4 gauze pads, applied normal saline to the gauze pads and to the wound and proceeded to cleanse the sacral wound. LPN #204 disposed of the used gauze pads and opened two packages of hydrofera blue and one large dry clean dressing. LPN #204 placed the hydrofera blue into the sacral wound and covered the wound with the large border foam dressing. LPN #204 removed her gloves and assisted Resident #85 with repositioning. Interview on 01/10/24 with LPN #204, following the observation of dressing changes for Residents #40 and #85, verified she did not perform hand hygiene or change her gloves between cleansing the wounds and applying clean dressings during wound care for Resident #9 on 01/09/24 or on 01/10/24 during wound care for Residents #40 and #85. LPN #204 stated she does not perform hand hygiene or change gloves between the step of cleaning a wound and applying the new clean dressing (moving from dirty to clean). Interview on 01/10/24 at 4:00 P.M. with the Corporate Registered Nurse #203 verified infection control practices were not followed by LPN #204 when hand hygiene was not completed between cleaning a wound and applying a new, clean dressing. Review of the facility policy titled Wound Management, dated November 2021, revealed the maintenance of a physiological local wound includes preventing and managing infection, cleansing the wound with general infection control practices maintained during wound care and dressing changes. This deficiency represents non-compliance investigated under Complaint Numbers OH00149464, OH00149314 and OH00149303. 365830 Page 15 of 15