Health inspection·February 23, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to cover residents' catheter bags to promote privacy and dignity. This affected four (Residents #192, #33, #34, and #39) of four residents reviewed for dignity. The facility's census was 42. Findings include: 1. Review of the medical record revealed Resident #192 admitted to the facility on [DATE] and had diagnoses of type II diabetes, non-pressure chronic ulcer, unspecified major depressive disorder, and peripheral vascular disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident # 192 was a two-person assist, was independent with eating, and required extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. Review of the care plan dated 02/13/23 revealed Resident #192 had the potential for complications related to the use of a Foley catheter. Interventions included change catheter as needed, change Foley collection bag as per policy, position catheter bag and tubing below the level of the bladder, ensure tubing is not under the resident's legs, obtain output every shift, encourage fluids, observe/report signs of infection, report abnormal labs, and provide Foley catheter care per policy. Observation on 02/21/23 at 11:20 A.M. revealed Resident #192 had a urine collection bag in a clear trash liner attached to the right side of the bed and visible from the hallway. Interview on 02/21/23 at 11:52 A.M. Licensed Practical Nurse (LPN) #308 verified Resident #192's catheter bag was hanging from bed in a clear trash liner and should have been in a dignity bag (a bag used to cover the catheter bag showing any urine drainage). LPN #308 stated the aides had asked about dignity bags that morning and she had told them if they could not locate them in the storage room, they should use pillowcases to cover the urine collection bags. 2. Medical record review revealed Resident #33 admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, retention of urine, mononeuropathy, benign prostatic hyperplasia without lower urinary tract symptoms, heart failure, and diabetes mellitus. Review of Resident #33's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing, Page 1 of 5 366043 366043 02/23/2023 Carlisle Manor Health Care Inc 730 Hillcrest Drive Carlisle, OH 45005

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some toileting, and personal hygiene. Resident #33 required total dependence with transfers and set up with eating. The resident utilized a Foley catheter for bladder, and was incontinent of bowel, wore briefs, and required peri care every two hours and as needed. Observation on 02/21/23 at 12:13 P.M. of Resident #33 revealed a Foley catheter bag hanging on the bed frame covered with a clear trash liner instead of a privacy (dignity) bag. Interview at the time of the observation with LPN #301, verified the catheter bag was covered with a clear trash liner instead of a dignity bag. 3. Medical record review revealed Resident #34 admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, cerebral infarction, hyperlipoidemia, and obstructive and reflux uropathy. Review of Resident #34's entry Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively intact and required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Resident #34 required total dependence with transfers and set up with eating. The resident utilized a Foley catheter for bladder and a colostomy for bowel. Observation on 02/21/23 at 12:15 P.M. of Resident #34 revealed a Foley catheter bag hanging on the bed frame covered with a clear trash liner instead of a dignity bag. Interview at the time of the observation with LPN #301, verified the catheter bag was covered with a clear trash liner instead of a dignity bag. 4. Medical record review revealed Resident #34 admitted to the facility on [DATE] with essential hypertension, urinary tract infection, hematuria, other retention of urine, hyperlipidemia, and tachycardia. Review of Resident #39's entry Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively intact and required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Resident #39 required total dependence with transfers and set up with eating. The resident utilized a Foley catheter for bladder, was incontinent of bowel and required peri care every two hours and as needed. Observation on 02/21/23 at 12:35 P.M. of Resident #39 revealed a Foley catheter bag hanging on the bed frame covered with a clear trash liner instead of a dignity bag. Interview at the time of the observation with LPN #301, verified the catheter bag was covered with a clear trash liner instead of a dignity bag. Interview on 02/22/23 at 09:30 A.M. with the Director of Nursing (DON) verified Foley catheter bags were to be covered with privacy (dignity) bags per policy. Review of policy titled, Catheter Care, dated 08/22/22 revealed privacy (dignity) bags will be available, and catheter drainage bags will be covered at all times while in use. 366043 Page 2 of 5 366043 02/23/2023 Carlisle Manor Health Care Inc 730 Hillcrest Drive Carlisle, OH 45005

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record, staff interview and policy review, the facility failed to provide adequate care and treatment to a resident's pressure ulcers. This affected one (#242) out of two residents reviewed for wound care. The facility census was 42. Residents Affected - Few Findings include: Review of the Resident #242's chart revealed Resident #242 was admitted to the facility on [DATE] with diagnoses including non st elevation myocardial infarction, sepsis, paroxysmal atrial fibrillation, depression, multiple sclerosis, hyperlipidemia, anxiety disorder, obstructive sleep apnea, personal history of urinary tract infections, hypertension, congestive heart failure and type two diabetes mellitus. Resident #242 discharged from the facility 12/26/22. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #242's cognition was not assessed. The resident required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Resident #242 required total dependence with transfers and Resident #242 was independent with eating. Resident #242 had a stage four pressure ulcer present upon admission. Review of the wound care note dated 12/13/22, completed by a different facility prior to Resident #242's admission to the current facility, revealed the resident had a stage four pressure ulcer to his sacrum measuring 8.52 centimeters (cm) in length by (x) 11.51 cm in width x 5.0 cm in depth. Additional review revealed the resident had a stage one pressure ulcer to the left heel measuring 4.61 cm in length x 4.76 cm in width, and a suspected deep tissue injury to the right heel measuring 2.45 cm in length x 3.55 cm in width. Resident #242 was ordered to have his right and left heels cleaned with wound cleanser and have skin barrier wipes applied with a foam bordered dressing. Review of the progress note dated 12/22/22, revealed Resident #242 arrived at the current facility at approximately 9:00 P.M. The Director of Nursing (DON), family, and physician were made aware of Resident #242's arrival. Review of the Braden score assessment dated [DATE] revealed Resident #242 was at low risk for developing pressure ulcers. Review of the admission assessment and baseline care plan dated 12/23/22, revealed Resident #242 had a pressure area to the left heel measuring 2.0 cm in length x 1.5 cm in wide x 0.01 cm in depth, a pressure area to the right heel measuring 4.5 cm in length x 4.0 cm in width x 0.01 cm in depth, and an unstageable pressure ulcer to the sacrum that was 11.5 cm in length x 9.0 cm in width x 0.5 cm in depth. Review of the wound progress note dated 12/26/22, revealed Resident #242 had a deep tissue injury to his left heel that was 3.0 cm x 2.0 cm, an unstageable deep tissue injury to the right heel measuring 4.5 cm x 4.0 cm, with a small amount of blood pooled and was palpable under the skin. Additionally, the resident had a stage four sacrum wound measuring 9.0 cm x 14 cm x 4.0 cm. The physician was in to see the resident. Review of the progress notes dated 12/26/22, revealed Resident #242's wife was at the facility requesting Resident #242 be sent out to the hospital for evaluation. The resident was sent to the 366043 Page 3 of 5 366043 02/23/2023 Carlisle Manor Health Care Inc 730 Hillcrest Drive Carlisle, OH 45005

F 0686 hospital per request. Level of Harm - Minimal harm or potential for actual harm Review of Resident #242's physician progress note dated 12/26/22, revealed Resident #242 was seen by the physician and the resident wanted to go home with home health. Resident #242 had a rectal tube and Foley catheter. Resident #242 had a stage three to the sacrum. Residents Affected - Few Review of Resident #242's physician orders from 12/22/22 to 12/26/22 revealed Resident #242 did not have any wound treatment orders in place for the pressure ulcers on his right and left heels. Interview on 02/24/23 at 3:38 P.M. with Wound Care Licensed Practical Nurse (WC LPN) #366 verified Resident #242 did not have any treatment orders in place for his pressure areas on his right and left heel and stated skin prep could have been continued from his prior facility. WC LPN #366 reported Resident #242's pressure ulcers on his heels were not opened on 12/26/22 and she felt that the nurse that did Resident #242's admission assessment incorrectly recorded depth on Resident #242's pressure areas to his heels. WC LPN #366 also stated she notified Physician #900 of Resident #242's pressure ulcers on his right and left heel on 12/26/22 but was not sure if the physician was notified of the areas to Resident #242's heels prior to 12/26/22. WC LPN #366 stated she was not sure if Resident #242 had heel boots on when she assessed him on 12/26/22. Review of the undated negative pressure wound therapy policy revealed the facility will provide evidenced based treatments in accordance with current standards of practice and physician orders. Review of the facility's wound care policy dated November 2018 revealed the facility will provide therapeutic treatment to heal wounds. Treatments implemented by a nurse require a physician order. This deficiency represents non-compliance investigated under Complaint Number OH00138942. 366043 Page 4 of 5 366043 02/23/2023 Carlisle Manor Health Care Inc 730 Hillcrest Drive Carlisle, OH 45005

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, staff interview, and policy review, the facility failed to ensure medications were disposed of safely. This had the potential to affect four (Residents #11, #30, #34, and #36) who the facility identified as independently mobile and cognitively impaired. The facility census was 42. Findings include: Observation on 02/22/23 at 8:08 A.M. revealed Registered Nurse (RN) #312 threw away medications in the trash can on the 200-Hall medication cart. Medications thrown away included isosorbide 60 mg, amlodipine 5 mg, metoprolol 100 mg, metoprolol 50 mg, losartan 50 mg, and dicyclomine 20 mg. Interview on 02/22/23 at 8:09 A.M. RN #312 verified she had thrown the medications in the trash can and stated she always threw medications away in the trash can and emptied the trash when she was finished with her medication pass because they were no longer allowed to throw medications away in the sharp's container. Review of policy titled, Storage of Controlled Medications, dated 06/2017 revealed nurses were responsible for the storage and safe handling of medications. 366043 Page 5 of 5