Every finding on record at Admirals Pointe Nursing & Rehabilitation

Based on record review, resident and staff interview and observations, the facility failed to ensure Resident #61 was assisted with the specific activity of daily living (ADL) of brushing her teeth. This had the potential to affect 18 residents on the memory care unit who required assistance with ADL. The facility census was 79. Findings include: Review of Resident #61's medical record revealed an admitted [DATE]. Diagnoses included dementia, dysphagia following cerebral infarction, and morbid obesity. Review of the annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed she had moderate cognitive impairment. Her functional ability for oral hygiene revealed she required set up or clean up assistance for personal hygiene. The oral/dental status section revealed she did not have dentures. She had her own natural teeth that were not broken, loose, or likely to have a cavity. There was no abnormal mouth tissue. She did not have inflamed or bleeding gums. She did not have pain, discomfort or difficulty chewing. Her mouth was able to be examined. Review of the care plan dated 04/14/24 revealed Resident #61 has her own teeth with probable decay. Interventions included completing an oral assessment per schedule and refer to the dentist as needed, provide oral care at least every day and more frequently as needed, and provide the resident with all necessary items to perform adequate oral care (i.e. toothbrush, toothettes, toothpaste and mouthwash). The care plan also stated Resident #61 may require assistance with ADLs and may be at risk for developing complications associated with decreased ADL self-performance. Fairly high functioning in controlled setting; level of functioning fluctuates at times. Interventions for oral care was supervision and report any changes in ADL self-performance. Review of the dental appointment list for Resident #61 revealed she had an appointments on 05/01/23 and 01/22/24. The Summary Report dated 05/01/23 revealed Resident #61 had heavy calculus and moderate plaque and flossing was completed. Recommended her to use a proxabrush (a gentle in and out motion to remove plaque and food particles between teeth in hard-to-reach areas thats are missed by brushing alone). The dental documentation from the visit on 01/22/24 revealed oral hygiene instructions were given on brushing any dentition, her tongue and tissues along with rinsing and/or swabbing her mouth out daily to decrease bacteria. There was heavy calculus and heavy plaque. Flossing was unable to be completed. The recommendation was for staff to assist for daily hygiene. Review of the oral care STNA task look back for Resident #61's dated 04/01/24 through 06/25/24 revealed the task was staff provided eight times and 133 times the document stated the resident performed the task. Interview on 06/26/24 at 4:03 P.M. with Resident #61 revealed she brushes her teeth when she thinks about it. It was not always twice or even once a day. Observations on 06/24/24 at 11:15 A.M. and 4:00 P.M., on 06/25/24 at 9:00 A.M. and 2:30 P.M., on 06/26/24 at 8:54 A.M. and at 4:05 P.M. revealed Resident #61's teeth, when she smiled revealed, her teeth were heavy with food debris and plaque. Interview on 06/26/24 at 4:18 P.M. with State tested Nursing Assistant (STNA) #188 stated she was Resident #61's STNA on 06/25/24, 06/26/24 and 06/27/24, day shift. STNA #188 stated Resident #61 was independent for morning care including brushing her teeth and she brushes her own teeth. The STNA did not brush Resident #61's teeth. Observation on 06/27/24 at 1:39 P.M. revealed Resident #61 did not have a proxabrush in her bathroom. She had a regular toothbrush, a bag of toothettes, a tube of toothpaste and mouth wash.

Based on review of the lunch meal menu, resident and staff interview, and observation, the facility failed to ensure appropriate meals were served at an appetizing temperature. This had the potential to affect all residents in the facility except Resident #31 who the facility identified as receiving no food from the kitchen. The facility census was 83. Findings include: Interview on 12/13/21 with Resident #34, #39, and #67 revealed the meals from the kitchen are cold. Review of the lunch menu for 10/27/21 revealed the main entrée hot foods included ham, au gratin potatoes, and carrots that were substituted for a mixed vegetable. Observation on 12/14/21 at 2:01 P.M. of the test tray revealed meal tempting of the hot foods. The ham tempted at 98 degrees Fahrenheit. The potatoes tempted at 110 degrees Fahrenheit. The cooked mixed vegetables tempted at 104 degrees Fahrenheit. The ham was barely warm to the touch. Interview on 12/14/21 at 2:02 P.M. with the Director of Nursing (DON) verified the meal was not tempting to a preferred temperature. Observation on 12/14/21 at 2:04 P.M. of the lunch meal revealed the ham and vegetables were not at a palatable temperature and the potatoes were minimally acceptable. Interview on 12/14/21 at 2:15 P.M. with Resident #34 verified the lunch meal was not a palatable temperature.

Based on medical record review, staff interview, and facility policy the facility failed to properly monitor and record blood glucose levels and failed to notify the physician of blood glucose levels and use of emergency medication. This affected one (Resident #67) of seven residents reviewed for unnecessary medication. The facility census was 83. Findings include: Review of the medical record for Resident #67 revealed an initial admitted [DATE] and re-entry on 11/12/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS), dated [DATE], revealed the resident is cognitively intact. The assessment also revealed Resident #67 received insulin. Review of the Blood Sugar Summary, dated 12/08/21 at 6:50 A.M., revealed Resident #67 blood glucose was 45 milligrams per deciliter (mg/dL). The medical record was silent of any additional blood glucose records on 12/08/21 and 12/09/21. Review of physician note, dated 12/08/21, revealed Resident #67 was seen for a follow-up skilled visit. Staff had reported Resident #67 had symptomatic [CONDITION(S)] and required [MEDICATION(S)] twice. Review of the Blood Sugar Summary, dated 12/10/21 at 3:41 A.M., revealed Resident #67's blood sugar glucose was 40 mg/dL. The record was silent for record of blood sugar until 8:49 P.M. with a blood sugar level of 156 mg/dL. Review of Resident #67's Medical Administration Record (MAR), dated December 2021, revealed [MEDICATION(S)] Emergency Kit 1 MG (milligram) was administered on 12/08/21, 12/10/21, and 12/14/21. Review of Resident #67's progress notes, dated 12/10/21, were silent of information of low blood glucose, justification for use of emergency medication, and physician notification. Interview on 12/15/21 at 12:15 P.M. with Registered Nurse (RN) verified blood glucose below 70 mg/dL should be reported the physician. Interview on 12/15/21 at 3:30 P.M. with the Director of Nursing (DON) verified no documentation of monitoring and documenting blood glucose levels on 12/08/21 and 12/10/21 after administration of [MEDICATION(S)] Emergency Kit 1 MG. The DON verified there was no notification to the physician on 12/10/21 of the low blood glucose or use of the [MEDICATION(S)] Emergency Kit. Interview on 12/15/21 at 3:44 P.M. with the Assistant Director of Nursing (ADON) #240 verified on 12/08/21 providing care to Resident #67 and reported the blood glucose level was 45 mg/dL. ADON #240 verified not calling the doctor after utilization of the emergency medication. ADON #240 verified on 12/08/21 the physician assessed the resident during rounds and verified not calling the physician to provide an update until 12/14/21. Review of facility policy, Change in Condition, revised April 2013, verified the unit supervisor or charge nurse will notify the resident, physician, and guardian/interested family member of changes or situations requiring notification.

Based on observation, staff interview and facility policy review ,the facility failed to ensure an extended release medication was administered properly. This affected one Resident (#03) of one resident observed for administration of [MEDICATION(S)] extended release tablet. The facility census was 83. FINDINGS INCLUDED: Review of Resident #03's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #03's medical record revealed a physician's order dated 02/23/21 for [MEDICATION(S)] ER tablet extended release 20 milliequivalent (mEq) tablet. Directions were to administer one tablet by mouth one time a day for supplementation related to [CONDITION(S)]. Observation of medication administration on 12/15/21 at 8:14 A.M. revealed Licensed Practical Nurse (LPN) #210 prepared Resident #03's medication for administration. Further observation revealed LPN #200 pulled a [MEDICATION(S)] extended release tablet and placed the tablet in a plastic bag stating she would crush the tablet due to Resident #03 having issues swallowing the large tablet. Interview with LPN #210 on 12/15/21 at 8:15 A.M. verified she was attempting to crush the [MEDICATION(S)] extended release tablet to place in applesauce. Review of the Institute for Safe Medication Practices located at http://www.ismp.org/tools/DoNotCrush.pdf revealed Klor-Con (potassium) should not be crushed. Review of the facility policy titled Medication Administration dated 06/21/17 revealed for tablets that appear on the Do Not Crush List, check with the pharmacist regarding a suitable alternative, and obtain a new order from prescriber, if appropriate, prior to crushing.

Based on observation, resident and staff interview, and medical record review, the facility failed to ensure a resident's call light was accessible. This affected two Resident's (#186 and #229) of 24 sampled residents. The facility census was 83. Findings include: 1. Review of the medical record revealed Resident #229 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 12/03/21 revealed the resident was moderately cognitively impaired. Resident #229 required extensive one person assistance with bed mobility, transfers, and locomotion on unit. Review of the care plan, initiated 11/28/21, revealed Resident #229 is at risk for falls and interventions included keeping the call light within reach, encouraged and reminded to ask for assistance. Review of the fall investigation, dated 12/11/21, revealed Resident #229 had a fall allegedly attempting to transfer from the chair. At the time of the incident, the call light was in hand and not on. Observation on 12/13/21 at 10:50 A.M. and 12:37 P.M. revealed Resident #229 in bed and the call light out of reach laying on the floor near the wall and side table. Interview on 12/13/21 at 12:37 P.M. with State tested Nursing Assistant #300 verified Resident #229's call light was out of reach. 2. Review of the medical record for Resident #186 revealed the resident was admitted [DATE] after a fall with injury at home. Resident #186 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) 3.0 assessment for Resident #186, dated 12/01/21, revealed the resident had a moderate degree of cognitive impairment. The assessment indicated Resident #186 required assistance of one for walking in the room and toileting, and assistance of two staff, for transfers. The assessment further indicated Resident #186 was not steady and was only able to stabilize with staff assistance when moving from a seated to standing position, and during surface-to-surface transfers. Review of the care plan for Resident #186 revealed it identified a risk for falls with a goal to be free from injury from a fall. Interventions included placement of the call light within the resident's reach. Observation on 12/15/21 at 4:08 P.M. revealed Resident #186 was sitting in a chair next to the bed. The call light cord was wrapped around the bed's grab bar, on the opposite side of the bed. During this observation, Resident #186 confirmed she was unable to reach the call light. Interview on 12/15/21 at 4:20 P.M. with State tested Nursing Assistant (STNA) #270 confirmed Resident #186's call light was out of the resident's reach. The aide further confirmed Resident #186 was at a high risk for falls.

Based on observations, review of Centers for Medicare and Medicaid Services (CMS) guidelines, review of the COVID-19 Nursing Home Data site and staff interview, the facility failed to follow CMS guidelines regarding in facility visitation to prevent the spread of COVID-19. This had the potential to affect 69 of 69 residents. The facility census was 69. Findings include: Observation on 02/02/21 at 9:05 A.M., revealed Resident (#32) was receiving a visitor in the lounge. Further observation revealed the visitor stayed for approximately 30 minutes. Interview with the Director of Nursing on 02/02/21 at 11:50 A.M., revealed a letter was sent from the State Of Ohio revealing the facility was now allowed indoor visitation and that is what the facility is following. The residents had visitors indoors for 30 minutes at a time. Observation on 02/02/21 at 12:03 P.M., revealed three visitors entered the building and after being screened went into the lounge to wait for their family member. Review of the CMS guideline QSO-20-39-NH titled Nursing Home Visitation - COVID-19 dated 09/17/20 revealed facilities should use the COVID-19 county positivity rate, found on the COVID-19 nursing home data site as additional information to determine how to facilitate indoor visitation. High rate (over 10%) means visitation should only occur for compassionate care situations according to the core principles of the COVID-19 infection prevention and facility policies. Review of the COVID-19 Nursing Home Data site, https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg., revealed the week dated 01/27/21 to 02/03/21, [NAME] County, Ohio was at a high rate of COVID-19 at 11.7%.

Based on observations, medical record review, facility investigation review, witness statement review, physician and staff interviews, review of the National Institute of Health United States National Library of Medicine/Medline Plus website, review of facility policy, the facility failed to ensure a resident's environment was free from accident hazards to [MEDICAL CONDITION] one (#100) of five residents reviewed for burns. This resulted in Actual Harm for Resident #100, when the resident was found with his leg lying directly on the electric baseboard heater, resulting in first and second [MEDICAL CONDITION] his left lower extremity (LLE). Six residents (#25, #50, #65, #75, #85, #95) electric baseboard heaters with a surface temperature observed to be greater than 120 degrees Fahrenheit. The facility census was 66. Findings include: Review of the closed medical record for Resident #100 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 12/12/20, revealed the resident had impaired cognition. The resident was extensive assistance of two staff for bed mobility, transfers, ambulation, personal hygiene, and toilet use. Review of the plan of care dated 09/19/19 revealed Resident #100 may require assistance with activities of daily living (ADL). Interventions in place included encouraging the resident to participate and for staff to anticipate the needs and assist as needed. Review of the incident investigation dated 12/24/20 revealed the injury to resident occurred in the Resident #100's bedroom. Licensed Practical Nurse (LPN) #400 and State tested Nurse Aide (STNA) #125 where the staff with firsthand knowledge. Review of two pictures from the investigation, provided by the Assistant Director of Nursing (ADON) #20, revealed Resident #100's pictures of the initial assessment of the burn to the LLE on 12/24/20. Picture of a lower extremity of the shin to the toes with red and pink blistering. The blisters were filled with clear, see through, bright, yellow fluid (serous) which indicates damage to the epidermis. There was a thin dark red to black burn line, on the top of the foot to ankle. The thin red to black burn line would be imagined to be from the foot being under the grates of the baseboard, lying directly on the grate of the heater. Estimation of 0.5 cm in length by 25.0 millimeters (mm) in width. From a picture it was impossible to assess thickness of the burn. In reviewing the pictures, the color of [MEDICAL CONDITION] the appearance of a superficial (first degree), partial thickness (second degree) and (third degree) burns. Overall measurements were not able to be determined from the picture. A second picture which showed blistering, fluid filled red skin, was assumed to be the calf of the LLE. Review of skin grid nursing note dated 12/24/20 at 5:21 A.M., for Resident #100 revealed a wound acquired on 12/24/20, on the LLE, was described as a blister that measured 7.0 centimeters (cm) in length by 8.0 cm in width by 0.0 cm in depth, with clear drainage and no odor. Review of the nurse's progress notes dated 12/24/20 at 6:46 A.M., revealed LPN #400 went to Resident #100's room for medication pass and found Resident #100's leg off the side of bed and on top of the floor heater. Resident #100 had multiple blisters to the lower left extremity. The vital signs were taken and within normal limits. Resident #100 and no complaints or pain. Resident #100's bed was moved away from the heater. The family, facility ADON #20 and the physician nurse practitioner were notified per protocol. Review of a witness statement from LPN #400 dated 12/24/20 with no time noted revealed she was passing morning medications and observed the Resident #100's bed in the lowest position and his leg hanging off the left side of the bed onto the floor heater. LPN #400 noted redness, warmth, and blistering to the LLE. LPN #400 revealed she moved the bed away from the heater and took the vital signs of the resident. Resident #100 had no complaints or pain. She notified the family and physician and received an order for [REDACTED]. Review of physician orders for 12/24/20 revealed to cleanse the left lower leg burn with normal saline solution. Then pat dry burn and apply a burn ointment and cover with [MEDICATION NAME] (non-adherent pad) and army battle dressing (ABD). Then wrap burn with Kerlix which is an anti-micromal large roll dressing. Review of skin grid nursing note dated 12/25/20 for Resident #100 revealed a wound acquired on 12/24/20 of the LLE. The wound was described as a Superficial (first degree) and partial thickness (second degree) burns.[MEDICAL CONDITION] at 0.9% of TBSA (total body surface area) of the total body that was burned. The skin was described as having intact and uncompromising skin brides between areas of damage. There was blistering present of different sizes periodically over the LLE. Blisters were filled with clear, see through, bright, yellow fluid (serous) which indicates damage to the epidermis only and that the dermal layer has not been compromised. The burn wound area measured 54.0 cm in length by 13.0 cm in width by 0.0 cm depth, with clear drainage and no odor. Review of the plan of care dated 12/29/20 revealed the Resident #100 had alteration in skin integrity as evidenced by burn present at left lower extremity (LLE). The goal revealed the resident would have signs of the wound resolving with a decrease in necrotic tissue and wound dimensions. Interventions included assessing the area for size, color, and drainage. The interventions also included to assess for pain and provide treatment as needed. Review of physician orders for 12/30/20 revealed Resident #100 was to be admitted to Hospice. Review of skin grid dated 01/01/21 at 3:41 P.M., for Resident #100 acquired a LLE burn and the injury measured 50.0 cm in length, 11.0 cm in width and 0.1 cm depth. The area presented with slough (a consequence of the [MEDICAL CONDITION] phase of skin wounds). The skin bridge (a more permanent and thicker attachment) was still present. The note further revealed Resident #100 was signed on to hospice, and by mouth intact was poor. Some medications have since been discontinued. If resident continues to decline and healing of this impairment is highly unlikely. Observation on 01/11/21 from 5:00 P.M. to 5:30 P.M., revealed baseboard heaters were hot to the touch in the following resident (#25, #50, #65, #75, #85, #95) rooms. Hand could only be put on baseboards for a few seconds and it started to burn hand. Interview on 01/11/21 at 5:44 P.M., with the Director of Nursing (DON) and ADON #20, who is the wound nurse confirmed Resident #100's bed was too close to the heater. The DON and ADON #20 confirmed on 12/24/20, Resident #100 was found with his leg laying directly on the baseboard heater. The facility did not send Resident #100 to the emergency room (ER). The DON and ADON #20 confirmed there were about four inches between the bed and the baseboard heater and Resident #100's bed was in the lowest position. The DON confirmed her personal observations were that she could not place her hand on the baseboard heaters but for a few seconds and it started to hurt and burn. Interview on 01/12/21 at 9:16 A.M., with Medical Director (MD) #300 revealed he did not see [MEDICAL CONDITION]. He revealed his Physician Assistant (PA) #500's evaluation revealed [MEDICAL CONDITION] improving with no granulation. MD #300 [MEDICAL CONDITION] described to him as a stage one or stage two burn. MD #300 revealed he singed the death certificate, and the cause of death was COVID-19 related. He revealed he knew for sure [MEDICAL CONDITION] nothing to do with the Resident #100's death. Interview on 01/12/21 at 10:23 A.M., with Director of Maintenance (DM) #34 revealed he used a [MEDICATION NAME] temperature gun and took about a dozen surface temperatures. The temperatures ranged from 130 to 155 degrees Fahrenheit. DM #34 revealed he put aluminum foil over the grates to conduct the surface heat. He revealed with the foil in the grates the temperatures would now range from about 95 to 100 degrees. He stated he had been doing eight-hour audit checks throughout each day since 12/24/20 incident. He revealed the audits were to ensure the beds were at least two feet away from the heaters. DM #34 revealed the corporation is working on a permanent solution and the audit checks of beds and heaters would be done until they have a solution. Observation on 01/12/21 at 10:37 A.M., with DM # 34 revealed a baseboard surface temperature of 150 degrees, when positioned on high, with no foil in the grates of an empty resident room (#219). Observation on 01/12/21 at 12:59 P.M., with DM #34 revealed a baseboard surface temperature of 125 degrees, with aluminum foil in the grates, of the baseboard heater. Observation was completed in room [ROOM NUMBER], the room Resident #100 had resided in. Interview on 01/12/21 at 1:00 P.M., with DM #34 confirmed 125 degrees baseboard surface temperature in room [ROOM NUMBER] with foil in the grates. Review of the facility policy titled Resident Bill of Rights, dated 1990, revealed residents had the right to a safe and clean-living environment. Review of the National Institute of Health, United States National Library of Medicine/Medline Plus website https://medlineplus.gov/ency/article/ 0.htm, [MEDICAL CONDITION] there are three levels of burns: First-[MEDICAL CONDITION] only the outer layer of the skin. They cause pain, redness, and swelling. Second-[MEDICAL CONDITION] both the outer and underlying layer of skin. They cause pain, redness, swelling, and blistering. They are also called partial thickness burns. Third-[MEDICAL CONDITION] the deep layers of skin. They are also called full thickness burns. They cause white or blackened, burned skin. The skin may be numb. [MEDICAL CONDITION]: Third-degree burns, Second-[MEDICAL CONDITION] than two to three inches (5 to 7.5 centimeters) wide, Second-[MEDICAL CONDITION] the hands, feet, face, groin, buttocks, or over a major joint.[MEDICAL CONDITION] the face, hands, feet, and genitals can be particularly serious. This deficiency substantiates Complaint Number OH 998.

Based on medical record review, observation, staff and resident interview, and review of resident's right pamphlet revealed the facility failed to provide reasonable notice and written notification to a resident and their representative prior to a room change. Additionally, the facility failed to ensure two residents' choice to share a room was honored. This affected two (#1 and #2) of two residents reviewed for room change. The facility census was 83. Findings include 1. Medical record review revealed Resident #2 had an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had intact cognition. Review of a social service note dated 09/16/19 at 10:52 [NAME]M. revealed social services spoke with Resident #2's Power of Attorney (POA) notifying him the resident would have a room change. The reason for the room change was not documented. Review of a nurse's note dated 09/16/19 at 2:10 P.M. revealed Resident #2 returned from the hospital. Further review of the nurses' notes revealed no documentation Resident #2 or Resident #2's POA were provided the reason of the room change or written notice prior to the room change. Review of a nurse's note dated 09/17/19 at 1:40 P.M. revealed Resident #2 was upset about room change and was missing her old room and roommate. Interview on 09/25/19 at 2:50 P.M. with Resident #2 revealed when she returned from a hospital stay, the facility had moved her to a different room. Resident #2 revealed she used to share a room with Resident #1 and wanted to continue to share a room with Resident #1. Resident #2 revealed she had lived in her former room for years. Resident #2 revealed the facility never asked her if she wanted a different room. Resident #2 revealed the facility had not provided her written notice of the room change prior to moving her. Resident #2 also indicated the facility never told her why they moved her to a different room. Interview on 09/25/19 at 2:44 P.M. with Social Service Designee (SSD) #82 revealed Resident #2's POA was called and notified the resident would be moving to a new room when she returned from the hospital. SSD #82 revealed the facility had not notified the resident of the move because the POA said he would tell the resident. Interview on 09/25/19 at 3:21 P.M. with the Administrator revealed Resident #2 was moved because Resident #1 (former roommate) was too involved with Resident #2's care. Further interview with the Administrator revealed there were no documented evidence signed by Resident #2 or Resident #2's POA indicating they had received written notification prior to the room change. The Administrator revealed the facility had no policy regarding room changes. Telephone interview on 09/25/19 at 3:27 P.M. with Resident #2's POA revealed he never received written notice regarding Resident #2's room change. Resident #2's POA revealed the facility called him the day the resident was to get out of the hospital and told him they were moving her to another room. Resident #2's POA revealed the facility never told him why they were moving Resident #2. The POA revealed he told Resident #2 in the hospital of the room change. The POA revealed Resident #2 was very surprised and did not understand why she had to move. The POA revealed neither of us understood it. 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition. Observation on 09/25/19 at 9:41 [NAME]M. revealed Resident #1 resided in two-person room. Resident #1 had no roommate. Interview on 09/25/19 at 3:27 P.M. with Resident #1 revealed her choice was to share a room with Resident #2. Resident #1 revealed she used to share a room with Resident #2. Resident #1 revealed Resident #2 went to the hospital and the facility put Resident #2 in a different room when she returned from the hospital. Review of the explanation of resident's rights pamphlet You Have the Right, given to residents in their admission packet revealed residents had the right to receive reasonable notice before the resident's room or roommate was changed, including an explanation of the reason for either change. This is an incidental finding discovered during the investigation of Compliant Number OH 087.

Based on medical record review, hospital discharge summary review, review of facility Self-Reported Incidents (SRI), staff interview, and review of facility policy the facility failed to implement their abuse policy when they failed to report an injury of unknown origin and failed to report an allegation of physical abuse between two residents. This affected three (#35, #36, and #54) of four residents reviewed for abuse. The facility census was 87. Findings include: 1. Medical record review revealed Resident #54 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #54 discharged to a hospital on [DATE] and was readmitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 05/08/18, revealed the resident's cognition was moderately impaired. Review of a progress note dated 02/24/19, at 7:24 A.M. and 7:25 A.M., revealed Resident #54 had increased swelling and pain in his right foot and lower leg. The physician was notified and ordered for the resident to be sent to the emergency room for an evaluation and treatment. At 12:48 P.M., documentation revealed the resident was being transferred to a different hospital. Review of the hospital Discharge Summary, dated 02/27/19, revealed Resident #54 was transferred to this hospital, from a different hospital, on 02/25/19. The resident's principal problem was a right distal (lower end) tibia fracture. The resident underwent [REDACTED]. Resident #54 was discharged back to the facility on [DATE]. Interview on 05/19/19 at 1:03 P.M., Resident #54 revealed he suffered a broken leg and had to have surgery to fix it. Resident #54 stated he did not know how his leg got broken. Interview on 05/20/19 at 10:21 A.M., the Director of Nursing (DON) verified on 02/24/19, Resident #54 was sent to the emergency room for increased pain and swelling in his right leg. The DON revealed hospital reports indicated the resident suffered a right distal tibia fracture and required surgery. The DON further verified the cause of the fracture was unknown. Interview on 05/20/19 at 10:23 A.M., the Administrator revealed the DON and herself were responsible for reporting all allegations of abuse, including injuries of unknown origin, to the Ohio Department of Health (ODH) by way of a SRI. The Administrator verified the cause of Resident #54's injury was unknown, and the facility should have submitted an SRI to the ODH. Review of the facilities SRIs revealed the facility had not submitted an SRI since 02/05/18. Review of a facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, defined an injury of unknown source as an injury that was not observed by any person or the source of the injury could not be explained by the resident; and the injury was suspicious because of the extent of the injury, location of the injury, the number of injuries observed at one particular point in time, or over time. The policy revealed all incidents and allegations of Abuse, Neglect, Exploitation, Mistreatment of [REDACTED]. 2. Medical record review revealed Resident #35 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #35's progress notes, dated 06/05/18 at 8:00 P.M., revealed staff observed Resident #35 walk over to Resident #37 and hit her in the arm while Resident #37 sat in her wheelchair. When staff attempted to intervene, Resident #35 grabbed a hold of Resident #37's wheelchair and pushed it forward. Resident #37 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Interview on 05/22/19 at 8:15 A.M., the Administrator revealed the she and the DON were responsible for reporting all allegations of abuse to the ODH by way of a SRI. The Administrator further revealed a physical altercation occurred on 06/05/19 between Resident #35 and Resident #37 where Resident #35 slapped Resident #37 and pushed her wheelchair with her in it. The Administrator verified the facility should have submitted a SRI to the ODH. Review of the facilities SRIs revealed the facility had not submitted an SRI since 02/05/18. Review of a facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy revealed all incidents and allegations of Abuse, Neglect, Exploitation, Mistreatment of [REDACTED].

Based on medical record review, observation, staff interview, and policy review the facility failed to follow a physician order [REDACTED]. Findings include: Medical record review revealed Resident #7 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of physician order [REDACTED]. Observation on 05/19/19 at 10:58 A.M., 2:18 P.M., and 5:17 P.M., revealed the resident's oxygen concentrator was set to deliver one and a half liters of oxygen per minute. An observation on 05/20/19 at 12:30 P.M., revealed the concentrator was set to deliver three and a half liters of oxygen per minute. Interview on 05/20/19 at 12:36 P.M., Licensed Practical Nurse (LPN) #200 confirmed Resident #7's oxygen concentrator was delivering three and a half liters of oxygen per minute. LPN #200 further confirmed Resident #7's physician order [REDACTED]. Review of facility policy titled, Respiratory: Oxygen Per Concentrator, revision date 04/2009, revealed oxygen will be used to correct hypoxic conditions so that residents were adequately [MEDICATION NAME] and to increase comfort and breathing efficiency for resident's with [MEDICAL CONDITION].

Based on medical record review, hospital discharge summary review and staff interview, the facility failed to ensure resident's care plans were revised when a resident had a change in condition. This affected one Resident (#54) of five residents reviewed for care plans. The facility census was 87. Findings include: Medical record review revealed Resident #54 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #54 discharged to a hospital on [DATE] and was readmitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Sets assessment, dated 05/08/18, revealed the resident's cognition was moderately impaired. Review of a progress note dated 02/24/19, at 7:24 A.M. and 7:25 A.M., revealed Resident #54 had increased swelling and pain in his right foot and lower leg. The physician was notified and ordered for the resident to be sent to the emergency room for an evaluation and treatment. At 12:48 P.M., documentation revealed the resident was being transferred to a different hospital. Review of the hospital Discharge Summary, dated 02/27/19, revealed Resident #54 was transferred to this hospital, from a different hospital, on 02/25/19. The resident's principal problem was a right distal (lower end) tibia fracture. The resident underwent [REDACTED]. Resident #54 was discharged back to the facility on [DATE]. Review of Resident #54's plan of care revealed no evidence the care plan was revised to address the resident's fractured leg. Interview on 05/21/19 at 7:37 A.M., Registered Nurse (RN) #300 revealed she was responsible for updating resident's care plans. RN #300 further revealed changes in a resident's condition, including fractures, were supposed to be care planned to address any special needs and/or complications the resident was at risk for related to the change. RN #300 verified she did not revise Resident #54's care plan to address the resident's fractured leg.

Based on medical record review, review of facility Self-Reported Incidents (SRI) staff interview, and review of facility policy the facility failed to report an injury of unknown origin for Resident #54. The facility further failed to report an allegation of physical abuse between two Residents (#35 and #57). The facility census was 87. Findings include: 1. Medical record review revealed Resident #54 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #54 discharged to a hospital on [DATE] and was readmitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 05/08/18, revealed the resident's cognition was moderately impaired. Review of a progress note dated 02/24/19, at 7:24 A.M. and 7:25 A.M., revealed Resident #54 had increased swelling and pain in his right foot and lower leg. The physician was notified and ordered for the resident to be sent to the emergency room for an evaluation and treatment. At 12:48 P.M., documentation revealed the resident was being transferred to a different hospital. Review of the hospital Discharge Summary, dated 02/27/19, revealed Resident #54 was transferred to this hospital, from a different hospital, on 02/25/19. The resident's principal problem was a right distal (lower end) tibia fracture. The resident underwent [REDACTED]. Resident #54 was discharged back to the facility on [DATE]. Interview on 05/19/19 at 1:03 P.M., Resident #54 revealed he suffered a broken leg and had to have surgery to fix it. Resident #54 stated he did not know how his leg got broken. Interview on 05/20/19 at 10:21 A.M., the Director of Nursing (DON) verified on 02/24/19, Resident #54 was sent to the emergency room for increased pain and swelling in his right leg. The DON revealed hospital reports indicated the resident suffered a right distal tibia fracture and required surgery. The DON further verified the cause of the fracture was unknown. Interview on 05/20/19 at 10:23 A.M., the Administrator revealed the DON and herself were responsible for reporting all allegations of abuse, including injuries of unknown origin, to the Ohio Department of Health (ODH) by way of a SRI. The Administrator verified the cause of Resident #54's injury was unknown, and the facility should have submitted an SRI to the ODH. Review of the facilities SRIs revealed the facility had not submitted an SRI since 02/05/18. Review of a facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, defined an injury of unknown source as an injury that was not observed by any person or the source of the injury could not be explained by the resident; and the injury was suspicious because of the extent of the injury, location of the injury, the number of injuries observed at one particular point in time, or over time. The policy revealed all incidents and allegations of Abuse, Neglect, Exploitation, Mistreatment of [REDACTED]. 2. Medical record review revealed Resident #35 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #35's progress notes, dated 06/05/18 at 8:00 P.M., revealed staff observed Resident #35 walk over to Resident #37 and hit her in the arm while Resident #37 sat in her wheelchair. When staff attempted to intervene, Resident #35 grabbed a hold of Resident #37's wheelchair and pushed it forward. Resident #37 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Interview on 05/22/19 at 8:15 A.M., the Administrator revealed the she and the DON were responsible for reporting all allegations of abuse to the ODH by way of a SRI. The Administrator further revealed a physical altercation occurred on 06/05/19 between Resident #35 and Resident #37 where Resident #35 slapped Resident #37 and pushed her wheelchair with her in it. The Administrator verified the facility should have submitted a SRI to the ODH. Review of the facilities SRIs revealed the facility had not submitted an SRI since 02/05/18. Review of a facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/21/16, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy revealed all incidents and allegations of Abuse, Neglect, Exploitation, Mistreatment of [REDACTED].

Based on medical record review, review of facility policy, and staff interviews, the facility failed to ensure a resident received timely care and treatment for [REDACTED]. This affected one (#81) of three residents reviewed for constipation. The facility census was 80. Findings include: Review of Resident #81's medical record revealed the resident was admitted to the facility on [DATE] following a hospitalization for a fractured femur. Resident #81 had additional medical [DIAGNOSES REDACTED]. Review of the admission assessment dated [DATE] identified Resident #81 was alert and oriented and the resident's last bowel movement was on 09/29/18. Resident #81 was noted to be ordered and taking narcotic pain medication ([MEDICATION NAME] 10 milligrams) for the surgical repair of her fracture. Resident #81 was additionally receiving two tablets of a laxative named Senna for constipation twice a day since admission on 09/29/18. Review of the resident's care plan for constipation revealed the goal included for the resident to have a bowel movement at least every three days. Review of the resident's physician visit notes, dated 10/04/18, revealed the resident told the physician she did not have a bowel movement for two or three days. The physician was noted to order a laxative, [MEDICATION NAME] 10 grams. Review of the resident's Medication Administration Record [REDACTED].M. The MAR further identified the medication was ineffective. Review of the resident's bowel elimination record revealed no bowel movements were noted for eight consecutive days, from admission date of [DATE] through 10/07/18. Review of the resident's medical record from 09/30/18 through 10/07/18 revealed there was no notification to the physician of the lack of Resident #81 having bowel movements and or the ineffectiveness of the laxative ordered on [DATE]. There were no physician orders to change the resident's medication/treatment during this time. Interview with Licensed Practical Nurse #200 on 11/28/18 at 11:58 A.M. confirmed the facilities computer system sends alerts to nursing staff if residents go more than two days without a bowel movement. LPN #200 confirmed the nursing staff should then identify if an as needed medication can be administered and follow up to ensure medication was effective. Interview with the Director of Nursing (DON) on 11/28/18 at 2:10 P.M. verified Resident #81 did go eight days without a bowel movement. The DON confirmed Resident #81 refused the ordered medication on 10/04/18, because she was leaving for a physician appointment, however the medication was administered on 10/05/18. The DON further confirmed the MAR indicated [REDACTED]. Review of the facilities policy on change of condition, dated (MONTH) 2003, identified a change in condition is defined as deterioration in the health status of a resident. The policy identified the physician will be notified of all changes and this will be documented in the medical record. This deficiency substantiates Complaint Number OH 215.

Based on medical record review, review of facility policy and staff interviews, the facility failed to ensure a resident's physician was notified when the treatment was ineffective. This affected one (#81) of three residents reviewed for notification of change. The facility census was 80. Findings include: Review of Resident #81's medical record revealed the resident was admitted to the facility on [DATE] following a hospitalization for a fractured femur. Resident #81 had additional medical [DIAGNOSES REDACTED]. Review of the admission assessment dated [DATE] identified Resident #81 was alert and oriented and the resident's last bowel movement was on 09/29/18. Resident #81 was noted to be ordered and taking narcotic pain medication ([MEDICATION NAME] 10 milligrams) for the surgical repair of her fracture. Resident #81 was additionally receiving two tablets of a laxative named Senna for constipation twice a day since admission on 09/29/18. Review of the resident's care plan for constipation revealed the goal included for the resident to have a bowel movement at least every three days. Review of the resident's physician visit notes, dated 10/04/18, revealed the resident told the physician she did not have a bowel movement for two or three days. The physician was noted to order a laxative, [MEDICATION NAME] 10 grams. Review of the resident's Medication Administration Record [REDACTED].M. The MAR further identified the medication was ineffective. Review of the resident's bowel elimination record revealed no bowel movements were noted for eight consecutive days, from admission date of [DATE] through 10/07/18. Review of the progress notes from 09/30/18 through 10/07/18 revealed there was no notification to the physician of the lack of Resident #81 having bowel movements and or the ineffectiveness of the laxative ordered on [DATE]. Interview with Licensed Practical Nurse #200 on 11/28/18 at 11:58 A.M. confirmed the facilities computer system sends alerts to nursing staff if residents go more than two days without a bowel movement. LPN #200 confirmed the nursing staff should then identify if an as needed medication can be administered and follow up to ensure medication was effective. Interview with the Director of Nursing (DON) on 11/28/18 at 2:10 P.M. verified Resident #81 did go eight days without a bowel movement. The DON confirmed Resident #81 refused the ordered medication on 10/04/18, because she was leaving for a physician appointment, however the medication was administered on 10/05/18. The DON further confirmed the MAR indicated [REDACTED]. Review of the facilities policy on change of condition, dated (MONTH) 2003, identified a change in condition is defined as deterioration in the health status of a resident. The policy identified the physician will be notified of all changes and this will be documented in the medical record. This deficiency substantiates Complaint Number OH 215.

Based on medical record reviews, observations, staff interview, and review of facility policy and procedures, the facility failed to ensure staff implemented appropriate isolation precautions when providing care for a resident with a transmittable infection. Additionally, the facility failed to ensure nursing staff preformed hand hygiene prior to donning (to put on) sterile gloves, and providing tracheotomy care. This affected two (#2 and #180) residents observed for infection control practices. The facility census was 83. Findings included: 1. Medical record review revealed Resident #180 was admitted to the facility on [DATE] with the following diagnoses; [MEDICATION NAME] (inflammation of the colon) due to [MEDICAL CONDITION] ([MEDICAL CONDITION]/infection), [MEDICAL CONDITION] of the prostate. Review of Resident #180's physician orders [REDACTED]. Observation on 04/23/18 at 4:39 P.M., revealed an isolation precaution to report to the nurse prior to entering Resident #180's room. Also outside of the resident's room personal protective equipment (PPE) was noted. Observation on 04/24/18 at 9:19 A.M., with State tested Nursing Assistants (STNAs) #50 and #60 revealed both STNAs entered Resident #180's room and were not wearing gowns during resident care. In addition, STNA #50 was not wearing gloves during resident care. Interview at the time of the observation with both STNAs confirmed they were to wear gloves and gowns during resident care, however did not. The facility policy dated 11/2017 titled, [DIAGNOSES REDACTED] Isolation Precautions Best Practice, revealed for a resident suspected or confirmed to be infected, [MEDICAL CONDITION] was mainly transmitted via the hands of healthcare personnel who touched a contaminated surface or item. Gloves to be worn, change gloves if soiled with feces. Gowns to be worn as needed, for contact with surfaces/items contaminated with spores. 2. Medical record review revealed Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a tracheotomy and was cognitively intact. Observation on 04/26/18 at 8:28 A.M., of tracheotomy care, provided by Licensed Practical Nurse (LPN) #100 and LPN #110, revealed both LPNs washed their hands and donned clean gloves. LPN #100 placed a pulse oximeter on the resident right first finger and used a stethoscope to listen to the residents lungs. LPN #100 then cleaned the residents bed side table with a tissue, obtained the tracheotomy care supply tray container, opened the container, and took out the sterile field and placed it on the bedside table. LPN #100 removed her gloves, donned sterile gloves and provided the tracheotomy care for Resident #2. LPN #100 did not wash her hands prior to donning sterile gloves and providing the tracheotomy care. Interview on 04/26/18 at 8:40 A.M., LPN #100 revealed staff were to wash their hands after removing gloves and/or prior to donning sterile gloves. LPN #100 verified she forgot to wash her hands prior to putting on sterile gloves and providing care for the resident. Review of a facility policy titled, Glove Technique-Sterile, dated 10/18/01, revealed the purpose was to protect the resident from pathogenic organisms and to maintain surgical asepsis. Further review revealed staff were to wash hands and dry thoroughly prior to donning sterile gloves.

Based on medical record review and staff interview, the facility failed to ensure coordination of care between the facility and hospice services for one (#17) of one resident reviewed for hospice services. The facility census was 83. Findings included: Review of the medical record for Resident #17 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #17's physician orders [REDACTED]. Review of the resident's medical record and a hospice binder revealed no documentation of hospice nurse and/or physician visits, or care provided during those visits, or a valid hospice re-certification, which had expired [DATE]. Further review revealed no evidence of a plan of care was to be provided by hospice staff. Interview on [DATE] at 5:35 P.M., the Director of Nursing (DON) verified Resident #17's medical record did not contain a plan of care to address the resident's needs, nursing and/or physician progress notes [REDACTED]. Review of the Hospice Services Agreement dated [DATE] between the facility and Hospice, revealed Hospice and the facility would communicate with one another regularly to ensure the needs of the Hospice patient were met. Further review revealed Hospice would furnish to the facility the most recent hospice plan of care specific to each Hospice patient, the physician certification and re-certification.

Based on medical record review, observation, and staff interview, the facility failed to provide oral care for a resident who required total assistance with hygiene. This affected one (#69) of 24 residents reviewed for assistance with activities of daily living (ADLs). The facility census was 83. Findings included: Medical record review revealed Resident #69 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was severely impaired. The resident was totally dependent on staff for all of his/her ADL's including personal hygiene. Review of the most recent quarterly MDS revealed the resident required extensive assistance for his/her ADL's with the exception of meals for which the resident was dependent. Review of the plan of care for Resident #69, dated 04/20/18, revealed the resident was dependent of staff for daily care related to an [MEDICAL CONDITIONS], decreased mobility, and contractures. Interventions included staff were to provide mouth care for Resident #69. Review of the ADL flow sheet for Resident #69, dated 03/28/18 through 04/25/18, revealed oral care task was to be documented for the 7:00 A.M. to 3:00 P.M. shift, the 3:00 P.M. to 11:00 P.M. shift, and the 11:00 P.M. to 7:00 A.M. shift. Further review revealed on 13 of those days, oral care was provided for the resident only once a day. Oral care was provided twice a day on 14 of those days. On 04/03/18 and 04/21/18 staff did not provide any oral care for Resident #69. Observation on 04/24/18 at 9:53 A.M., of Resident #69's teeth, revealed a build up of a beige colored substance on the resident's teeth. Interview on 04/24/18 at 4:30 P.M., Licensed Practical Nurse (LPN) #120 revealed the resident was dependent on staff for all of his/her ADL's. LPN #120 revealed staff were to provide oral care for the resident every shift. Interview on 04/25/18 at 2:07 P.M., State tested Nursing Assistant (STNA) #50 revealed the resident was dependent on staff for all of his/her ADL's. STNA #50 revealed oral care was to be provided for the resident every shift. STNA #50 verified he/she had already provided oral care for the resident this day. Observation of the resident teeth at this time, STNA #50 verified the residents teeth still had a beige colored substance build up on his bottom teeth. STNA #50 revealed he/she did not used a sponge type swab to clean the residents teeth, however used a toothbrush, because it was easier. Interview on 04/26/18 at 7:46 A.M., The Director of Nursing (DON) verified the resident was dependent on staff for his/her ADL's and staff should have been cleaning his teeth at least three times a day.

Based on medical record reviews, facility policy review, resident family and staff interviews, the facility failed to provide care planning meetings on a quarterly basis for one (#3) of one resident reviewed for care planning meetings. The facility also failed to update one (#11) resident's care plan per a physician order. Lastly, the facility failed to include the care of one (#179) resident's hearing aides on the care plan. This affected three of 22 resident's care plans reviewed. The facility census was 83. Findings included: 1. Medical record review for Resident #3 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the annual comprehensive Minimum Data Set (MDS) assessment, dated 04/02/18, revealed the residents cognition was severely impaired. Review of a progress note, dated 5/18/17, revealed a care planning meeting was held with Resident #3's husband. There was no evidence of any other care planning meetings being held with the resident's husband, or family. Interview via telephone on 04/23/18 at 4:46 P.M., with Resident #3's daughter-in-law, revealed a care planning meeting was held shortly after the resident was first admitted to the facility. The daughter-in-law revealed no other meeting had been held to her knowledge. The daughter-in-law further revealed the family felt they did not know what going on with the resident, and would have welcomed more care planning meetings. Interview on 04/25/18 at 11:39 A.M., with Social Service Designee (SSD) #130 revealed after the initial care plan meeting for Resident #3, no other meeting was offered until a year later when the residents annual MDS assessment was completed, unless the resident or family requested one. Review of a facility policy titled, Resident/Family/Responsible Party Care Conference, dated 08/2006, revealed the purpose of a care planning meeting was to provide resident and families the opportunity to participate in the residents plan of care. 2. Review of Resident #11's medical record revealed an admitted [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #11's quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact. Resident #11 required extensive assistance with dressing. Review of Resident #11's medical records revealed a physician's order dated 09/24/17 for Tubi Grip knee high compression stockings, to be applied in the morning, and removed at bedtime. Review of Resident #11's most recent comprehensive care plan revealed no evidence the resident was to wear Tubi Grip compression stockings. Interview with Registered Nurse (RN) #200 on 04/26/18 at 10:39 A.M., verified the facility failed to included the Tubi Grip compression stockings in the most recent comprehensive care plan. 3. Review of Resident #179's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #179's admission MDS assessment revealed the resident was severely cognitively impaired and required extensive assistance with all activities of daily living. The MDS revealed the resident had difficulty hearing, and wore hearing aids in both ears. Review of Resident #179's most recent comprehensive care plan revealed no evidence for the application and care of hearing aids. Interview with Resident #179's family on 04/25/18 at 10:25 A.M., revealed the facility failed to apply the resident's hearing aids on a daily basis. Interview with State tested Nursing Aide (STNA) #170 on 04/26/18 at 10:10 A.M., revealed the STNA was unaware Resident # 179 wore hearing aids, and there was no information on the STNAs daily reports. Interview with RN #200 on 04/26/18 at 11:14 A.M., verified the facility failed to care plan Resident #179's hearing aide requirements. Review of the facility policy titled Care Plan dated 07/2010 revealed the care plan is reviewed and revised at least quarterly with the MDS (Minimum Data Set) and on an as needed basis as changes occur in the resident's regimen.

Based on medical record review, and staff interview the facility failed to ensure resident medications were obtained and administered in accordance with physician orders [REDACTED].#1) out of three residents reviewed for medication administration. The facility census was 86. Findings include: Review of the medical record revealed Closed Record (CR) #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of hospital discharge physician orders, dated 06/17/16, noted orders for administered Advair inhaler 250/50 micrograms (mcg) one inhalation twice daily, albuterol 2.5 milligrams (mg) per three milliliters four times per day, atenolol 25 mg one half tablet every twelve hours with hold parameters for blood pressure less than 100 or pulse rate less than 60, Coumadin 1 mg every other day, doxycycline 100 mg every Monday/Wednesday/Friday, ferrous sulfate delayed release 325 mg two times daily, isosorbide 60 mg every day at 8:00 A.M., Januvia 100 mg every day, Lasix 40 mg twice daily, Lipitor 20 mg once daily at bedtime, lisinopril 2.5 mg once daily, magnesium oxide 400 mg two times daily, metolazone 2.5 mg one half tablet every Monday/Wednesday/Friday before Lasix if blood pressure greater than 100, omeprazole 20 mg twice daily, potassium chloride 15 milliequivalents two tablets daily while on Lasix, Propylthiouracil 50 mg give one and one half tablets twice daily at 0800 and 2100, Senna-gen 8.6 mg two tablets twice daily at 1400 and 2100, Vitamin D3 2000 units every day, and the antibiotic Keflex 500 mg four times daily for urinary tract infection for five days. Review of nurses notes documented the resident was admitted to the facility on [DATE] at 11:05 A.M. via ambulance. The resident was described as alert to self and the resident denied any pain or discomfort. Documentation indicated the physician was made aware of the residents arrival, orders orders were verified, and no new orders were requested. On 06/18/16 at 2:00 A.M. the resident was transported to the the hospital. Review of June 2016 medication administration records revealed no documentation indicating the following medications were administered as ordered by the physician on 06/17/16: Keflex 500 mg at 1:00 P.M., 5:00 P.M. and 9:00 P.M., Advair inhaler 250/50 mcg at 9:00 P.M., albuterol 2.5 mg at 1:00 P.M., 5:00 P.M. and 9:00 P.M., atenolol 12.5 mg at 9:00 P.M., ferrous sulfate 325 mg at 5:00 P.M., Lipitor 20 mg due at 9:00 P.M., lisinopril 2.5 mg due at 5:00 P.M., and magnesium oxide 400 mg at 5:00 P.M. Interview on 06/27/16 at 1:30 P.M., the Director of Nursing verified no documentation was available indicating the medications were provided as ordered by the physician. This deficiency substantiates complaint number OH 122.

Based on observation, review of facility policy and staff interview, the facility failed to ensure staff followed infection control procedures to prevent the spread of infection. This affected three (#103, #77, #96) of ten residents reviewed for medication administration. This had the potential to affect ten residents. The facility census is 77. Findings include: Observation on 08/13/14 at 12:40 P.M., revealed Licensed Practical Nurse (LPN) #10 was observed during the afternoon medication administration to residents. LPN #10 was observed to not wash her hands between passing medications to Residents #96, #103 and #77, nor did LPN #10 wear gloves to give an insulin injection to Resident #96. Interview with LPN #10 immediately following the medication administration observation revealed LPN #10 verified she did not wash her hands between medication administration for Residents #96, #103 and #77. LPN #10 also verified she did not wear gloves to give an insulin injection to Resident #96. Review of the facility policy and procedure titled "Infection control policy and procedure manual" revealed, all personnel shall follow hand washing procedures to prevent the spread of infections and disease to other personnel, patients, and visitors. Employees are to perform appropriate twenty second hand washing procedures under the following conditions: before performing invasive procedures; after handing items potentially contaminated with blood, body fluids, excretions, or secretions. When drawing up medication doses staff are to wear gloves. The policy also revealed the use of gloves does not replace hand washing.