Every finding on record at Ahc of Landerhaven LLC

Based on record reviews, review of a Self-Reported Incident (SRI), interviews and review of facility policy, the facility failed to ensure nursing staff reported an allegation of abuse in a timely manner. This affected two residents (#51 and #52) of three residents reviewed for abuse reporting. The facility census was 41.Findings included: Review of the Self-Reported Incident (SRI) submitted by the facility on 08/12/25 at 9:43 A.M. and closed on 08/15/25 at 5:31 P.M. submitted for an allegation of sexual abuse revealed it involved Resident #51 and Resident #52. Review of the closed medical record for Resident #51 revealed an admission date of 07/31/25. Diagnoses included strain of right quadriceps muscle, spinal stenosis and chronic kidney disease. Resident #51 was moderately cognitively impaired.Review of the closed medical record for Resident #52 revealed an admission date of 08/09/25 and a discharge date of 08/12/25. Diagnoses included dementia, urinary tract infection, alcohol use, chronic kidney disease and contusion to head. Resident #52 was cognitively impaired and had wandering behavior one to three days a week and behavior towards others. Review of a progress note dated 08/12/25 at 5:29 A.M. and authored by Registered Nurse (RN) #100 revealed Resident #52 was found in another resident room. RN #52 directed this resident back to her room and educated her about where her room was located and she could not go into others' room unless ok.Further review of the SRI and related investigation revealed the incident occurred on 08/12/25 at 2:30 A.M. however in the first paragraph it indicated it occurred on 08/11/25. Resident #52 tried to touch Resident #51 under his clothing and climb on top of him so Resident #51 pushed her away. Review of a handwritten statement dated 08/12 (no year), no author, (later revealed by the DON to be written by RN #100) revealed Resident Resident #51 stated a patient was in his room and was touching him inappropriately, CNA removed Resident #52 from his room and put her in bed and informed nurse. Nurse checked on Resident #51 to make sure patient was okay. Review of the witness statement by CNA #150 emailed to the DON on 08/12/25 at 10:56 A.M. revealed Certified Nursing Assistant (CNA) #150 stated it was around 3:00 A.M. or 4:00 A.M. the morning of 08/12/25. She did her rounds. Resident #52 was still up and asked her if she wanted to go back to bed. She said no so CNA #150 stated she sat down for about 10 minutes when she heard Resident #51 yelling. When she went to the room the resident was in his doorway holding onto doorway and handle of bathroom. She grabbed a wheelchair for him to sit down. CNA #150 stated that was when she saw Resident #52 sitting on Resident #51's bed and told her she was in the wrong room, CNA #150 assisted Resident #52 back to her room.When she went back to Resident #51's he told her Resident #52 touched him sexually and made him uncomfortable. She stated she would tell the nurse. The nurse was on break but she told her immediately when she saw her. Review of questions for residents completed on during the facility investigation revealed the Administrator and DON asked them the following questions: 1)Do you fee safe in the building?; 2)Have you had any issues with the other patients entering your room?; 3) If so, when did that happen?; and 4) Have you had any issues with the care provided to you while in the building? There were no concerns needing followed up on in answers.Review of questions for staff completed within the facility investigation revealed the Administrator and DON asked them the following questions: 1) who is mandated reporter in the building?; 2) If a patient, family member or employee reports abuse to you, what should you do next?; 3) Who is the abuse coordinator in the building?; 4)What do you believe abuse is?; and 5) Have you ever witnessed abuse either by other patients or staff members while working here? The questions were answered by the staff who worked 08/12/25.Review of the Employee Separation Form dated 08/13/25 for CNA #150 revealed she was terminated for not following policy and procedures.Review of the Employee Separation Form dated 08/13/25 for RN #100 revealed she was terminated for not being compliant with rules and investigation.Interview on 09/19/25 at 1:20 P.M. with CNA #150 confirmed what she wrote in her statement about the incident involving Resident #51 and #52. She added it was her third week there and she could not remember everything in policy or how quickly she needed to report allegations of abuse. She stated she told the nurse, but did not recall what time. CNA #150 stated the DON called her at home asking for a statement which she emailed. She stated she was suspended during investigation and terminated a couple of days later.Interviews were attempted with RN #100 but were unsuccessful.Interview on 09/19/25 at 5:00 P.M. with the Administrator and DON revealed both RN #100 and CNA #150 were terminated for not reporting timely regarding the incident of allegation of sexual abuse involving Resident #51 and Resident #52. The DON stated RN #100 would not call back to clarify information in her witness statement so they were unclear on the time of events. The DON and Administrator verified the date of 08/11/25 listed in the SRI was a mistake, as the incident did occur on 08/12/25. The time of notification from CNA #150 to RN #100 was unknown. Review of the facility policy titled Abuse Policy and Procedure, not dated, revealed the person observing the incident of patient abuse or suspecting patient abuse must immediately ensure patient safety then immediately report such incidents to their immediate supervisor and /or the charge nurse. The supervisor and/or charge nurse will then contact the Administrator or Director of Nursing. When an incident of patient abuse, neglect, mistreatment, misappropriation, or exploitation is suspected, the incident must be reported to a supervisor and /or charge nurse regardless of the time lapse since the incident occurred.This deficiency represents non-compliance investigated under complaint number 2601780.

Based on medical record review and staff interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level I screen was completed after a resident remained in the facility longer than 30 days as required. This affected four residents (#6, #16, #30 and #35) of four residents reviewed for PASRR. The facility census was 40. Findings include: 1. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses that included fracture of the left leg, schizophrenia and dementia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was severely cognitively impaired and required assistance of one staff person for completing his activities of daily living (ADLs). Review of census records for Resident #6 revealed Resident #6 was admitted to the facility on a hospital exemption indicating Resident #6's expected length of stay at the facility was less then 30 days and Resident #6 was exempt from the completion of a full PASRR screen for 30 days. Review of both the electronic and hard charts revealed no PASRR was completed after Resident #6's 30th day at the facility as required. Interview on 06/18/25 at 10:10 A.M. with Marketer #300 verified Resident #6 had no completed PASRR screen completed after their 30th day at the facility as required. 2. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses that included epileptic syndrome, urinary tract infection, type two diabetes and heart failure. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #16 was severely cognitively impaired and required assistance of one staff person for completing his ADL's. Review of census records for Resident #16 revealed Resident #16 was admitted to the facility on a hospital exemption indicating Resident #16's expected length of stay at the facility was less then 30 days and Resident #16 was exempt from the completion of a full PASRR screen for 30 days. Review of both the electronic and hard charts revealed no PASRR was completed after Resident #16's 30th day at the facility as required. Interview on 06/18/25 at 10:10 A.M. with Marketer #300 verified Resident #16 had no completed PASRR screen completed after their 30th day at the facility as required. 3. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses that included age related osteoporosis, urinary tract infection, elevated white blood cell count and dementia. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #30 was severely cognitively impaired and required assistance of one staff person for completing her ADL's. Review of census records for Resident #30 revealed Resident #30 was admitted to the facility on a hospital exemption indicating Resident #30's expected length of stay at the facility was less then 30 days and Resident #30 was exempt from the completion of a full PASRR screen for 30 days. Review of both the electronic and hard charts revealed no PASRR was completed after Resident #30's 30th day at the facility as required. Interview on 06/18/25 at 10:10 A.M. with Marketer #300 verified Resident #30 had no completed PASRR screen completed after their 30th day at the facility as required. 4. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses that included sepsis, chronic kidney disease, disorientation and unspecified convulsion. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #35 was cognitively intact and required assistance of one staff person for completing her activities of daily living (ADLs). Resident #35 discharged to the community on 06/16/25. Review of census records for Resident #35 revealed Resident #35 was admitted to the facility on a hospital exemption indicating Resident #35's expected length of stay at the facility was less then 30 days and Resident #35 was exempt from the completion of a full PASRR screen for 30 days. Review of both the electronic and hard charts revealed no PASRR was completed after Resident #35's 30th day at the facility as required. Interview on 06/18/25 at 10:10 A.M. with Marketer #300 verified Resident #35 had no completed PASRR screen completed after their 30th day at the facility as required.

Based on observation and interview, the facility failed to ensure residents were treated in a dignified manner. This affected three residents (#22,#150, and #151) of three observed for dignified treatment. The facility census was 40. Findings include: Review of Resident #22's medical records revealed an admission date of 05/27/25. Diagnoses included diabetes, right arm fracture and falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition and required supervision with eating and moderate assistance with toileting. Review of Resident #150's medical records revealed an admission date of 06/09/25. Diagnoses included Alzheimer's, dementia and falls. Review of Resident #150's MDS assessment dated [DATE] revealed the assessment was still recorded as in progress. Review of Resident #151's medical records revealed an admission date of 06/14/25. Diagnoses included right femur fracture, falls and dementia. Review of Resident #151's MDS assessment dated [DATE] revealed the assessment was still recorded as in progress. Observation of 06/17/25 at 9:43 A.M. revealed yelling was observed outside of Resident #151's room. Further observation revealed Certified Nursing Assistant (CNA) #229 and Agency CNA #507 were present in Resident #151's room. CNA #229 was loudly complaining about the lack of staff and her assignment to Agency CNA #507. Resident #151 was observed seated in his wheelchair in his room, in close proximity to CNA #229 who had been changing Resident #151's linens. Upon entering Resident #151's room, CNA #229 had exited the room. Interview with Agency CNA #507, who had remained in Resident #151's room, confirmed CNA #229 had been loudly complaining about her work assignment with Resident #151 present. Interview with Resident #22's private companion (located across the hall from Resident #151) at time of observation revealed she had heard the staff member loudly complaining about her work assignment and Resident #22 had been present in her room during that time. Resident #22's private companion stated the interaction had not been appropriate for others to hear. Interview with Resident #150 (located across the hall from Resident #151) at time of observation revealed she had also heard the staff members loudly complaining about their work assignment and had felt the interaction was not appropriate. Interview on 06/18/25 at 8:46 A.M. with the Administrator revealed she had not been made aware of the incident and stated the only requirement needed to work at the facility was to be nice. The Administrator stated she would inservice the staff members on appropriate customer service and stated the interaction was not appropriate. Review of the facility's undated customer service statement provided to employees upon hire, undated revealed staff were to maintain a friendly cheerful disposition and keep their tones even and be courteous and respectful.

Based on interview, record review, and staff interview, the facility failed to ensure timely care and assistance was provided to Resident #146 who experienced a change in condition. This affected one resident (#146) of two reviewed for changes in condition. The facility census was 40. Findings include: Review of Resident #146's medical records revealed an admission date of 06/06/25. Diagnoses included Parkinson's Disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #146 had intact cognition. Review of progress note dated 06/09/25 timed 2:22 P.M., authored by Registered Nurse (RN) #508, revealed Resident #146 had called nine-one-one (911) to summon emergency services herself because she was short of breath and no one had answered her call light. The progress note further stated RN #508 was on a break and did not get a chance to transfer Resident #146. Review of progress note dated 06/12/25 timed 7:37 P.M. authored by RN #239 revealed Resident #246 was readmitted to the facility with a diagnoses of pneumonia. Interview on 06/17/25 at 10:36 A.M. with Resident #146 revealed she had feelings of shortness of breath, a cough, and was nauseous and stated she had told anyone and everyone that walked by her door. Resident #146 stated no one had responded to her call light being on either and stated her call light was on for over an hour. Resident #146 stated due to no staff responding to her she had called 911 herself and was transported to the hospital and was diagnosed with pneumonia. Interview on 06/18/25 at 11:32 A.M. with Certified Nursing Assistant (CNA) #308 revealed she worked the day Resident #146 went to the hospital. CNA #308 stated she recalled Resident #146 telling her she didn't feel well and stated she had observed Resident #146 appeared to be having difficulty breathing. CNA #308 stated she had immediately informed the nurse (could not provide name and stated it may have been an agency nurse) and stated later that day she had been made aware Resident #146 had called 911 herself and was taken to the hospital. Review of facility policy titled Change in Patient Condition undated revealed the charge nurse/supervisor was to be made aware of a change in a residents condition and will record relevant information in the resident medical records.

Based on observation, interview, record review, and facility policy review, the facility failed to timely implement pressure ulcer treatment and interventions. This affected one resident (#152) of two residents reviewed for wounds. The facility census was 40. Findings include: Review of hospital paperwork dated 05/29/25, prior to Resident #152's admission to the facility, revealed Resident #152 presented to the emergency department due to pain in the buttocks secondary to stage two decubitus ulcers (partial thickness loss of skin bedsores). Measurements were not included in the hospital paperwork. Resident #152 had recently been placed on antibiotics by her primary care physician related to the bedsores. Review of Resident #152's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including stage two pressure ulcer to the left buttock. Review of facility admission skin grid dated 06/03/25, unable to determine author of assessment revealed Resident #152 had a discolored area to her buttocks. Skin grid did not include any further information. Review of dietary assessment dated [DATE] authored by Dietician #503 revealed Resident #152 required increased nutrition related to pressure injury of left buttock. Review of physician orders for June 2025 revealed to assist Resident #152 with turning every two hours, air mattress and ointment to bilateral buttocks every shift and Doxycycline (antibiotic) 100 milligrams twice a day for wound infection from 06/03/25 to 06/08/25. Review of wound care physician notes from 06/05/25 to 06/11/25 revealed no documentation related to buttocks for Resident #152. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #152 had intact cognition. Resident #152 required substantial assistance with bed mobility and toileting and was incontinent of bowel and bladder. MDS assessment had not included a stage two pressure ulcer to the buttock. Review of care plan dated 06/12/25 revealed Resident #152 had actual impaired skin integrity related to incontinence dermatitis (pressure ulcer to the buttocks was not included). Interventions included apply barrier ointment every shift and as needed, encourage repositioning at least every two hours, monitor for increased redness, measure wound area at least weekly to monitor response to treatment and request supplements and increased protein to monitor healing. Observation of incontinence care on 06/16/25 at 10:55 A.M. with Certified Nursing Assistant (CNA) #229 and Agency CNA #504 revealed Resident #152 was incontinent of a large amount of liquid stool that had covered her entire body from the top of her back to her lower extremities. CNA #229 stated she had not provided Resident #152 with incontinence care since the start of their shift at approximately 6:00 A.M. Continued observation of incontinence care being provided revealed during incontinence care Resident #152 yelled out that her buttocks were burning. Resident #152 was observed to have had an open area to her left buttock that was approximately 2 inches in length and 2 inches in width that was reddened and bleeding. Interview with CNA #229 at time of observation revealed she was not aware of Resident #152's open area and stated she would report the area to Resident #152's assigned nurse. Interview on 06/16/25 at 11:48 A.M. with Agency Registered Nurse (RN) #505 revealed she was not aware Resident #152 had a wound to her buttocks and stated staff had not reported the area to her. Interview on 06/16/25 at 3:12 P.M. with CNA #307 revealed Resident #152 had a buttock wound since she had been at the facility. CNA #307 stated she was not aware of what treatments were in place, however she had applied ointment to Resident #152's buttock after she had provided her with incontinence care and stated she had not observed a dressing to the area when she had previously cared for Resident #152. Interview on 06/17/25 at 1:15 P.M. with RN #255 revealed she was the facility's wound nurse and stated wound rounds were performed every Wednesday with the visiting wound physician. RN #255 stated she had not completed wound rounds the previous Wednesday (06/11/25) because she had been in a meeting. RN #255 stated she had not been made aware Resident #152 had a wound to her buttock. Observation and interview with RN #255 of Resident #152's buttock wound revealed the resident had an opened, red wound to her left buttock that was bleeding at the time of observation. RN #255 stated she would implement a treatment and inform the wound physician who would see the resident on 06/18/25. Review of a physician order dated 06/17/25 revealed an order to cleanse Resident #152's left buttock with normal saline, apply medihoney (a wound ointment), cover with calcium alginate (absorbent wound dressing), and cover with a silicone dressing daily and as needed. Interview on 06/18/25 at 9:42 A.M. with Dietician #503 regarding Resident #152's nutrition assessment dated [DATE] revealed she had likely received the information of Resident #152's pressure ulcer from her prior-to-admission hospital paperwork. Dietician #503 stated she was unaware of any concerns related to Resident #152's wound or care and stated she had placed orders for nutritional supplements to promote wound healing. Telephone interview on 06/18/25 at 11:13 A.M. with Wound Physician (WP) #506 revealed she had not been made aware Resident #152 had an area to her buttocks. WP #506 stated she had been following Resident #152 for a wound to her left heel and an area to her perineal area and had not been made aware to assess any areas to Resident #152's buttocks. WP #506 stated she would be seeing Resident #152 in the afternoon and would assess her buttocks then. A follow up interview on 06/18/25 at 4:46 P.M. with WP #506 revealed Resident #152 had a stage two pressure ulcer to her left buttock and her right thigh. WP #506 provided new treatment orders to facility staff to cover the wounds with calcium alginate and a foam dressing to be changed daily. Review of facility policy titled Pressure Ulcer Prevention undated revealed residents were to receive care consistent with professional standards to prevent pressure ulcers and a resident with pressure ulcers were to receive treatment and services to promote healing and Physician will be contacted to initiate appropriate treatment orders.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure timely incontinence care was provided. This affected two residents (#150 and #152) of two residents observed for incontinence care. The facility census was 40. Findings include: 1. Review of Resident #150's medical records revealed an admission date of 06/09/25. Diagnoses included Alzheimer's, dementia and urinary tract infections. Review of the baseline care plan dated 06/09/25 revealed Resident #150 was incontinent of bowel and bladder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #150 had impaired cognition. Resident #150 was incontinent of bowel and bladder. Review of physician orders for June 2025 revealed to toilet resident upon rising, before and after meal, at bedtime and as needed. Interview on 06/16/25 at 9:33 A.M. with Resident #150's private companion revealed Resident #150 had not received incontinence care since approximately 2:00 A.M. Observation of incontinence care at time of interview with Certified Nursing Assistant (CNA) #229 revealed Resident #150 was saturated with urine up her head that had soaked through her incontinence brief, mattress pad and also her mattress. A large dried urine ring was also observed on Resident #150's mattress pad. CNA #229 confirmed she had not provided Resident #150 with incontinence care since the start of her shift at 6:00 A.M. and was unable to state when Resident #150 had last received incontinence care. Resident #150 was not interviewable. 2. Review of Resident #152's medical records revealed an admission date of 06/03/25. Diagnoses included pressure ulcer of the left buttock, chronic obstructive pulmonary disease (COPD) and diabetes. Review of MDS assessment dated [DATE] revealed Resident #152 had intact cognition. Resident #152 required substantial assistance with toileting and was incontinent of bowel and bladder. Review of care plan dated 06/12/25 revealed Resident #152 was incontinent of bowel and bladder. Interventions included provide incontinence care as needed. Review of physician orders for June 2025 revealed to toilet resident upon rising, before and after meal, at bedtime and as needed. Interview on 06/16/25 at 10:00 A.M. with Resident #152 revealed she had last received incontinence care sometime around 3:00 A.M. and required incontinence care at time of interview. Observation of incontinence care on 06/16/25 at 10:55 A.M. with CNA #229 and CNA #504 revealed Resident #152 was covered in a large amount of liquid stool that extended from the middle of her back to her feet. Interview with CNA #229 at time of observation revealed she had not provided Resident #152 with incontinence care since the start of her shift at 6:00 A.M. and was unable to state when Resident #152 had last received incontinence care. CNA #229 stated resident should be provided with incontinence care at least every two hours and as needed. Review of facility policy titled Incontinence Care undated revealed residents were to receive incontinence care after each incontinence episode.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents were provided with water as requested and required. This affected one resident (#22) of three residents reviewed for hydration. The facility census was 40. Findings include: Review of Resident #22's medical records revealed an admission date of 05/27/25. Diagnoses included right arm fracture, diabetes, and history of falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 required supervision with eating. Interview on 06/16/25 at 9:17 A.M. with Resident #22 revealed she had not been receiving ice water daily and stated she usually did not even receive it once a day, even if she requested. Observation at time of interview revealed an empty water pitcher on Resident #22's sink. Interview on 06/17/25 at 10:41 A.M. with Resident #22 revealed she had still not received any ice water and stated she had been asking for a few days, and stated she had obtained water from the sink in her room. Interview on 06/17/25 at 10:43 A.M. with Certified Nursing Assistant (CNA) #229 revealed the night shift was responsible for providing ice water prior to the end of their shift and stated during her shift from 6:00 A.M. to 2:00 P.M. she was responsible to pass water as needed and also at the end of her shift. CNA #229 stated she had not been aware Resident #22 had requested ice water or had not received water for a few days. Review of facility policy titled Fluids at the Bedside undated revealed residents were to be provided with a fresh supply of water at the bedside at least daily.

Based on observation, interview and record review the facility failed to ensure appropriate infection control techniques were used for a resident on enhanced barrier precautions. This affected one resident (#152) of two observed for infection control precautions. The facility census was 40. Findings include: Review of Resident #152's medical records revealed an admission date of 06/03/25. Diagnoses included stage two pressure ulcer to the left buttock. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #152 had intact cognition. Resident #152 required substantial assistance with toileting and was incontinent of bowel and bladder. Review of current physician orders for June 2025 revealed Resident #152 was on Enhanced Barrier Precautions (EBP) due to pressure ulcer. Observation on 06/16/25 at 10:00 A.M. revealed a sign posted outside of Resident #152's room that stated EBP and the use of gown and gloves was required prior to entering. Observation of incontinence care on 06/16/25 at 10:55 A.M. revealed Certified Nursing Assistant (CNA) #229 and #504 had entered Resident #152's room and had not donned personal protective equipment (PPE). CNA #229 and #504 had proceeded to provide Resident #152 with incontinence care that included Resident #152 being incontinent of a large amount of liquid stool and urine. After completion of incontinence care interview with CNA #229 revealed she was not aware Resident #152 was on EBP and confirmed she was not aware of having to don PPE prior to providing care. Interview on 06/16/25 at 11:48 A.M. with Registered Nurse (RN) #505 revealed she was not aware of what EBP precautions had meant and further indicated she was not aware of Resident #152 being on any type of precautions. Review of facility policy titled Enhanced Barrier Precautions undated revealed resident were to be placed on EBP for residents who had wounds that included pressure ulcers and staff were to donn PPE during high contact activities that included personal hygiene.

Based on interview, record review, and review of the facility policy the facility did not ensure medical records were maintained in an accurate manner including treatments were documented per the treatment administration record (TAR) as ordered. This affected three residents (#9, #14, and #23) out of nine medical records reviewed for accuracy. The facility census was 22. Findings include: 1. Review of the medical record for Resident #9 revealed an admitted [DATE] with diagnoses including dementia, acute respiratory failure, Parkinson's disease, congestive heart failure, and pressure ulcers to his sacral region, mid back, and right heel. Review of the undated care plan for Resident #9 revealed he had actual impaired skin integrity related to pressure injuries to his left heel, back, and coccyx and an arterial ulcer to his left toe. Interventions included an air mattress to the bed, encourage and assist to reposition at least every two hours, and treatments as ordered. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9's Brief Interview for Mental Status (BIMS) score indicated he had moderate cognitive impairment as his BIMS score was a nine out of 15. He required substantial to moderate staff assist with dressing, bathing, and personal hygiene. He was dependent on staff assist with rolling left and right, toileting hygiene, and transfers. He was unable to ambulate. During the assessment period he rejected care one to three days of the seven-day assessment reference period. Review of the July and August 2024 physician order's revealed Resident #9 had a physician order dated 07/11/24 to 08/02/24 to cleanse his mid back wound with normal saline, pat dry, apply hydrofera blue (sponge like wound dressing to assist in holding drainage) (cut to fit) slightly moistened with normal saline and apply foam dressing Monday, Wednesday, and Friday and as needed. Review of the July 2024 TAR revealed Resident #9's treatment to his mid back was documented as completed on 07/12/24 and on 07/31/24. The TAR revealed an X on all the other days from 07/11/24 to 07/31/24 and had no documentation the treatment was completed. Interview on 08/26/24 at 10:30 A.M. with the Director of Nursing (DON) verified Resident #9 was to have the dressing completed to his mid back Monday, Wednesday, and Friday but on 07/15/24, 07/17/24, 07/19/24, 07/22/24, 07/24/24, 07/26/24, and 07/29/24 there was no documentation this was completed as there was only an X on the TAR. 2. Review of the closed medical record for Resident #23 revealed an admitted [DATE], and she was discharged on [DATE]. Her diagnoses included displaced fracture of the left tibia, non-pressure chronic ulcer to her left heel and midfoot, diabetes with peripheral angiopathy (small blood vessels were damaged and burst open), and hypertension. Review of the July and August 2024 physician orders revealed Resident #23 had an order dated 07/04/24 to pack her left foot with gauze dressing of betadine (antiseptic), cover with an abdominal (ABD) pad and wrap with Kerlix gauze and an Ace bandage daily and an order dated 07/30/24 to have a wound vac to unspecified location and to change three times a week (Monday, Wednesday, and Friday). There was no physician order for a wet to dry dressing to be applied as indicated in the nursing notes dated 08/06/24. Review of the admission MDS assessment dated [DATE] revealed Resident #23 had intact cognition. Review of the care plan dated 07/14/24 revealed Resident #23 had actual impaired skin integrity related to chronic ulcer to left heel. Interventions included left leg boot when in bed, treatment as ordered, and measure wound areas at least weekly. Review of the physician progress note dated 07/29/24 completed by Podiatrist #655 revealed Resident #23 had left plantar heel wound and he ordered to continue treatment of betadine-soaked dressing, cover with an ABD pad, and wrap with Kling (Kerlix gauze) and Ace wrap. The progress note noted to order a wound vac and apply at 125 millimeter of mercury (mmHg) continuous suction and change every two to three days. Review of the August 2024 TAR revealed Resident #23 had an order for a wound vac to unspecified location and to change three times a week (Monday, Wednesday, and Friday): on 08/02/24 and 08/05/24 the TAR was blank indicating no documentation that the treatment was completed. The TAR also continued to have the treatment to pack her left foot with gauze dressing of betadine, cover with an ABD pad and wrap with Kerlix gauze and an Ace bandage daily. There was no documentation this was completed on 08/01/24, as it was blank. There was nothing on the TAR regarding documentation that a wet to dry dressing was applied to Resident #23's right heel as indicated in the nurse's notes on 08/06/24. Review of the nursing note dated 08/02/24 at 8:19 P.M. and completed by Registered Nurse (RN) #656 revealed the wound vac was applied to Resident #23's left foot, and she tolerated it well. Review of the nursing note dated 08/06/24 at 11:52 A.M. and completed by RN #657 revealed Resident #23 stated the wound vac was turned off because the nurse prior had changed it incorrectly. The note revealed Resident #23 had spoken to the physician and he stated that the wound vac could come off. RN #657 asked if she could turn it on and she stated no, and she wanted it removed. RN #657 educated the resident that the wound vac was the order, and that it was considered a refusal, but Resident #23 stated that it was her right and she wanted the wound vac removed. RN #657 applied a wet to dry dressing. (There was no order for the wet to dry in the physician orders and it was not on the TAR) Interview on 08/26/24 at 2:27 P.M. with the DON revealed when Podiatrist #655 ordered the wound vac to Resident #23's left heel, the other treatment (pack her left foot with gauze dressing with betadine, cover with an ABD pad and wrap with Kerlix gauze and an Ace bandage daily) should have been discontinued. She verified the TAR for Resident #23's wound vac was blank on 08/02/24 and 08/05/24. She also verified the order should have identified the location of where the wound vac should have been applied: left planter heel. She verified in the nursing notes dated 08/06/24 at 11:52 A.M. and completed by RN #657 indicated she applied a wet to dry dressing to Resident #23's left planter heel, but there was no physician's order, and it was not documented on the TAR. 3. Review of medical record for Resident #14 revealed an admitted [DATE] with diagnoses including displaced intertrochanteric fracture of right femur, diabetes, and pressure ulcer to right buttock. Review of the July and August 2024 physician order's revealed Resident #14 had an order from 07/12/24 to 08/07/24 to cleanse her right buttock with normal saline, pat dry, apply MediHoney (an antibacterial/ anti-inflammatory wound gel), and cover with a foam dressing twice a day. Review of the July 2024 TAR revealed Resident #14's treatment to her right buttock was not documented as completed: 07/13/24 (7:00 A.M. to 7:00 P.M.), 07/18/24 (7:00 P.M. to 7:00 A.M.), and 07/19/24 (7:00 A.M. to 7:00 P.M.). Review of the admission MDS assessment dated [DATE] revealed Resident #14 had impaired cognition. She was at risk for developing pressure ulcers and had one Stage two (partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough, may also present as an intact or open/ruptured serum filled blister) pressure ulcer present on admission. Review of the care plan dated 07/26/24 revealed Resident #14 had actual impaired skin integrity. Interventions included encourage and assist to reposition at least every two hours, pressure reducing cushion to wheelchair, and treatment per current orders. Review of the August 2024 TAR revealed Resident #14's treatment to her right buttock was not documented as completed: 08/01/24 (7:00 A.M. to 7:00 P.M.), 08/05/24 (7:00 P.M. to 7:00 A.M.), and 08/06/24 (7:00 A.M. to 7:00 P.M.). Interview on 08/22/24 at 8:39 A.M. with Resident #14 revealed she had no concerns regarding her treatment to her right buttock not being completed as ordered. Interview on 08/26/24 at 10:30 A.M. with the DON verified Resident #14's TAR had no documented evidence the right buttock treatment was completed on 08/01/24 (7:00 A.M. to 7:00 P.M.), 08/05/24 (7:00 P.M. to 7:00 A.M.), and 08/06/24 (7:00 A.M. to 7:00 P.M.) as the TAR was blank. Review of the facility policy labeled; Clean Dressing Change, dated 2023, revealed it is the policy of the facility to provide wound care in a manner to decrease potential for infection and/ or cross contamination. The policy revealed physician orders would specify type of dressing and frequency of changes. The policy did not have anything in regard to ensuring treatments were documented as ordered after the completion of the dressing change. Review of the facility policy labeled; Charting Requirements, last updated 06/25/24, revealed treatment nurses would be responsible for charting on each treatment they completed including condition of site. This deficiency represents non-compliance investigated under Master Complaint Number OH00156758 and Complaint Numbers OH00156639 and OH00156596.

Based on interview, observation, record review, review of Self-Report Incident (SRI) review, and review of the facility policy revealed the facility did not ensure Resident #9 had a thorough comprehensive care plan with interventions regarding his refusals of care and/ or dementia care. This affected one resident (#9) out of nine resident care plans reviewed. The facility census was 22. Findings include: Review of the medical record for Resident #9 revealed an admitted [DATE] with diagnoses including dementia, acute respiratory failure, Parkinson's disease, congestive heart failure, and pressure ulcers to his sacral region, mid back, and right heel. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9's Brief Interview for Mental Status (BIMS) score indicated he had moderate cognitive impairment as his BIMS score was a nine out of 15. He required substantial to moderate staff assist with dressing, bathing, and personal hygiene. He was dependent on staff assist with rolling left and right, toileting hygiene, and transfers. He was unable to ambulate. During the assessment period he rejected care one to three days of the seven-day assessment reference period. Review of the nursing note dated 08/03/24 at 4:17 A.M. and completed by Licensed Practical Nurse (LPN) #653 revealed Resident #9 refused skin assessment and morning medications. Review of SRI tracking number 250531 dated 08/07/24 revealed the Administrator filed an incident of neglect and mistreatment for Resident #9. The SRI revealed there was an allegation that Resident #9 was up in his wheelchair for an extended period as State tested Nursing Assistant (STNA) #624 had asked him a few times if he wanted to go to bed but he refused. The facility unsubstantiated the SRI but had revealed the facility would update the care plan to address Resident #9's refusals as he refused lab work, skin assessments, medications, and weights. Review of comprehensive care plan dated 08/13/24 revealed Resident #9 had identified the following refusals of treatment: all daily cares. Intervention listed on the care plan was treatments not to be provided: any daily cares that Resident #9 preferred not to participate in. There were no other care plans and/ or interventions regarding Resident #9's refusals of care and/ or dementia care. Interview and observation on 08/21/24 at 9:11 A.M. with Resident #9 revealed he was lying in bed and refused to be interviewed as he requested the surveyor leave his room as he did not want to talk, which was honored. Observation on 08/21/24 at 10:02 A.M. revealed STNA #618 came up to LPN #613 and reported Resident #9 was refusing to be turned as he was hitting out when she attempted to turn him. Interview on 08/21/24 at 10:50 A.M. with STNA #618 revealed Resident #9 refused activities of daily living (ADL) frequently including turning, personal hygiene, incontinence care, and transfers in and/out of bed. When she was asked what types of interventions were in place if he refused, she revealed the only thing was to continue to go into his room and offer/encourage him to participate. Observation on 08/21/24 at 11:30 A.M. revealed therapy, Occupational Therapy (OT) #650 and Occupational Therapy Assistant (OTA) #654, were in Resident #9's room attempting to encourage him to get up in his chair for lunch. Resident #9 yelled out refusing but after encouragement allowed staff to assist in getting him out of bed. Resident #9 then began to yell again once up in the wheelchair that he did not want his lunch despite alternatives offered. Resident #9 continued to yell out, but then started to drink his nutritional supplement when therapy reassured him that they would be back to assist him back to bed. Interview on 08/21/24 at 12:48 P.M. with Corporate Travel Registered Nurse (RN) #655 revealed Resident #9 refused wound care. Review of the nursing note dated 08/21/24 at 6:16 P.M. and completed by Corporate Travel RN #652 revealed Resident #9 refused all wound care treatments. Interview on 08/21/24 at 3:14 P.M. with OT #650 revealed a day at the beginning of August 2024 (she was unable to identify specific day) she had come in and staff had asked her for assistance as Resident #9 had been up in his wheelchair all day and night as he had refused to go to bed. She revealed she had a good rapport with Resident #9 and was able to encourage Resident #9 to lie down. Interview on 08/21/24 at 3:56 P.M. with Physical Therapy Assistant (PTA) #651 revealed there was a day at the beginning of August 2024 that Resident #9 had been up all day and night in his wheelchair as he refused to lie down. She revealed when she came in the morning after OT #605 and she were able to encourage Resident #9 to lie down and assisted him back into his bed. Interview on 08/22/24 at 11:24 A.M. with STNA #624 revealed approximately two weeks ago she worked 11:00 P.M. to 7:00 A.M. and when she came in Resident #9 was still up in his wheelchair. She revealed approximately 11:30 P.M. she went into his room and asked Resident #9 if he was ready to go to bed and he refused. She revealed approximately 12:30 A.M. she had gone back in his room, and he yelled at her and stated he was not getting in the bed. She revealed she had attempted again at 1:30 A.M. but he became aggressive stating, don't touch me, and he attempted to put his arm out to have STNA #624 back up from his personal space. She revealed he then began to yell to leave his room despite all attempts to encourage him to go to bed. She revealed since that was the third time she had attempted; she did not attempt any other times on her shift because he made it clear he was not going to bed and wanted to remain up in his chair. When asked if she was aware if there were any interventions in his care plan regarding how to address his refusals, she stated she was not. STNA #624 revealed she notified RN #638 of his refusals but was not aware if any other staff, including nurses, had attempted to encourage Resident #9 to get back into his bed. Interview on 08/22/24 at 12:55 P.M. with Administrator and Director of Nursing (DON) verified Resident #9's care plan was not thorough regarding what staff should do if Resident #9 was refusing care including if Resident #9 refused to go to bed for prolonged period. They verified he had pressure ulcers on his mid back and sacrum area. They verified the only thing in his care plan was they had identified Resident #9 refused treatments including all daily cares. They verified there was only one intervention listed on the care plan: treatments not to be provided: any daily cares that Resident #9 preferred not to participate in. There were no other care plans and/or interventions regarding Resident #9's refusals of care and/or dementia care. Observation on 08/23/24 at 10:20 A.M. of incontinence care and wound care completed by LPN #612 and STNA #605 revealed Resident #9 yelled out refusing care to be completed. LPN #612 and STNA #605 explained and educated on the importance of the incontinence care and treatments, but he continued to refuse. STNA #605 then stated that Resident #9 had been a lawyer and was asking him to describe the funniest case he had. Resident #9 proceeded to talk about his profession and consented to have incontinence care and wound care completed. Interview on 08/26/24 at 10:09 A.M. with RN #638 revealed approximately two weeks ago she had worked night shift 12:00 A.M. to 8:00 A.M. not as the floor nurse but to assist with paperwork. She revealed the dayshift staff had come in and questioned why Resident #9 was up in his chair, and at that time, STNA #624 stated that she had asked him multiple times to go to bed and he refused. RN #638 revealed that was the first time she was aware that he had refused all night to lie down as STNA #624 had not reported it to her previously. RN #638 had asked Agency LPN #900 if she was aware and all she stated was she had seen Resident #9 up in his wheelchair in no distress but did not seem to know anything else regarding him being up in his chair all night. Review of the facility policy labeled, Comprehensive Care Plan, dated July 25, 2023, revealed the facility would develop a comprehensive person-centered care plan based on the patients' strengths and preferences. The facility can help the individual exercise the right of choice effectively by discussing condition, treatment options including related risks and benefits and expected outcomes. The policy revealed if the resident declines specific interventions the facility must address the individuals concerns and offer relevant alternatives. The policy revealed a variety of interventions should be used to meet the individuals needs and patients' rights based on many factors. This deficiency represents non-compliance investigated under Master Complaint Number OH00156758 and Compliant Numbers OH00156670, OH00156639, and OH00156596.

Based on interview, record review and emergency department summary notes, the facility failed to ensure residents were free from significant medication errors when one resident (Resident #30) was not administered physician ordered medications including an anti-[CONDITION(S)] medications, a blood thinner, insulin and other medications as prescribed. This resulted in Immediate Jeopardy and serious life-threatening harm when on 08/08/21 at 9:15 A.M., Resident #30 experienced seizures and an undetectable, high blood sugar level requiring hospitalization and admission to the intensive care unit (ICU). Admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one resident (Resident #30) of five residents reviewed for medication administration. The facility census was 45. On 08/17/21 at 3:09 P.M., the Administrator and the Interim Director of Nursing (DON) were notified the Immediate Jeopardy began on 07/30/21 at 9:00 A.M. when [MEDICATION(S)] (anti-[CONDITION(S)] medication) was not available for scheduled administration to Resident #30. This medication continued to be unavailable for administration through 08/08/21, for a total of 19 missed doses. On 08/07/21 at 7:00 A.M., Resident #30 did not receive [MEDICATION(S)] (anti-[CONDITION(S)] medication), [MEDICATION(S)] (anti-coagulant or blood thinning medication), [MEDICATION(S)] insulin 24 units and [MEDICATION(S)] insulin per sliding scale based on blood sugar level checks which were ordered before meals and at bedtime. On 08/07/21 at 6:00 P.M., Resident #30 had a blood sugar reading of 220 with 2 units of [MEDICATION(S)] insulin administered per sliding scale and at 8:30 P.M. Resident #30 had an elevated blood sugar reading of 379 and 5 units of [MEDICATION(S)] insulin was administered per sliding scale. Normal blood sugar levels per the facility are between 70 to 110. There was no evidence Resident #30's blood sugar was checked the morning of 08/08/21 before breakfast. On 08/08/21 at 9:15 A.M., Resident #30 was found by Licensed Practical Nurse (LPN) #302 (an agency nurse) having [CONDITION(S)]-like activity and a blood sugar reading of HI on the facility blood glucose meter (blood glucose meters read HI when the blood sugar level exceeds the level detectable) and was sent to the local emergency department by ambulance for evaluation. On arrival at the emergency department on 08/08/21, Resident #30 was still having seizures and had an elevated blood glucose level of 511. She was admitted to the ICU with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardy was removed on 08/18/21 when the facility implemented the following corrective action: · On 08/13/21, the contracted Pharmacy Registered Nurse (RN) #314 conducted a whole house medication availability audit and provided the results to the Interim DON on 08/17/21 at 9:00 A.M. Quarterly audits by Pharmacy RN #314 would be completed for one year and would be reviewed by the Quality Assurance/Performance Improvement (QAPI) Committee. All identified concerns would be reported to and addressed immediately by the DON or designee. · On 08/17/21 at 3:00 P.M., the Medical Director, Administrator and Interim DON reviewed the facility's policies and procedures for medication administration, documentation and ordering of medications. No revisions to these policies and procedures were required. · On 08/17/21 at 4:30 P.M., the Interim DON started individual in-service training with licensed nursing staff on medication administration, documentation and medication ordering processes. The in-service training of all licensed nursing staff was completed on 08/18/21 at 7:30 A.M. · On 08/17/21 and 08/18/21, individual training on medication administration, documentation and medication ordering processes was provided by the Interim DON to licensed nursing staff to include RN #301, RN #307; RN #308, Licensed Practical Nurse (LPN) #305, the nurses who did not administer the [MEDICATION(S)] to Resident #30, and RN #309. · On 08/17/21 at 3:00 P.M., the Interim DON started in-service training of all agency nurses upon arrival for their scheduled shifts at the facility. Additional agency nurses will be in-serviced upon arrival at the facility prior to their shift and off-going nurses will provide nurse login and orientation to agency nurses prior to their assumption of duties at the facility. · On 08/17/21 at 3:30 P.M., the Interim DON, Regional Nurse LPN #313 and LPN Supervisor #305 conducted an audit of all resident stock medication to ensure medications were available for administration as per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. with one medication discrepancy identified and immediately corrected for Resident #27. · On 08/17/21 the Interim DON reviewed the agency nurse computer login system and orientation process and implemented an updated process in which the facility human resources staff will be responsible for setting up computer logins prior to agency staff arriving for their scheduled shifts and for orientation to be completed upon arrival for their scheduled shifts. · On 08/17/21, the DON and/or designee started daily audits of medication availability for residents and 10% or five residents on each unit will be audited daily for two weeks, then randomly for 10% of five residents weekly for four weeks, then monthly for 10% or five residents for one year. Identified concerns from audits will be addressed immediately by the DON or designee and be reviewed by the facility Quality Assurance Performance Improvement (QAPI) Committee for additional direction. · Starting on 08/17/21, the DON or designee will conduct daily nurse schedule audits to ensure dedicated agency nurses with computer log in credentials are assigned and orientation conducted. Identified concerns from audits will be addressed immediately by the DON or designee and be reviewed by the facility QAPI Committee for additional direction. · On 08/18/21 at 11:00 A.M., the Administrator notified the nurse staffing agency to place agency LPN #302 on a Do Not Return list for their facility because of the medication/nurse practice issues and documentation issues on 08/08/21 for Resident #30. · On 08/19/21 at 12:37 P.M., agency nurse in-service training on medication administration, documentation and medication ordering processes was verified via interviews with RN #310, LPN #311, LPN #312, LPN #303, and LPN #304. In-service training on medication administration, documentation and medication ordering processes was also confirmed via interviews with the Interim DON, RN #301, RN #307; RN #308, RN #309, and LPN #305. · On 08/19/21 at 1:00 P.M., the Administrator contacted the nurse staffing agency to coordinate consistent agency staff assignments at the facility starting immediately. · On 08/19/21, the Interim DON provided verbal warnings to RN #300, RN #308, RN #307, and LPN #305 for not following medication protocols for Resident #30. · On 08/23/21 at 3:00 P.M., the Administrator and Interim DON transitioned from electronic Medication Administration Records (MARs) and Electronic Treatment Administration Records (TARs) to paper MARs and TARs for all residents due to system issues with agency nurses' ability to access MARs and TARs in their electronic medical record system. · On 08/23/21 at 3:00 P.M., the Interim Director of Nursing provided education to all facility staff and agency nurses regarding the use of paper MARs and TARs for all residents. The facility will still provide agency nurses with login and password access for the computers for documentation in progress notes and documentation of observations/assessments. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission documentation on 06/29/21 indicated Resident #30 was identified as being alert with confusion and oriented only to herself. The comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 was not able to be evaluated for cognition or memory. The medication section indicated she received insulin, anticoagulant therapy, and [CONDITION(S)] medications. Resident #30 was totally dependent on two staff for bed mobility and toilet use and was totally dependent on one staff person for dressing, eating and personal hygiene. Review of the plan of care dated 07/14/21 revealed Resident #30 was at risk for injury related to [CONDITION(S)] disorder with staff interventions to include administer medications as ordered, assess characteristics before, during and after [CONDITION(S)], assess resident after [CONDITION(S)] for vital signs, neurological checks and assess time, length, involved body part and level of consciousness if [CONDITION(S)] occurs. This care plan indicated Resident #30 had severe cognitive impairment with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included nursing staff to administer anticoagulants as ordered and observe for signs of active bleeding. Resident #30 was documented as at risk for complications related to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Records (MARs) for July and August 2021 revealed the [MEDICATION(S)] [CONDITION(S)] medication was not marked as administered on 07/30/21 at 9:00 A.M. and 8:00 P.M., 07/31/21 at 9:00 A.M. and 8:00 P.M., 08/01/21 at 9:00 A.M. and 8:00 P.M., 08/02/21 at 9:00 A.M. and 8:00 P.M., 08/03/21 at 9:00 A.M. and 8:00 P.M., and on 08/04/21 at 9:00 A.M. On 08/04/21 at 8:00 P.M. and 08/06/21 at 8:00 P.M., the nurse documented the [MEDICATION(S)] was administered to Resident #30, however the medication had not been delivered to the facility from the pharmacy and would not have been available. There was no reason documented why the [MEDICATION(S)] was not given for some of these doses and some doses were marked as not available for administration. The progress note authored by CNP #300 on 08/04/21 1:44 P.M. indicated Resident #30 had advanced dementia with a history of seizures and had not had the [MEDICATION(S)] [CONDITION(S)] medication for quite a while per nursing staff. CNP #300 indicated Resident #30 was ordered [MEDICATION(S)] medication, also for seizures, and discussed with the primary care physician, to increase the [MEDICATION(S)] medication to 500 mg twice a day. They also discussed having the facility staff contact the family to find out which neurologist had been treating Resident #30 for her [CONDITION(S)] disorder. The CNP and physician were reluctant to modify the [MEDICATION(S)] orders without a neurologist's input. There were no orders to hold or discontinue the [MEDICATION(S)] medication. The CNP indicated the nursing progress notes were silent regarding the [MEDICATION(S)] medication not being available and not administered as ordered. There was no evidence found to indicate the family was contacted for this information. The MAR for August 2021 revealed the [MEDICATION(S)] was not administered on 08/05/21 at 9:00 A.M. and 8:00 P.M., on 08/06/21 at 9:00 A.M., on 08/07/21 at 9:00 A.M. and 8:00 P.M., and on 08/08/21 at 9:00 A.M. In addition to the [MEDICATION(S)] not administered, on 08/07/21 at 7:00 A.M., the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation Resident #30's blood sugar level was obtained before breakfast in order to give the correct dose of [MEDICATION(S)] insulin via sliding scale coverage. On 08/07/21 at 11:00 A.M., LPN #306 did not complete the ordered blood sugar testing for Resident #30 prior to the lunch meal and did not administer [MEDICATION(S)] insulin per sliding scale. On 08/07/21 at 5:57 P.M. Resident #30's blood sugar was 220 and on 08/07/21 at 8:29 P.M. her BS was 379. These blood sugars were covered with [MEDICATION(S)] insulin administered according to the sliding scale orders by a different nurse. No further blood sugar testing or insulin administration was completed after 08/07/21 at 8:29 P.M. Review of nursing progress notes revealed a note on 08/08/21 at 4:08 P.M., in which LPN #302 documented Resident #30 had [CONDITION(S)] like symptoms that morning and was shaking and blinking [her] eyes. She was noted to be clammy and when her blood sugar was checked, the testing machine read HI (a HI reading for this glucometer indicated the blood sugar was greater than 600). The nurse indicated the physician was called via the answering service and the physician was paged, but the physician did not respond. The nurse spoke with Resident #30's daughter and attempted to call the DON twice but there was no answer. LPN #302 documented she was unable to assess vital signs due to Resident 30's shaking and then later called 911 for transport to the local emergency room . There were no specific times recorded as to when these notifications were done, blood sugar testing was completed, time the emergency transport arrived and when they transported Resident #30 to the hospital earlier that morning. Review of the hospital emergency department (ED) provider notes dated 08/08/21 revealed, on 08/08/21 at 11:25 A.M., Resident #30 arrived at the emergency department while having a [CONDITION(S)] and was treated with [MEDICATION(S)] 1 mg, a medication used to treat seizures. The note indicated Resident #30 also had a [CONDITION(S)] enroute to the hospital and emergency medical staff administered Versed 5 mg, a medication to increase sedation/relaxation, prior to arrival at the ED. This note revealed Resident #30's blood sugar in the ED remained very elevated at 511 and other laboratory testing was normal (blood chemistry, blood counts, blood cultures and urinalysis). There was no indication of specific medication levels being tested for [CONDITION(S)] medications. The emergency room physician documented on 08/08/21 at 4:41 P.M. that Resident #30 had diabetic ketoacidosis, ( seizures and metabolic [CONDITION(S)]- a neurological disorder and alteration in consciousness caused by diffuse or global [CONDITION(S)] from impaired cerebral metabolism resulting from systemic illness such as diabetes, which can result in [CONDITION(S)], loss of memory, impaired coordination for motor tasks, jaundice, coma, seizures, tremors, breathing problems, heart rhythm disorders, agitation and nausea/vomiting). Resident #30 was admitted to the hospital ICU. Interview on 08/17/21 at 7:15 A.M. with RN #301 stated she believed Resident #30 was having her blood sugar tested and recalled several occasions when the [MEDICATION(S)] medication ordered for Resident #30 was not available for administration. RN #301 stated she would have sent a facsimile to the prescriber to notify of the medication not being available however she did not receive a response from the prescriber when she sent the facsimiles. RN #301 stated she also notified the DON when the [MEDICATION(S)] medication was not available. RN #301 confirmed she did not document these notifications to the physician or the DON in the medical record. Interview on 08/17/21 at 10:56 A.M. with the Interim DON revealed she was currently investigating the [MEDICATION(S)] and other medication issues and the [CONDITION(S)] activity that required Resident #30 to be sent to the hospital on 08/08/21. The DON stated her preliminary investigation was not available at that time. The Interim DON verified between 07/30/21 and 08/08/21, Resident #30 did not receive any doses of the [MEDICATION(S)] medication for her [CONDITION(S)] disorder because the medication was not available from the pharmacy. The Interim DON verified the nurses were documenting in the MARs that the [MEDICATION(S)] was not available, but there was no documentation regarding the nurses notifying the prescribers or facility nurse administrators of this concern. The DON said she reviewed Resident #30's medical record documentation on 08/08/21 at 7:00 A.M. and 11:00 A.M., and the agency nurse, LPN #302, did not document the administration of all medications including [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] and insulin and she did not document blood sugar levels were tested to provide insulin per the sliding scale orders. According to the Interim DON, the facility utilized a glucometer where the HI reading indicated the blood sugar level was over 600. The Interim DON verified there was no documentation in the medical record to indicate any facility staff contacted the family for the name of the neurologist for Resident #30. Interview by telephone on 08/17/21 at 11:17 A.M. with LPN #306 verified she was assigned to work on 08/07/21 from 6:00 A.M. to 3:00 P.M. on the unit where Resident #30 resided. LPN #306 stated she could not recall any specifics of the medication administration on 08/07/21 at 7:00 A.M. and 11:00 A.M., but she believed she would have administered the medications as ordered and obtained blood sugar readings. LPN #306 stated she did not document the blood sugar readings in Resident #30's medical record. LPN #306 stated she routinely administered medications to residents and did not document their administration until the end of her shift, instead of at the time of the administration per nursing standards. Interview by telephone on 08/17/21 at 11:33 A.M. with the Former DON, who was employed at the facility at the time of this incident, revealed at the time of the concerns for Resident #30, she was on vacation and was not available to respond to staff communications about resident care. The Former DON stated, when she returned from vacation, she was informed of the issue with Resident #30 having a [CONDITION(S)] and transfer to the hospital. She said she felt there was no reason for an investigation to be completed. Interview on 08/19/21 at 12:37 P.M. with LPN #305 stated when Resident #30 was out of [MEDICATION(S)] medication, he sent a facsimile to the prescriber's office to notify them of the missing medication and received no response from the prescriber. LPN #305 stated he also left a voice message for the Former DON regarding this issue. LPN #305 admitted he did not document these notifications to the prescriber or Former DON in Resident #30's medical record. Interview on 08/23/21 at 8:11 A.M. with Director of Human Resources (DHR) #201 stated, on 08/08/21 around 8:00 A.M., she arrived at the facility for her manager on duty rounds. DHR #201 stated, while she was visiting with a resident, she received a telephone call from State tested Nurse Aide (STNA) #500 asking her to check on Resident #30 who was shaking all over. DHR #201 stated, around 9:15 A.M., she entered the resident's room and found Resident #30 shaking all over, sweating and having white foam coming from her mouth. DHR #201 stated LPN #302 was in the room and was asking if Resident #30 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] #500 stay with the resident. DHR #201 stated she then returned to the resident's room and the seizures continued. DHR #201 directed the nurse to call the DON and physician. Interview on 08/24/21 at 7:45 A.M. with LPN #311 stated, on 08/07/21 from 11:00 P.M. to 08/08/21 at 8:00 A.M., she worked as an agency nurse at the facility. LPN #311 stated, on 08/08/21 around 9:43 A.M., she returned to the facility and was informed by the agency nurse on duty (LPN #302) that Resident #30 had been having a [CONDITION(S)] for about 20 minutes and LPN #302 wasn't sure of what to do. LPN #311 stated she told LPN #302 if the resident was seizing for an extended period, she needed to send the resident to the emergency department for evaluation. LPN #311 stated she then went to resident's room and observed Resident #30 in a full tonic/clonic [CONDITION(S)] with shaking all over, blinking her eyes quickly and having white foam coming from her mouth. LPN #311 stated DHR #201, who was the manager on duty, was also helping with Resident #30. LPN #311 stated, around 10:00 A.M., she called 911 and handed the telephone to LPN #302 for her to provide report on Resident #30's status to the ambulance personnel. LPN #311 stated Resident #30 was having a shaking all over [CONDITION(S)] with slight lessening of the shaking at one point, then the heavy shaking resumed. LPN #311 stated she then let the facility because she was not on the clock. Interview on 08/24/21 at 8:19 A.M. with State tested Nurse Aide, (STNA) #500 revealed on 08/08/21, she entered Resident #30's room at approximately 9:00 A.M. and found the resident shaking all over, her eyes were blinking quickly, she was sweaty and had a white substance coming from her mouth. STNA #500 stated she immediately went and notified LPN #311. STNA #500 stated she also called DHR #201 who was the manager on duty for her to help with Resident #30. STNA #500 stated she then went to answer call lights and provide care for other residents. STNA #500 stated, between 9:45 A.M. and 10:00 A.M. she went back to check on Resident #30, who was alone in her room and she was still shaking all over and sweating. STNA #500 said she again notified LPN #311. STNA #500 stated LPN #311 then called 911 and the ambulance arrived and transported Resident #30 to the hospital. Interview on 08/24/21 at 2:21 P.M. with CNP #300 revealed she made rounds on 08/04/21 and the facility nurses reported Resident #30 was ordered [MEDICATION(S)], but she had not been receiving the [MEDICATION(S)] as ordered for a while. CNP #300 stated she reviewed Resident #30's medical records and was not able to find the name of a neurologist who would have ordered the [MEDICATION(S)] for the resident. CNP #300 stated she contacted the former DON to see if they could contact the family and find out who Resident #30's neurologist was, and she never heard back from the DON or any other nurse. CNP #300 stated she was informed Resident #30's insurance would not cover the [MEDICATION(S)] medication, so she contacted primary care physician (PCP) for Resident #30, and they decided to increase the [MEDICATION(S)] dose. CNP #300 stated since the [MEDICATION(S)] was not available per insurance and the resident was not getting the medication, she could not discontinue or hold the order. CNP #300 stated no facility staff had ever informed her that Resident #30 was not receiving the [MEDICATION(S)] medication prior to the 08/04/21 visit. CNP #300 stated she could not state whether or not Resident #30's seizures on 08/08/21 were due to the [CONDITION(S)] medication administration or insulin medication not being given. She said the lack of [CONDITION(S)] medications and high blood sugar could lead to increased [CONDITION(S)] activity. Interview by telephone and email correspondence on 08/25/21 at 10:44 A.M. with Consulting Pharmacist (RPh) #202 revealed on 07/29/21, the pharmacy received a telephone/verbal order from a nurse at the facility requesting a new prescription for [MEDICATION(S)] for Resident #30. RPh #202 stated the [MEDICATION(S)] order was canceled due to the third-party payor (insurance) requirement for prior authorization and a supporting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RPh #202 stated the pharmacy then sent a notification of the order being canceled and the request for prior authorization and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RPh #202 stated they also could not fill the prescription because the facility had already exceeded their allowance for facility instructions for non-covered medications. RPh #202 stated they sent a notification to the facility on [DATE] regarding the non-covered medication allowance and no response was received from the facility. RPh #202 stated the pharmacy always goes through the facility for clarification of physician orders. Review of the facility General Dose Preparation and Medication Administration, policy revised 01/01/13; the facility Reordering, Changing, and Discontinuing Orders, policy revised 10/31/16; and the Medication Shortages/Unavailable Medication, policy revised 01/01/13 revealed facility staff should verify medications are administered to ensure it is the correct medication at the correct dose, the correct route, correct rate, and time and for the correct resident. Facility staff should re-order medications using the electronic list of residents and medications that are due or by using the barcode technology. Upon discovery that the facility has an inadequate supply of medication to administer to a resident, the facility staff should immediately initiate action to obtain the medication from the pharmacy. The staff should contact the pharmacy to determine the status of the medication orders. If the medication is not available for administration, the nurse should notify the nurse supervisor and the Medical Director for orders and directions. This deficiency substantiates Complaint Number OH 928. This is an example of continued noncompliance from the survey dated 07/19/21.

Based on interview and record review and emergency department summary notes, the facility failed to assess and provide medical care/treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Actual harm occurred when Resident #30 was found having seizures and the licensed nursing staff failed to assess her and obtain prompt medical treatment as evidenced by waiting approximately 45 minutes to call the emergency squad (911) for transport to the emergency department. Resident #30 was admitted to the intensive care unit for seizures and diabetic ketoacidosis. This affected one resident (Resident #30) of three residents reviewed for seizures. The facility census was 45. Findings include: Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission documentation on 06/29/21 indicated Resident #30 was identified as being alert with confusion and oriented only to herself. The comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 was not able to be evaluated for cognition or memory. She was totally dependent on two staff for bed mobility and toilet use and was totally dependent on one staff person for dressing, eating and personal hygiene. Review of the plan of care dated 07/14/21 revealed Resident #30 was at risk for injury related to [CONDITION(S)] disorder with interventions for staff to administer medications as ordered, assess characteristics before, during and after [CONDITION(S)], assess resident after [CONDITION(S)] for vital signs, complete neurological checks and assess length of [CONDITION(S)] and involved body part as well as level of consciousness with [CONDITION(S)] activity. This care plan indicated Resident #30 had severe cognitive impairment with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nursing progress notes revealed a note dated 08/08/21 at 4:08 P.M., in which Licensed Practical Nurse (LPN) #302 documented Resident #30 had [CONDITION(S)] like symptoms that morning and was shaking and blinking [her] eyes. She was noted to be clammy and when her blood sugar was checked, the testing machine read HI (a HI reading for this glucometer indicated the blood sugar was greater than 600). The nurse indicated the physician was called via the answering service and the physician was paged, but no response from the physician was received. The nurse spoke with Resident #30's daughter and attempted to call the facility's Director of Nursing (DON) twice but there was no answer and no return call. LPN #302 documented she was unable to assess vital signs due to Resident 30's shaking and then called 911 for transport to the local emergency room . There were no specific times recorded as to when these notifications and blood sugar testing were completed for Resident #30 earlier that morning. Review of the hospital emergency department (ED) provider notes dated 08/08/21 revealed, on 08/08/21 at 11:25 A.M., Resident #30 arrived at the emergency department while having a [CONDITION(S)] and was treated with [MEDICATION(S)] 1 mg, a medication used to treat seizures. The note indicated Resident #30 also had a [CONDITION(S)] enroute to the hospital and emergency medical staff administered Versed 5 mg, a medication to increate sedation/relaxation, prior to arrival at the ED. This note revealed Resident #30's blood sugar in the ED remained very elevated at 511 and other laboratory testing was normal (blood chemistry, blood counts, blood cultures and urinalysis). The emergency room physician documented on 08/08/21 at 4:41 P.M. that Resident #30 had diabetic ketoacidosis, seizures and metabolic [CONDITION(S)] (a neurological disorder and alteration in consciousness caused by diffuse or global [CONDITION(S)] from impaired cerebral metabolism resulting from systemic illness such as diabetes which can result in [CONDITION(S)], loss of memory, impaired coordination for motor tasks, jaundice, coma, seizures, tremors, breathing problems, heart rhythm disorders, agitation and nausea/vomiting) and was admitted to the hospital intensive care unit (ICU). Interview on 08/17/21 at 10:56 A.M. with the DON revealed in her preliminary investigation, she discovered on 08/08/21 around 9:15 A.M., State tested Nurse Aide (STNA) #500 witnessed Resident #30 shaking all over, sweating and blinking her eyes rapidly and had a white substance around her mouth and immediately notified LPN) #302 (an agency nurse). The DON stated STNA #500 also contacted the Director of Human Resources (DHR) #201 who was the manager on duty and in the building at the time. The DON stated STNA #500 and DHR #201 reported Resident #30 was having [CONDITION(S)] activity from 9:15 A.M. until about 10:00 A.M. LPN #302 called 911 to transport Resident #30 to the hospital and the ambulance departed with Resident #30 at 10:26 A.M. The DON stated, according to information provided by the ambulance service, they received a call from the facility requesting assistance and an ambulance on 08/08/21 at 10:02 A.M. At 10:06 A.M., the ambulance arrived at the facility and departed the facility to the local hospital at 10:26 A.M. The ambulance arrived at the hospital at 10:31 A.M. The DON stated there was at least a 45 minute delay between Resident #30 first observed having [CONDITION(S)] activity and when LPN #302 called 911/ambulance for transport to the hospital. The DON verified there was no documentation of the care and services in the Situation, Background, Assessment and Recommendation (SBAR) communication records or the resident's nursing progress notes until 08/08/21 at 4:08 P.M. when LPN #302 entered a vague note about Resident #30's [CONDITION(S)] and transfer to the hospital. The DON stated 45 minutes was too long to wait to send Resident #30 to the hospital and thinking about this delay makes her feel sick to her stomach. Interview on 08/23/21 at 8:11 A.M. with DHR #201 revealed on 08/08/21 around 8:00 A.M., she arrived at the facility for her manager on-duty rounds. DHR #201 stated, while she was visiting with a resident, she received a telephone call from STNA #500 asking her to check on Resident #30, who was shaking all over. DHR #201 stated, around 9:15 A.M., she entered Resident #30's room and found her shaking all over, sweating and with white foam coming from her mouth. DHR #201 stated LPN #302 was in the room and was asking if Resident #30 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] #500 stay with the resident. DHR #201 stated she then returned to the resident's room and Resident #30 continued having seizures. DHR #201 stated she directed the nurse to call the DON and physician. DHR #201 stated she also directed LPN #302 to call 911 and send Resident #30 to the emergency department for evaluation for her prolonged [CONDITION(S)]. DHR #201 stated she then left the facility believing the nurse was sending Resident #30 to the hospital. Interview on 08/23/21 at 3:28 P.M. with LPN #302 verified, on 08/08/21 at 4:08 P.M., she wrote a brief note on assessment and care of Resident #30 at the end of her shift. LPN #302 stated she did not include the times of her assessments and notifications in the resident's record as she was busy with care of other residents and had not had the time to document on Resident #30 earlier in the day. LPN #302 stated, on 08/08/21, she was working at the facility as an agency nurse and had no information of the residents at the facility. LPN #302 stated around 9:00 A.M., 9:30 A.M. or 10:00 A.M., she had not been able to pass medications to Resident #30 or any other residents due to computer issues. She said an STNA came and reported Resident #30, didn't look right. LPN #302 stated she went and checked Resident #30 and found her to be shaking and her eyes were twitching and blinking. LPN #302 stated she went and checked Resident #30's chart and found she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #302 stated she attempted to call the physician, left messages on his answering machine and made two attempts to call the DON without success. LPN #302 stated she then called the resident's daughter to ask about hospice care, but the daughter reported Resident #30 was not in hospice care. LPN #302 stated Resident #30 then calmed down a little bit and she went to check her medications. LPN #302 said the STNA came back and reported Resident #30 started seizing again, so she decided to call 911 and send Resident #30 to the hospital for evaluation. LPN #302 stated around 4:08 P.M., she started documenting the events from earlier in the day related to Resident #30 but could not recall the times of the events. Interview on 08/24/21 at 7:45 A.M. with LPN #311 revealed on 08/08/21 around 9:43 A.M., she returned to the facility and was informed by the other agency nurse on duty, LPN #302, that Resident #30 had been having seizures for about 20 minutes and LPN #302 wasn't sure what to do. LPN #311 stated she told LPN #302 if the resident was seizing for an extended period, she needed to send the resident to the emergency department for evaluation. LPN #311 stated she then went to resident's room and observed Resident #30 in a full tonic/clonic [CONDITION(S)] with shaking all over, blinking her eyes quickly and having white foam coming from her mouth. LPN #311 stated the DHR #201 was also helping with Resident #30. LPN #311 stated, around 10:00 A.M., she called 911 and handed the telephone to LPN #302 for her to provide report on Resident #30's status to the ambulance personnel. LPN #311 stated Resident #30 was having a shaking all over, seizures with a slight lessening of the shaking at one point, then the heavy shaking resumed. LPN #311 stated she then left the facility because she was not punched in and working. LPN #311 stated, when she first observed Resident #30 having a [CONDITION(S)], she informed LPN #302 that she should call 911 and send her out to the hospital. LPN #311 stated LPN #302 told her she did not know if Resident #30 was a hospice resident or if Resident #30 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] .M., she decided to call 911 herself and then handed the telephone to LPN #302 to provide report to the ambulance company. Interview on 08/24/21 at 8:19 A.M. with STNA #500 revealed on 08/08/21, she entered Resident #30's room at approximately 9:00 A.M. and found the resident to be shaking all over, her eyes were blinking quickly, she was sweaty and had a white substance coming from her mouth. STNA #500 stated she immediately went and notified LPN #311. STNA #500 stated she also called DHR #201 who was the manager on duty for her to help with Resident #30. STNA #500 stated she then went to answer call lights and provide care for other residents. STNA #500 stated, between 9:45 A.M. and 10:00 A.M. she went back to check on Resident #30, who was still shaking all over and sweating. She said she again notified LPN #311. STNA #500 stated LPN #311 then called 911 and the ambulance arrived and transported Resident #30 to the hospital. Review of the facility, Notification of Change, policy last reviewed on 07/2021, the resident's physician and responsible party must be notified when an event involving the resident occurs or when the resident experiences a change in condition, potential discharge, room transfer or death. Also, when a licensed nurse is made aware of a resident change in condition, the licensed nurse will assess the resident, call the physician and document using Situation, Background, Assessment and Recommendation (SBAR) Communication Form and/or progress notes. If the situation is emergent or becomes emergent, the licensed nurse may initiate the 911 system. The licensed nurse is to provide frequent checks on the resident's condition while waiting for return call backs from the physician or nurse practitioner. This deficiency substantiates Complaint Number OH 928. This is an example of continued noncompliance from the survey dated 07/19/21.

Based on observation, record review, interview, and policy review, the facility failed to ensure staff donned the appropriate personal protective equipment (PPE) prior to entering a resident room who was on transmission-based precautions for observation related to COVID-19. This had the potential to affect all 45 residents residing in the facility. Findings include: Review of Resident #2's medical record revealed an admission on 08/03/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were also special instructions for staff to wear PPE including a gown, gloves, a mask, and a face shield or goggles when providing care to the resident. Observation during a facility tour on 08/04/21 at approximately 10:00 A.M. revealed there was Resident #2 was quarantined as a precaution for COVID-19 as a new admission. There were signs clearly posted next to the outside of the door instructing visitors were to see a nurse or staff member prior to entering the room. Signage was also posted related to the sequence for donning PPE and how to safely remove PPE, including a gown, a mask or respirator, goggles or a face shield, and gloves. There was a three drawer cart with adequate supplies of PPE located outside the door, at the entrance to the room. However, there were no face shields or goggles observed to be in or on the supply cart. Interview on 08/04/21 at 10:23 A.M. with State tested Nurse Aide (STNA) #201, revealed they were unaware Resident #2 was on transmission-based precautions and verified they had been in the room wearing just a surgical mask and without wearing a gown, gloves, a face shield, or an N95 mask. Interview on 08/04/21 at 10:31 A.M. with Registered Nurse (RN) #506, revealed Resident #2 was admitted to the facility on [DATE] and was on transmission-based precautions as a precaution for COVID-19. RN #506 reported the PPE which was required to enter Resident #2's room consisted of a disposable gown, gloves, and an N95 mask. RN #506 was unsure whether a face shield was required to enter the room. Interview on 08/04/21 at 10:55 A.M. with STNA #202, revealed Resident #2 was a new admission on transmission-based precautions as precaution for COVID-19. STNA #202 reported PPE required to enter Resident #2's room consisted of a disposable gown, gloves and an N95 mask. STNA #202 was unsure of whether a face shield was required to enter the room. Interview with the Administrator on 08/04/21 at 11:50 A.M. revealed there was one resident, Resident #2, on transmission-based precautions as a precaution for COVID-19. The Administrator reported PPE staff should wear in this room consisted of a gown, gloves, an N95 mask, and a face shield. Observation on 08/07/21 at 9:13 A.M., revealed Certified Occupational Therapy Assistant (COTA) #610 was wearing a surgical mask, sanitized her hands and entered Resident #2's room after donning a disposable gown. COTA #610 was not wearing an N95 mask, gloves, a face shield, or goggles upon entering the resident's room. Interview at 9:15 A.M. with COTA #610, verified Resident #2 was new to the facility and on precautions. She said she was unsure why Resident #2 was on precautions. COTA #610 confirmed she wore only a surgical mask and a disposable gown into Resident #2's room and did not wear an N95 mask, gloves, goggles or a face shield into the room. Observation on 08/07/21 at 9:25 A.M. revealed STNA #203 donned an N95 mask and a disposable gown prior to entering Resident #2's room. STNA #203 was not wearing gloves, goggles, or a face shield when she entered the resident's room. Interview at 9:27 A.M. with STNA #203, confirmed staff were required to wear an N95 mask, gloves, a disposable gown, and a face shield or goggles when entering Resident #2's room. STNA #203 confirmed she was not wearing the required PPE. STNA #203 said there were no face shields or gloves in the supply cart outside of the resident's room and was unsure of where she could obtain this equipment but could have asked someone. Review of facility policy, 2019 Novel Coronavirus (COVID-19), dated 01/2021, revealed all recommended PPE should be worn during the care of residents under observation; this includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or disposable face shield that covers the front and sides of the face), gloves, and gown. This deficiency substantiates Complaint Numbers OH 364 and OH 031. This deficiency is an example of continued noncompliance from the survey dated 07/19/21.

Based on interviews and record reviews, the facility failed to ensure complete, accurate and timely documentation of assessments and care provided to a resident experiencing a [CONDITION(S)]. This affected one resident (Resident #30) of ten residents reviewed for documentation. The facility census was 45. Findings include: Review of the medical record for Resident #30 revealed Resident #30 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On admission documentation on 06/29/21, Resident #30 was identified as having confusion and only oriented only to self. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was not evaluated for cognition or memory issues. Resident #30 received insulin, anticoagulant therapy and [CONDITION(S)] medications. Resident #30 was totally dependent on two staff persons for bed mobility and toilet use and totally dependent on one staff person for dressing, eating and personal hygiene and transfers did not occur. Prescriber orders for July and August 2021 revealed Resident #30 was prescribed the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . For blood sugars of 151 to 200, give 1 unit; for blood sugars of 201 to 250, give 2 units; for blood sugars of 251 to 300, give 3 units; for blood sugars of 301 to 350, give 4 units; for blood sugars of 351 to 400, give 5 units; and if blood sugar is greater than 400 or less than 70 nurses were to call the physician. On 08/04/21 at 1:44 P.M., Certified Nurse Practitioner (CNP) #300 increased the orders for [MEDICATION(S)] to 500 mg twice a day since the [MEDICATION(S)] medication was not available from the pharmacy. Review of the Medication Administration Records (MARs) for July and August 2021 revealed, on 07/30/21 at 9:00 A.M. and 8:00 P.M., and 07/31/21 at 9:00 A.M. and 8:00 P.M. [MEDICATION(S)] 200 mg was not available for administration to Resident #30. Also, on 08/01/21 at 9:00 A.M. and 8:00 P.M., on 08/02/21 at 9:00 A.M. and 8:00 P.M., on 08/03/21 at 9:00 A.M., on 08/04/21 at 9:00 A.M., on 08/05/21 at 9:00 A.M. and 8:00 P.M., on 08/06/21 at 9:00 A.M., on 08/07/21 at 8:00 P.M., and on 08/08/21 at 9:00 A.M. the [MEDICATION(S)] medication was marked by nursing staff as not available for administration. On 08/03/21 at 8:00 P.M. and 08/07/21 at 9:00 A.M. there was no documentation related to the administration of or availability of the [MEDICATION(S)] medication. On 08/04/21 at 8:00 P.M. and 08/06/21 at 8:00 P.M. a nurse documented the [MEDICATION(S)] medication was administered to Resident #30., when it had never been delivered to the facility from pharmacy. Review of nursing progress notes revealed a note on 08/08/21 at 4:08 P.M., in which Licensed Practical Nurse (LPN) #302 documented Resident #30 had [CONDITION(S)] like symptoms that morning and was shaking and blinking [her] eyes. She was noted to be clammy and when her blood sugar was checked, the testing machine read HI (a HI reading for this glucometer indicated the blood sugar was greater than 600). The nurse indicated the physician was called via the answering service and the physician was paged, but the physician did not respond. The nurse spoke with Resident #30's daughter and attempted to call the DON twice but there was no answer. LPN #302 documented she was unable to assess vital signs due to Resident 30's shaking and then later called 911 for transport to the local emergency room . There were no specific times recorded as to when these notifications were done, that blood sugar testing was completed, that any physical assessments were completed, the time the emergency transport arrived and when they transported Resident #30 to the hospital earlier that morning. Interview on 08/17/21 at 7:15 A.M. with Registered Nurse (RN) #301 revealed she recalled several occasions were the [MEDICATION(S)] medication was ordered for Resident #30, but the medication was not available for administration to the resident. RN #301 stated she recalls sending facsimiles of notifications to the prescriber, but she did not receive any responses from the prescriber. RN #301 stated she also attempted to contact the Director of Nursing (DON) to notify her of the medication not being available for administration, but received no response. RN #301 stated she documented the [MEDICATION(S)] was not available on the MARs. RN #301 stated she never documented the attempts of notifications to the prescriber or to the DON in the medical records. RN #301 stated she could not recall the dates the [MEDICATION(S)] was not available for Resident #30. Interview on 08/17/21 at 10:56 A.M. with the Interim Director of Nursing (DON) stated, on 08/08/21, there was a lack of documentation of assessments and care for Resident #30 who had a [CONDITION(S)] and needed sent out to the hospital for evaluation. The DON stated LPN #302 did not provide timely, accurate documentation for Resident #30 on 08/08/21 when the resident had a [CONDITION(S)] and needed sent to the hospital for evaluation. Interview by telephone on 08/17/21 at 11:17 A.M. with LPN #306 stated, verified, on 08/07/21 at 7:00 A.M. and 11:00 A.M., she did not document medications administration or blood sugar test results with insulin sliding scale results in Resident #30's MARs or medical record. LPN #306 stated, on 08/07/21 at 7:00 A.M. and 11:00 A.M., she believes she administered scheduled medications to Resident #30 per the prescriber orders, but could not recall the blood sugar test results or the amount of insulin per sliding scale that she administered. LPN #306 stated she remembers documenting the results on her 24-hour sheet, but did not transfer the data into the resident's medical files. LPN #306 stated she usually administered the medications to the residents, then she would document her administrations of the medications and treatments at the end of her shift so she could ensure she was able to administer all of the resident medications in a timely manner. LPN #306 stated she could not recall any issues with [MEDICATION(S)] or other [CONDITION(S)] medications. LPN #306 stated, if she had to document her administrations at the time she administered the medications, she would never get her medication pass done, timely. Interview on 07/19/21 at 12:37 P.M. with LPN #305 stated he recalls several occasions where he worked and [MEDICATION(S)] was not available for administration to Resident #30. LPN #305 stated he sent a facsimile of a notification of the [MEDICATION(S)] missed doses to the prescriber, but did not receive a response from the prescriber. LPN #305 stated he also attempted to contact the DON to notify her of the medication discrepancy, but he did not receive a response from the DON. LPN #305 stated he documented the [MEDICATION(S)] was not available in the MARs but never documented the notifications of the prescriber or the DON in the medical records. LPN #305 stated he could not recall the dates of when the [MEDICATION(S)] was not available for Resident #30. Interview on 08/23/21 at 3:28 P.M. with LPN #302 (an agency nurse) verified, on 08/08/21 at 4:08 P.M., she wrote a brief note on assessments and care of Resident #30 at the end of her shift. LPN #302 stated she did not include the times of her assessments and notifications in the resident's records as she was busy with care of other residents and had not had the time to document on Resident #30 earlier. LPN #302 stated, on 08/08/21, she was working at the facility as an agency nurse and had no information of the residents at the facility. LPN #302 stated there was another agency nurse working on the other side of the facility. LPN #302 stated she was having difficulty accessing the computer for her medication pass because her login was not working and she needed the scheduler to try to help her out. LPN #302 stated around 9:00 A.M. or 9:30 A.M. or 10:00 A.M., she had not been able to pass medications to Resident #30 or any other residents when one of the STNA came and reported Resident #30 didn't look right. LPN #302 stated she went and checked Resident #30 and found her to be shaking and her eyes were twitching and blinking. LPN #302 stated she went and checked Resident #30's chart and found she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #302 stated she made attempts to call the doctor, left messages on his answering machine and made two attempts to call the Director of Nursing without success. LPN #302 stated she then called the resident's daughter to ask about hospice care, but the daughter reported Resident #30 was not in hospice care. LPN #302 stated Resident #30 then calmed down a little bit and she went to check her medications. Then the STNA came back and reported Resident #30 started seizing again, so she made a decision to call 911 and send Resident #30 to the hospital for evaluation. LPN #302 stated around 4:08 P.M., she sat down and started documenting on Resident #30, but could not recall all of the times for all of the events that morning. Review of the policy, General Dose Preparation and Medication Policy, revised 01/01/13, revealed nurses are to document necessary medication administration and treatment information to include when medications are given, injections sites of medications and any as needed medication administrations on appropriate forms. Review of the policy, Notification of Change, revised July 2021, revealed nurses are to document in the Situation, Background, Assessment and Recommendation (SBAR) communication forms and/or progress notes and document attempts to communicate with the prescribers and DON. Review of the policy, Documentation of Medication Administration, dated 09/2020, revealed nurses shall document all medications administered to each resident on the resident's MAR and the administration of the medication must be documented immediately after (never before) the medication is given. This deficiency substantiates Complaint Number OH 928. This deficiency is an example of continued noncompliance from the survey dated 07/19/21.

Based on interview and record review the facility failed to provide sufficient nursing staff to provide safe and timely care and medication administration to residents. This had the potential affect all 44 residents residing in the facility. Findings include: Interview with Resident #34 on 07/07/21 at 10:28 A.M. revealed call lights are not answered timely on weekends or holidays and stated the facility is understaffed. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] aerosol inhaler 90 micrograms (mcg) per actuation, two puffs every four hours (to prevent and treat wheezing and shortness of breath caused by breathing problems such as asthma or chronic obstructive pulmonary disease): · Scheduled on 07/01/21 at 4:00 A.M. was administered on 07/01/21 at 5:29 A.M. · Scheduled on 07/01/21 at 8:00 A.M. was administered on 07/01/21 at 12:08 P.M. · Scheduled on 07/02/21 at 8:00 A.M. was administered on 07/02/21 at 10:16 A.M. · Scheduled on 07/02/21 at 12:00 P.M. was administered on 07/02/21 at 5:04 P.M. · Scheduled on 07/02/21 at 8:00 P.M. was administered on 07/02/21 at 10:01 P.M. · Scheduled on 07/04/21 at 12:00 A.M. was administered on 07/04/21 at 1:53 A.M. · Scheduled on 07/04/21 at 8:00 A.M. was administered on 07/04/21 at 11:13 A.M. · Scheduled on 07/04/21 at 12:00 P.M. was administered on 07/04/21 at 6:13 P.M. · Scheduled on 07/04/21 at 4:00 P.M. was administered on 07/04/21 at 6:13 P.M. · Scheduled on 07/05/21 at 8:00 P.M. was administered on 07/05/21 at 11:26 P.M. · Scheduled on 07/07/21 at 12:00 A.M. was administered on 07/07/21 at 4:18 A.M. · Scheduled on 07/07/21 at 4:00 A.M. was administered on 07/07/21 at 6:20 A.M. [MEDICATION(S)] 10 milligrams (mg) at bedtime (medication to treat high cholesterol): · Scheduled on 07/05/21 at 9:00 P.M. was administered on 07/05/21 at 11:26 P.M. [MEDICATION(S)] suspension for nebulization 0.25 mg per 2 milliliters (ml), 2 ml inhalation twice daily (steroid): · Scheduled on 07/01/21 at 9:00 A.M. was administered on 07/01/21 at 12:08 P.M. · Scheduled on 07/03/21 at 9:00 A.M. was administered on 07/03/21 at 11:04 A.M. · Scheduled on 07/04/21 at 9:00 A.M. was administered on 07/04/21 at 11:19 A.M. [MEDICATION(S)] 5 mg three times daily (muscle relaxer): · Scheduled on 07/02/21 at 2:00 P.M. was administered on 07/02/21 at 5:04 P.M. · Scheduled on 07/04/21 at 2:00 P.M. was administered on 07/04/21 at 6:13 P.M. · Scheduled on 07/05/21 at 10:00 P.M. was administered on 07/05/21 at 11:26 P.M. · Scheduled on 07/06/21 at 2:00 P.M. was administered on 07/06/21 at 10:43 P.M. [MEDICATION(S)] 100 mg twice daily (anticonvulsant and nerve pain medication): · Scheduled on 07/01/21 at 8:00 A.M. was administered on 07/01/21 at 12:08 P.M. · Scheduled on 07/02/21 at 8:00 A.M. was administered on 07/02/21 at 10:16 A.M. · Scheduled on 07/02/21 at 8:00 P.M. was administered on 07/02/21 at 10:01 P.M. · Scheduled on 07/03/21 at 8:00 A.M. was administered on 07/03/21 at 11:04 A.M. · Scheduled on 07/04/21 at 8:00 A.M. was administered on 07/04/21 at 11:13 A.M. · Scheduled on 07/04/21 at 8:00 P.M. was administered on 07/04/21 at 9:20 P.M. · Scheduled on 07/05/21 at 8:00 P.M. was administered on 07/05/21 at 11:26 P.M. · Scheduled on 07/06/21 at 8:00 A.M. was administered on 07/06/21 at 9:35 A.M. [MEDICATION(S)]-[MEDICATION(S)] solution for nebulization 0.5 mg/3 mg per 3 ml inhalation every four hours while awake (used to prevent wheezing, difficulty breathing, chest tightness, and coughing in people with chronic obstructive pulmonary disease): · Scheduled on 07/01/21 at 4:00 A.M. was administered on 07/01/21 at 5:29 A.M. · Scheduled on 07/01/21 at 8:00 A.M. was administered on 07/01/21 at 12:08 P.M. · Scheduled on 07/02/21 at 8:00 A.M. was administered on 07/02/21 at 10:16 A.M. · Scheduled on 07/02/21 at 12:00 P.M. was administered on 07/02/21 at 5:04 P.M. · Scheduled on 07/02/21 at 8:00 P.M. was administered on 07/02/21 at 10:01 P.M. · Scheduled on 07/03/21 at 8:00 A.M. was administered on 07/03/21 at 11:04 A.M. · Scheduled on 07/04/21 at 12:00 A.M. was administered on 07/04/21 at 1:53 A.M. · Scheduled on 07/04/21 at 8:00 A.M. was administered on 07/04/21 at 11:19 A.M. · Scheduled on 07/04/21 at 12:00 P.M. was administered on 07/04/21 at 6:13 P.M. · Scheduled on 07/04/21 at 4:00 P.M. was administered on 07/04/21 at 6:13 P.M. · Scheduled on 07/05/21 at 8:00 P.M. was administered on 07/05/21 at 11:26 P.M. · Scheduled on 07/07/21 at 12:00 A.M. was administered on 07/07/21 at 4:18 A.M. · Scheduled on 07/07/21 at 4:00 A.M. was administered on 07/07/21 at 6:20 A.M. [MEDICATION(S)] 25 mg every twelve hours (used to treat high blood pressure, chest pain, and heart failure): · Scheduled on 07/01/21 at 8:00 A.M. was administered on 07/01/21 at 12:08 P.M. · Scheduled on 07/02/21 at 8:00 A.M. was administered on 07/02/21 at 10:16 A.M. · Scheduled on 07/02/21 at 8:00 P.M. was administered on 07/02/21 at 10:01 P.M. · Scheduled on 07/01/21 at 8:00 A.M. was administered on 07/01/21 at 12:08 P.M. · Scheduled on 07/03/21 at 8:00 A.M. was administered on 07/03/21 at 11:04 A.M. · Scheduled on 07/04/21 at 8:00 A.M. was administered on 07/04/21 at 11:13 A.M. · Scheduled on 07/04/21 at 8:00 P.M. was administered on 07/04/21 at 9:20 P.M. · Scheduled on 07/05/21 at 8:00 P.M. was administered on 07/05/21 at 11:26 P.M. · Scheduled on 07/06/21 at 8:00 A.M. was administered on 07/06/21 at 9:35 A.M. [MEDICATION(S)] 40 mg daily in morning (used to treat gastroesophageal reflux disease): · Scheduled on 07/01/21 at 9:00 A.M. was administered on 07/01/21 at 12:08 P.M. · Scheduled on 07/03/21 at 9:00 A.M. was administered on 07/03/21 at 11:04 A.M. · Scheduled on 07/04/21 at 9:00 A.M. was administered on 07/04/21 at 11:13 A.M. Senna 8.6 mg twice daily (laxative): · Scheduled on 07/01/21 at 9:00 A.M. was administered on 07/01/21 at 12:08 P.M. · Scheduled on 07/03/21 at 9:00 A.M. was administered on 07/03/21 at 11:04 A.M. · Scheduled on 07/04/21 at 9:00 A.M. was administered on 07/04/21 at 11:13 A.M. [MEDICATION(S)] 10 mg daily (anti-inflammatory): · Scheduled on 07/04/21 at 5:00 P.M. was administered on 07/04/21 at 6:27 P.M. Review of the July 2021 MAR for Resident #37 revealed: [MEDICATION(S)] 80 mg daily: · Scheduled on 07/01/21 upon retiring in evening 8:00 P.M. to 11:00 P.M. was administered on 07/02/21 at 4:46 A.M. · Scheduled on 07/05/21 upon retiring in evening 8:00 P.M. to 11:00 P.M. was administered on 07/06/21 at 1:17 A.M. · Scheduled on 07/06/21 upon retiring in evening 8:00 P.M. to 11:00 P.M. was administered on 07/07/21 at 2:29 A.M. [MEDICATION(S)] 3.125 mg twice daily (used to treat high blood pressure and heart failure): · Scheduled on 07/02/21 at 4:00 P.M. to 6:00 P.M. was administered on 07/02/21 at 8:18 P.M. · Scheduled on 07/03/21 at 8:00 A.M. to 10:00 A.M. was administered on 07/03/21 at 11:34 A.M. · Scheduled on 07/05/21 at 4:00 P.M. to 6:00 P.M. was administered on 07/05/21 at 8:36 P.M. Culturelle (lactobacillus rhamnosus) 10 billion cell twice daily (probiotic): · Scheduled on 07/05/21 upon retiring in evening 8:00 P.M. to 11:00 P.M. was administered on 07/06/21 at 1:17 A.M. · Scheduled on 07/06/21 upon retiring in evening 8:00 P.M. to 11:00 P.M. was administered on 07/07/21 at 2:29 A.M. [MEDICATION(S)]-salmeterol blister with device 250-50 mcg per dose, 1 puff inhalation twice daily (allergy medication): · Scheduled on 07/05/21 upon retiring in evening 8:00 P.M. to 11:00 P.M. was administered on 07/06/21 at 1:17 A.M. · Scheduled on 07/06/21 upon retiring in evening 8:00 P.M. to 11:00 P.M. was administered on 07/07/21 at 2:29 A.M. [MEDICATION(S)] 300 mg twice daily: · Scheduled on 07/01/21 at 9:00 A.M. was administered on 07/01/21 at 11:15 A.M. · Scheduled on 07/02/21 at 5:00 P.M. was administered on 07/02/21 at 8:30 P.M. · Scheduled on 07/03/21 at 9:00 A.M. was administered on 07/03/21 at 11:34 A.M. · Scheduled on 07/03/21 at 5:00 P.M. was administered on 07/03/21 at 6:18 P.M. · Scheduled on 07/05/21 at 5:00 P.M. was administered on 07/05/21 at 8:36 P.M. [MEDICATION(S)] cream 0.1% topically to open lesion/boil to back twice daily (antibiotic): · Scheduled on 07/01/21 upon retiring in evening 8:00 P.M. to 11:00 P.M. was administered on 07/02/21 at 4:46 A.M. · Scheduled on 07/03/21 upon rising 8:00 A.M. to 11:00 A.M. was administered on 07/03/21 at 6:25 P.M. · Scheduled on 07/05/21 upon retiring in evening 8:00 P.M. to 11:00 P.M. was administered on 07/06/21 at 1:17 A.M. · Scheduled on 07/06/21 upon retiring in evening 8:00 P.M. to 11:00 P.M. was administered on 07/07/21 at 2:29 A.M. [MEDICATION(S)] KwikPen Insulin (insulin lispro) insulin pen 100 units per milliliter per sliding scale · Scheduled on 07/01/21 at 7:30 A.M. was administered on 07/01/21 at 11:15 A.M. · Scheduled on 07/01/21 at 11:00 A.M. was administered on 07/01/21 at 1:56 P.M. · Scheduled on 07/01/21 at 9:00 P.M. was administered on 07/02/21 at 4:46 A.M. · Scheduled on 07/02/21 at 4:00 P.M. was administered on 07/02/21 at 8:18 P.M. · Scheduled on 07/03/21 at 11:00 A.M. was administered on 07/03/21 at 6:22 P.M. · Scheduled on 07/03/21 at 4:00 P.M. was administered on 07/03/21 at 6:22 P.M. · Scheduled on 07/05/21 at 4:00 P.M. was administered on 07/05/21 at 8:36 P.M. · Scheduled on 07/06/21 at 7:30 A.M. was administered on 07/06/21 at 11:25 A.M. · Scheduled on 07/06/21 at 11:00 A.M. was administered on 07/06/21 at 1:32 P.M. · Scheduled on 07/06/21 at 9:00 P.M. was administered on 07/07/21 at 2:29 A.M. [MEDICATION(S)]-[MEDICATION(S)] solution for nebulization 0.5 mg-3 mg per 3 ml inhalation twice daily: · Scheduled on 07/01/21 upon retiring in evening 8:00 P.M. to 11:00 P.M. was administered on 07/02/21 at 4:46 A.M. · Scheduled on 07/03/21 upon rising 8:00 A.M. to 11:00 A.M. was administered on 07/03/21 at 6:25 P.M. [MEDICATION(S)] 20 mg twice daily · Scheduled on 07/02/21 at 4:00 P.M. to 6:00 P.M. was administered on 07/02/21 at 8:18 P.M. · Scheduled on 07/03/21 at 8:00 A.M. to 10:00 A.M. was administered on 07/03/21 at 11:34 A.M. [MEDICATION(S)] 5 mg at bedtime: · Scheduled on 07/01/21 at 9:00 P.M. was administered on 07/02/21 at 4:46 A.M. · Scheduled on 07/06/21 at 9:00 P.M. was administered on 07/07/21 at 2:29 A.M. [MEDICATION(S)] 75 mg daily (blood thinner): · Scheduled on 07/03/21 at 8:00 A.M. to 10:00 A.M. was administered on 07/03/21 at 11:34 A.M. [MEDICATION(S)] ([MEDICATION(S)]) 40 mg twice daily (used to treat gastroesophageal reflux disease): · Scheduled on 07/01/21 upon retiring in evening 8:00 P.M. to 11:00 P.M. was administered on 07/02/21 at 4:46 A.M. · Scheduled on 07/06/21 upon retiring in evening 8:00 P.M. to 11:00 P.M. was administered on 07/07/21 at 2:29 A.M. [MEDICATION(S)] 500 mg every six hours (muscle relaxant): · Scheduled on 07/01/21 at 12:00 A.M. was administered on 07/01/21 at 3:53 A.M. · Scheduled on 07/01/21 at 6:00 A.M. was administered on 07/01/21 at 7:21 A.M. · Scheduled on 07/02/21 at 12:00 A.M. was administered on 07/02/21 at 4:46 A.M. · Scheduled on 07/02/21 at 12:00 P.M. was administered on 07/02/21 at 8:18 P.M. · Scheduled on 07/02/21 at 6:00 P.M. was administered on 07/02/21 at 8:18 P.M. · Scheduled on 07/05/21 at 12:00 P.M. was administered on 07/05/21 at 8:36 P.M. · Scheduled on 07/05/21 at 6:00 P.M. was administered on 07/05/21 at 8:36 P.M. · Scheduled on 07/06/21 at 12:00 P.M. was administered on 07/06/21 at 1:32 P.M. · Scheduled on 07/07/21 at 12:00 A.M. was administered on 07/07/21 at 2:29 A.M. [MEDICATION(S)] 25 mg daily (antipsychotic): · Scheduled on 07/01/21 upon retiring in evening 8:00 P.M. to 11:00 P.M. was administered on 07/02/21 at 4:46 A.M. · Scheduled on 07/06/21 upon retiring in evening 8:00 P.M. to 11:00 P.M. was administered on 07/07/21 at 2:29 A.M. Review of the July 2021 MAR for Resident #27 revealed: [MEDICATION(S)] 20 mg daily · Scheduled on 07/02/21 upon rising 8:00 A.M. to 11:00 A.M. was administered on 07/02/21 at 5:31 P.M. [MEDICATION(S)] 2.5 mg twice daily (blood thinner): · Scheduled on 07/02/21 upon rising 8:00 A.M. to 11:00 A.M. was administered on 07/02/21 at 5:31 P.M. [MEDICATION(S)] 25 mg twice daily · Scheduled on 07/02/21 upon rising 8:00 A.M. to 11:00 A.M. was administered on 07/02/21 at 5:31 P.M. Review of the July 2021 MAR for Resident #38 [MEDICATION(S)] 10 mg daily (used to treat high blood pressure and chest pain): · Scheduled on 07/05/21 upon rising 8:00 A.M. to 11:00 A.M. was administered on 07/05/21 at 6:26 P.M. Aspirin 81 mg daily: · Scheduled on 07/05/21 upon rising 8:00 A.M. to 11:00 A.M. was administered on 07/05/21 at 6:26 P.M. [MEDICATION(S)]-[MEDICATION(S)] 25-100 mg every eight hours (used to treat [CONDITION(S)] disease): · Scheduled on 07/02/21 at 2:00 P.M. was administered on 07/02/21 at 8:19 P.M. · Scheduled on 07/05/21 at 2:00 P.M. was administered on 07/05/21 at 8:17 P.M. · Scheduled on 07/06/21 at 2:00 P.M. was administered on 07/05/21 at 7:19 P.M. [MEDICATION(S)] (vitamin D3) 25 mcg (1,000 unit) daily (supplement): · Scheduled on 07/05/21 upon rising 8:00 A.M. to 11:00 A.M. was administered on 07/05/21 at 6:26 P.M. Dorzolamide drops 2%, one drop to right eye every eight hours (used to treat glaucoma): · Scheduled on 07/02/21 at 2:00 P.M. was administered on 07/02/21 at 8:19 P.M. · Scheduled on 07/05/21 at 2:00 P.M. was administered on 07/05/21 at 8:17 P.M. [MEDICATION(S)] 20 mg daily (diuretic) · Scheduled on 07/05/21 upon rising 8:00 A.M. to 11:00 A.M. was administered on 07/05/21 at 6:26 P.M. [MEDICATION(S)] 400 mg three times daily: · Scheduled on 07/02/21 at 1:00 P.M. was administered on 07/02/21 at 8:19 P.M. · Scheduled on 07/02/21 at 5:00 P.M. was administered on 07/02/21 at 8:19 P.M. · Scheduled on 07/05/21 at 1:00 P.M. was administered on 07/05/21 at 8:17 P.M. · Scheduled on 07/05/21 at 5:00 P.M. was administered on 07/05/21 at 8:17 P.M. · Scheduled on 07/06/21 at 5:00 P.M. was administered on 07/06/21 at 7:19 P.M. [MEDICATION(S)] 20 mg daily (used to treat gastroesophageal reflux disease): · Scheduled on 07/05/21 upon rising 8:00 A.M. to 11:00 A.M. was administered on 07/05/21 at 6:26 P.M. Tylenol 650 mg four times daily (pain reliever) · Scheduled on 07/02/21 at 1:00 P.M. was administered on 07/02/21 at 8:19 P.M. · Scheduled on 07/02/21 at 5:00 P.M. was administered on 07/02/21 at 8:19 P.M. · Scheduled on 07/05/21 at 1:00 P.M. was administered on 07/05/21 at 8:17 P.M. · Scheduled on 07/05/21 at 5:00 P.M. was administered on 07/05/21 at 8:17 P.M. · Scheduled on 07/06/21 at 9:00 A.M. was administered on 07/06/21 at 11:10 A.M. · Scheduled on 07/06/21 at 5:00 P.M. was administered on 07/06/21 at 7:19 P.M. Interview with Assistant Director of Nursing (ADON) #3 on 07/07/21 at 6:25 P.M. confirmed medications were late as documented on MAR's for the above residents. Review of the concern forms from 04/20/21 revealed on 04/19/21 Resident #27 did not receive a shower for five days; on 04/20/21 Resident #23 complained it took too long to receive medication on 04/17/21 even after asking three times; on 05/04/21 Resident #38 was soaked with urine and had on the same clothes for two days; on 05/25/21 Resident #22 complained of being wet on 05/23/21 in the morning and waited for two hours to be changed; on 05/26/21 Resident #1 complained did not get dressed until early afternoon; on 06/08/21 Resident #10 complained of no showers and not getting resident out of bed; on 06/25/21 Resident #26 complained the call light was not answered, and Resident #36 complained the call light was not answered in a timely manner. Review of nursing staffing schedules from 06/07/21 to 07/07/21 revealed frequent staff call-offs, staff no-call no-show, and staff leaving early. Review of shower sheets for Resident #38 revealed showers for 06/08/21 through 07/08/21 revealed Resident #38 received a shower on 06/26/21 and refused a shower on 06/04/21. There were no other shower sheets available for any other resident in the facility per the Director of Nursing (DON). This deficiency substantiates Master Complaint Number OH 930 and Complaint Numbers OH 747 and OH 484.

Based on interview and record review the facility failed to provide a diet that met the nutritional needs of the residents. This affected all but three (Resident's #7, #14 and #39) who received nothing by mouth. The facility had a census of 44. Findings include: Interview with Resident #9 on 07/07/21 at 5:02 P.M. confirmed two slices of pizza were served for lunch on 07/05/21. She stated she heard staff discussing no kitchen staff had shown up for the day. Interview with Resident #42 on 07/07/21 at 5:17 P.M. revealed he was served cereal on Monday 07/05/21 for breakfast and two slices of pizza for lunch. He stated he heard staff discussing no kitchen staff had shown up for the day. Interview with the Administrator on 07/07/21 at 3:16 P.M. revealed the pizza boxes in the activities room were for staff personally ordered by the Administrator on 07/05/21. Interview with State tested Nurse Aide (STNA) #49 on 07/07/21 at 4:36 P.M. revealed the daughter of Resident #13 brought in breakfast for her mother due to breakfast not being served. She revealed the cook called off on 07/05/21, and the Administrator ordered pizza for the residents for lunch. Interview with the Administrator on 07/07/21 at 6:19 P.M. confirmed no cook or dietary staff were available on 07/05/21, and cereal, danishes, eggs, juices, coffee, and oatmeal were prepared by the nursing and STNA staff. Pizza was ordered by the Administrator for lunch. The residents on pureed diets had food prepared by the nursing staff. Review of the facility menu revealed on 07/05/21 the residents were supposed to receive quiche and toast for breakfast and beef tetrazzini, side salad, garlic toast and carrot cake for lunch. Review of the receipt from an outside eating establishment pizza was ordered and delivered to front door of the facility on 07/05/21.

Based on interview and record review the facility failed to provide a qualified dietary supervisor. This affected all but three (Resident's #7, #14 and #39) who received nothing by mouth. The facility had a census of 44. Findings include: Interview with the Dietitian on 07/07/21 at 6:00 P.M. revealed the facility has not had a dietary manager for five weeks. She stated the facility has been staffed by her and other cooperate staff in the meantime. She confirmed the cook and dietary staff reported off for 07/05/21, and she learned on 07/07/21 the Administrator had ordered pizza for the facility on 07/05/21. Interview with the Administrator on 07/07/21 at 6:19 P.M. confirmed no cook or dietary staff were available on 07/05/21, and cereal, danishes, eggs, juices, coffee, and oatmeal were prepared by the nursing and state tested nurse aide (STNA) staff. Pizza was ordered by the Administrator for lunch. Residents on pureed diets had food prepared by the nursing staff. Interview with the Administrator on 07/08/21 at 12:00 P.M. revealed Cook #30 was in the facility on 07/05/21. There was no time punch for Cook #30 noted on timecard detail report. Stated we did the best we could in an emergent situation and revealed they did not notify the resident's physicians of the menu change. Interview with the Director of Nursing (DON) on 07/08/21 at 12:11 P.M. revealed she did not work on 07/05/21, and she was not sure who prepared meals, and no physicians were notified of the menu changes. Review of the facility menu revealed on 07/05/21 the residents were supposed to receive quiche and toast for breakfast and beef tetrazzini, side salad, garlic toast and carrot cake for lunch. Review of the receipt from an outside eating establishment pizza was ordered and delivered to front door of the facility on 07/05/21. Review of the dietary schedule dated 07/04/21 to 07/10/21 revealed on 07/05/21 the cook called off and the two dietary aides were scheduled to work from 6:00 A.M./6:30 A.M. to 2:00 P.M. Review of the personnel documentation for the former Dietary Manager revealed the last day worked was 06/03/21.

Based on interview and record review the facility failed provide necessary dietary staff to meet resident needs. This affected all but three (Resident's #7, #14 and #39) who received nothing by mouth. The facility had a census of 44. Findings include: Interview with Resident #42 on 07/07/21 at 5:17 P.M. revealed he was served cereal on Monday 07/05/21 for breakfast and two slices of pizza for lunch. He stated he heard staff discussing no kitchen staff had shown up for the day. Interview with the Administrator on 07/07/21 at 3:16 P.M. revealed the pizza boxes in the activities room were for staff personally ordered by the Administrator on 07/05/21. Interview with State tested Nurse Aide (STNA) #49 on 07/07/21 at 4:36 P.M. revealed the daughter of Resident #13 brought in breakfast for her mother due to breakfast not being served. She revealed the cook called off for 07/05/21, and the Administrator ordered pizza for the residents for lunch. Interview with the Dietitian on 07/07/21 at 6:00 P.M. revealed the facility has not had a dietary manager for five weeks. She stated the facility has been staffed by her and other cooperate staff in the meantime. She confirmed the cook and dietary staff reported off for 07/05/21, and she learned on 07/07/21 the Administrator had ordered pizza for the facility on 07/05/21. Interview with the Administrator on 07/07/21 at 6:19 P.M. confirmed no cook or dietary staff were available on 07/05/21, and cereal, danishes, eggs, juices, coffee, and oatmeal were prepared by the nursing and STNA staff. Pizza was ordered by the Administrator for lunch. Residents on pureed diets had food prepared by the nursing staff. Interview with the Administrator on 07/08/21 at 12:00 P.M. revealed Cook #30 was in the facility on 07/05/21. There was no time punch for Cook #30 noted on timecard detail report. Stated we did the best we could in an emergent situation and revealed they did not notify the resident's physicians of the menu change. Interview with the Director of Nursing (DON) on 07/08/21 at 12:11 P.M. revealed she did not work on 07/05/21, and she was not sure who prepared meals, and no physicians were notified of the menu changes. Review of the dietary schedule dated 07/04/21 to 07/10/21 revealed on 07/05/21 the cook called off and the two dietary aides were scheduled to work from 6:00 A.M./6:30 A.M. to 2:00 P.M. Review of the receipt from an outside eating establishment pizza was ordered and delivered to front door of the facility on 07/05/21. Review of personnel documentation for former Dietary Manager revealed last day worked 06/03/21.

Based on record review, interview, and review of the Ohio Board of Nursing guidance for licensure, the facility failed to ensure Licensed Practical Nurse (LPN) #504 had an active Ohio nursing license. This had the potential to affect all 44 residents residing in the facility. Findings include: Review of the personnel file for LPN #504 revealed the LPN had a start date of [DATE] with an active Ohio nursing license at the time of hire. Review of LPN #504's Ohio nursing license verification on [DATE], revealed the LPN's nursing license expired on [DATE]. Review of facility job description on [DATE], revealed a qualified nurse must hold a current license to practice as a Registered Nurse or Licensed Practical Nurse in the practicing state. Review of the Ohio Board of Nursing guidance on licensure, https://nursing.ohio.gov/licensing-certification-ce/, retrieved on [DATE], revealed if your license is inactive, you cannot work in Ohio until you apply to reactivate your license. Interview on [DATE] at 4:25 P.M. with the Administrator and Human Resources #570, confirmed LPN #504's nursing license had unknowingly expired on [DATE]. They also confirmed LPN #504 had continued to work for the month of July on the following dates: [DATE] from 7:00 A.M. to 9:45 P.M., on [DATE] from 7:00 A.M. to 8:15 P.M., on [DATE] from 7:00 A.M. to 12:45 A.M. on [DATE], on [DATE] from 7:00 A.M. to 8:45 P.M., on [DATE] from 2:45 P.M. to 11:45 P.M., and on [DATE] from 2:45 P.M. to 1:15 A.M. on [DATE]. At time of interview, the Administrator revealed LPN #504 had been removed from the nursing schedule until proof was obtained that LPN #504's nursing license was reactivated.

Based on observation, interview and policy review, the facility failed to ensure staff donned the appropriate personal protective equipment (PPE) prior to entering a resident room under contact precautions. This had the potential to affect all 44 residents residing in the facility. In addition, based on observation, interview, review of the Centers for Disease Control and Prevention (CDC) guidance for cleaning blood glucose meters and manufactures guidelines, the facility failed to ensure blood glucose meters were properly cleaned between uses and failed to ensure sanitary medication administration to Resident #21. This affected one (Resident #21) of three residents reviewed for medication administration and had the potential to affect all 44 residents residing in the facility. Findings include: 1. Observation during a facility tour on 07/12/21 revealed resident room [ROOM NUMBER] was under contact precautions. Laminated signs were clearly posted on the outside of the door instructing providers and staff to stop and sanitize hands and to don PPE before entering the room. Signage was also posted related to the sequence for putting on PPE and how to safely remove PPE. A cart with enough face masks, gloves, and gowns was located outside the door at the entrance to the room. Observation on 07/12/21 at 11:20 A.M. Registered Nurse (RN) #503 and State tested Nurse Aide (STNA) #502 (wearing surgical masks) sanitized their hands and entered resident room [ROOM NUMBER] without donning a gown, gloves, and face shield, the required PPE, prior to entering the room. Observation on 07/12/21 at 11:23 A.M. revealed RN #503 and STNA #502 exit resident room [ROOM NUMBER] and sanitize their hands. Interview on 07/12/21 at 11:23 A.M. with RN #503 and STNA #502 both confirmed resident room [ROOM NUMBER] was clearly identified as being under contact precautions and had a PPE cart at the door with the required PPE. Both RN #503 and STNA #502 confirmed they had entered the resident's room without donning the required PPE as instructed by the signage posted outside of the door. Review of facility policy titled 2019 Novel Coronavirus (COVID-19), dated 01/2021, revealed all recommended PPE should be worn during the care of residents under observation; this includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or disposable face shield that covers the front and sides of the face), gloves, and gown. Interview on 07/12/21 at 12:18 P.M. with Infection Control Preventionist, RN #501, verified the resident in room [ROOM NUMBER] was admitted on [DATE] and would be in isolation for 14 days with contact precautions in place until 07/16/21. During the interview, RN #501 confirmed staff were required to wear the designated PPE prior to entering a resident room under contact precautions. 2. Observation of Registered Nurse (RN) #515 on 07/14/21 at 8:00 A.M. pouring medication for Resident #46 revealed she was pushing the [MEDICATION(S)] (medication to treat high blood pressure and chest pain) 10 milligram (mg) tablet out of the card it missed the medication cup and landed on the top of the medication cart. RN #515 then proceeded to pick up the medication with her hand and put it back in the resident's medication cup. Interview with RN #515 after all the medication was poured, revealed she verified she used her hands to pick up the [MEDICATION(S)] and put it into the medication cup. RN #515 then proceeded to crush all the medications that were in the cup with the [MEDICATION(S)], poured it into a new cup, added pudding to the crushed medications and walked into the resident's room with the medication. This surveyor stopped the RN in the room from administering the medication. Outside the room, this surveyor asked the RN what she did with the [MEDICATION(S)] that she touched, and she verified she had left it in the cup and did not remove it. Review of this facility's Medication Administration Procedures dated 05/19 revealed no medication is to be touched with the fingers of the nurse. Maintain sanitary techniques during medication administration. 3. Observation of a finger stick blood sugar check (accu-check) on 07/14/21 at 7:40 A.M. with RN #523 revealed she obtained an accu-check on Resident #9. RN #523 removed her gloves, washed her hands, and exited the resident's room. She stopped at her medication cart and grabbed one alcohol pad and wiped down the glucometer. She then walked into Resident #21's room and used hand sanitizer while holding the wet glucometer in her hand. She proceeded into Resident #21's room and obtained his accu-check. Interview with RN #523 on 07/14/21 at 8:00 A.M. verified that she did not wait for the glucometer to dry and wiped it off using an alcohol pad. She verified the accu-check was still damp when she obtained Resident #21's blood sugar. When asked what the policy regarding the cleaning of the glucometer was, she stated she did not know, and she did not know where the bleach wipes were at, so she wiped it down with alcohol. Review of the Center for Disease Control and Prevention retrieved on 07/15/21 revealed whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use per the manufacturer's guidelines. If the manufacturer does not specify how the device should be cleaned, then it should not be shared. Review of the Assure Platinum Glucose Monitoring Manual the monitor should be cleaned and disinfected taking care not to get any of the germicidal fluid into the test strip port. Wipe the surface of the meter to clean blood and other body fluids and then dispose of the towelette. Take out another towelette and wipe the entire surface of the meter again horizontally. Treated surface of the meter must remain wet for recommended contact time. The surface area of the glucometer must remain visibly wet for two full minutes to effectively kill blood borne pathogens and to prevent cross contamination. This deficiency substantiates Complaint Number OH 930.