Every finding on record at Altercare of Mayfield Village, Inc

Based on observation, interview, record review, and facility policy review, the facility failed to ensure Wildwood nursing unit's refrigerator was maintained in a safe, clean and sanitary manner to prevent bacterial growth and foodborne illness. This had the potential to affect 15 residents (Residents #1, #4, #5, #14, #20, #22, #26, #32, #37, #53, #60, #71, #75, #76 and #77) who resided on Wildwood nursing unit and had a diet order. The facility census was 43.Findings include:Observation on 07/27/26 at 8:56 A.M. of the Wildwood nursing unit refrigerator which sat upon a counter revealed the area right in front of the refrigerator door was heavily soiled with a dried brown colored substance. The inside of the refrigerator was packed with food items with a temperature of 44 degrees Fahrenheit (the Centers for Disease Control recommends keeping the refrigerator at 40 degrees Fahrenheit or below to prevent bacterial growth and foodborne illness). The inside door shelves had various food splatters. The inside bottom of the refrigerator had various splatters and was wet to the touch. On the next shelf up from the bottom was a container of moldy cake unlabeled and undated, and a plastic bag of food items not labeled or dated.Interview on 07/27/26 at 8:58 A.M. with Dietary Manager (DM) #547 verified the above findings and stated they would get the refrigerator cleaned. Review of the diet order report revealed 15 residents (Residents #1, #4, #5, #14, #20, #22, #26, #32, #37, #53, #60, #71, #75, #76 and #77) who resided on Wildwood nursing unit and had a diet order.Review of facility policy Food Brought to Residents by Family and Visitors, dated 11/01/17 revealed food item(s) will be labeled with the resident's name, the date it was prepared, if known, and an expiration date. Cleaning procedures were in place for the food storage and microwave areas. Monitoring food items for expiration will be completed by designated facility staff.

Based on medical record review, observation, interview, review of the Centers for Disease Control guidelines and facility policy review, the facility failed to ensure hand hygiene, enhanced barrier precautions (EBP) and contact isolation precautions were implemented and maintained. This affected four residents (Residents #4, #14, #20 and #32) of six residents reviewed for infection control. The facility census was 43. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 06/12/26 with diagnoses of cerebral infarction, hemiplegia and hemiparesis affecting the left non-dominant side, heart failure, vascular dementia, protein-calorie malnutrition, chronic kidney disease, and stage four (full-thickness skin and tissue loss exposing muscle, tendon, ligament, cartilage or bone) pressure ulcer to coccyx. Review of the Quarterly Minimum Data Set (MDS) assessment revealed Resident #14 was dependent on staff for all activities of daily living (ADLs). The resident was always incontinent with bowel and bladder and had pressure wounds. Review of Resident #14's care plan dated 07/20/26 revealed goals and interventions for hospice services, wound care for a stage four pressure wound on the coccyx, and EBP. Review of Resident #14's physician orders revealed the resident was placed on EBP on 06/15/26 due to a sacral/coccyx pressure wound. Observation on 07/27/26 at 9:40 A.M. of wound dressing change for Resident #14 with Registered Nurse (RN) #601 and Certified Nursing Assistant (CNA) #572 revealed they both performed hand hygiene prior to donning gloves, however; no gowns were donned prior to changing the wound dressing. On Resident #14's door was signage for EBP instructing to perform hand hygiene, and to don a gown and gloves prior to high contact care with the resident including dressing changes. Interview at the time of the observation with RN #601 and CNA #572 verified they both forgot to use a gown. Interview with Director of Nursing (DON) on 07/28/26 at 1:00 P.M. revealed all staff should be following the EBP guidelines and have been educated. Review of facility policy titled, Enhanced Barrier Precautions revised 05/01/25 revealed EBP were used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact resident care activities. EBP were indicated for residents with chronic wounds even if not known to be infected or colonized with a multidrug-resistant organism. 2. Record review of Resident #4 revealed an order dated 07/26/26 for contact isolation precautions until stool results were received and C. diff (Clostridioides difficile) infection could be ruled out. Review of her chart revealed a note on the same date revealing she had persistent diarrhea for five weeks, and the provider ordered her to go on contact isolation pending the results of a stool test. The record review revealed no evidence that the stool was collected or results were processed. Record review of the CDC guidelines C. diff: Facts for Clinicians website revealed C. diff was shed in the feces and could transfer to patients by the hands of healthcare personnel who touched contaminated items. If patients were suspected of C. diff, they were to be isolated and tested. Gloves and gowns were to be worn when treating them. Hand sanitizer did not kill C. diff. Observation of Resident #4's room on 07/28/26 at 9:19 A.M. revealed it had a posted EBP sign advising that anyone entering or leaving the room must wash or sanitize their hands, and that staff performing high-contact activities were to don gloves and a gown. The sign made no mention of requiring soap and water handwashing or of the resident being on contact precautions. Interview with RN #550 on 07/28/26 at 11:01 A.M. confirmed Resident #4 was ordered contact isolation for C. diff and did not have the correct isolation sign posted. Record review of the facility's undated C. diff policy revealed affected residents were to go on contact precautions. Hand sanitizer was not to be used for affected residents, as alcohol-based sanitizer was not effective in killing C. diff. Record review of the facility's undated isolation policy revealed residents on contact isolation were to have signs placed outside their room to inform visitors of appropriate protective equipment to wear. Gowns and gloves were to be worn when entering affected rooms. 3. Observation during medication administration on 07/28/26 at 7:30 A.M. by CNA/Medication Technician #572 on the 300-400 hallway revealed no hand hygiene was performed prior to compiling medications, and before/after contact with Residents #20 and #32 during the medication administration. CNA/Medication Tech #572 was stopped to prevent any further occurrences with other residents. Interview at the time of the observation with CNA/Medication Tech #572 verified he forgot to perform hand hygiene prior to compiling medications and contact with both Residents #20 and #32. Interview with DON on 07/28/26 at 1:00 P.M. stated hand hygiene should have been performed and she would re-educate staff. Review of facility policy titled, Hand Washing-Hygiene revised 05/01/24, revealed hand hygiene was to be performed before direct contact with a resident, before donning gloves, before preparing or handling medications, and after resident contact. This deficiency represents non-compliance investigated under Complaint Number 2729946.

Based on medical record review, interview, and review of facility policy and dialysis agreement, the facility failed to ensure ongoing communication between the facility and the dialysis center. This affected one resident (Resident #74) of one resident reviewed for dialysis treatment. The facility census was 43.Findings include:Review of the medical record for Resident #74 revealed an admission date of 07/22/26. Diagnoses included end stage renal disease, dependence on renal dialysis, cognitive communication deficit, and moderate vascular dementia with agitation.Review of Resident #74's physician orders for July 2026 revealed an order for dialysis every Monday, Wednesday, and Friday with chair time at 10:00 A.M; to complete the pre-dialysis observation and vital signs on dialysis days on Monday, Wednesday, and Friday; and Epogen solution (an injectable medication used to treat anemia) 10,000 units per milliliter (ml) 0.3 ml to be given at dialysis.Review of Resident #74's pre-hemodialysis observation forms dated 07/24/26 and 07/27/26 revealed section one noted completed by nursing home staff (send with patient to dialysis center) with section one completed with mental status, no significant changes since last dialysis treatment, vital signs, weight, and skin assessment. There was a section for the dialysis center to complete for post dialysis information, but the section was blank on both forms dated 07/24/26 and 07/27/26.Interview on 07/28/26 at 2:50 P.M. with Director of Nursing (DON) revealed there were no dialysis communication forms that go back and forth between the facility and the dialysis center. DON stated if there was an issue they would call or vice versa. DON stated the facility did their own pre and post forms at the facility. Interview on 07/28/26 at 3:43 P.M. with Regional Clinical Nurse (RCN) #600 verified the pre-hemodialysis forms dated 07/24/26 and 07/27/26 for Resident #74 indicated that they should be sent to the dialysis center with the resident.Interview on 07/29/26 at 10:43 A.M. with Dialysis Staff (DS) #606 via phone revealed typically facilities would have a communication log where they would complete the pre and post weights, vital signs, and medications given. DS #606 stated she was on vacation since 07/22/26 and was back today. DS #606 stated her coworker was covering and stated the facility did not send any paperwork with Resident #74 for them to complete during that time. DS #606 stated Resident #74 was at the dialysis center at time of interview and did not have paperwork from the facility.Review of the dialysis agreement between the facility and the dialysis center dated 02/17/17 revealed under article III, responsibilities of facility noted under the interchange of information use/necessary for the care of the resident, revealed the nursing facility agreed to cooperate in facilitating and communicating information to the dialysis center which was useful or necessary for the care of a resident. Review of the facility policy titled Hemo Dialysis, updated 05/01/25 revealed under general guidelines noted the facility will have a communication system with the dialysis center which may include phone calls, facsimiles, or report sheets.

Based on medical record review, interview, and facility policy preview, the facility failed to accurately identify and adequately treat a pressure wound. This affected one resident (Resident #36) of four residents reviewed for pressure injuries. The facility census was 43.Findings include:Review of the medical record for Resident #36 revealed an admission date of 04/13/26. Diagnoses included osteoarthritis, weakness, morbid (severe) obesity due to excess calories, and pain in left hip.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had intact cognition, rejection of care one to three days of the look back period, required setup and clean up help for eating, and was dependent on toileting hygiene, rolling left and right, and transfers. Resident #36 was noted with a skin tear and had pressure-reducing devices in place. Review of Resident #36's progress note dated 07/17/26 at 11:25 A.M. revealed a new skin tear on the left lower ankle exactly where the sock stopped, and plus two (moderate) pitting edema of the bilateral lower extremities. The nurse practitioner was made aware, and a message was left with Resident #36's daughter. A foam dressing was placed and there were no complaints of pain.Review of Resident #36's physician orders for July 2026 revealed an order for the left lower leg to cleanse with normal saline, pat dry, and apply a foam dressing every 24 hours and as needed dated 07/17/26 and discontinued on 07/20/26. There was an order dated 07/20/26 for the left lower leg to cleanse with normal saline, pat dry, and apply a foam dressing as needed and was discontinued on 07/23/26.Review of Resident #36's progress note dated 07/21/26 at 12:23 P.M. revealed Assistant Director of Nursing (ADON) #550 observed an area reported as a skin tear. The area was warm to touch, swollen, and red. The legs in general were edematous. Pulses were felt to both legs, and it was indicative of cellulitis. The nurse practitioner was made aware of the findings and a new order received for doxycycline (antibiotic)100 milligrams (mg) twice daily for seven days. All parties were made aware and the resident was to be seen by the wound nurse practitioner on the following Thursday. Care remained ongoing.Review of Resident #36's treatment administration record (TAR) for July 2026 revealed for the left lower leg orders were signed off as completed on 07/17/26, 07/18/26, and 07/19/26. There were no routine orders for or evidence of any dressing changes dated 07/20/26, 07/21/26 and 07/22/26.Review of Resident #36's wound care note dated 07/23/26 revealed an initial consultation for an in-house unstageable wound on the right medial leg measuring 2.5 centimeters (cm) length by 6.7 cm width and unable to determine the depth. The skin surrounding the wound was reddened, fragile, but intact. There were no signs or symptoms of infection for the wound but the skin around the wound was being treated with an antibiotic for cellulitis per the primary care physician. It indicated the wound had resulted from the tight socks due to Resident #36's severe edema. Treatment orders included normal saline, anasept gel (clear medical-grade hydrogel designed to maintain a moist healing environment and kill harmful bacteria), and bordered gauze dressing and ace wrap daily and as needed. Recommendations included to offload heels per facility protocol, reposition per facility protocol, and nutritional consult per facility protocol.Additional review of Resident #36's physician orders for July 2026 revealed an order dated 07/23/26 for right medial leg, cleanse with normal saline, pat dry, apply anasept gel and foam dressing daily and as needed once a day between 7:30 P.M. and 7:30 A.M. and ace wraps to bilateral legs on in the morning and off at bedtime for edema. There was no order for a nutrition consult.Review of Resident #36's plan of care dated 07/23/26 revealed a pressure injury located on the right medial leg related to impaired mobility, edema, urinary incontinence, bowel incontinence, poor nutritional intake, poor sensory perception, friction/shearing concerns, history of impaired skin integrity, and non-compliance. Interventions included nutritional status assessment as needed and perform current treatment as ordered. Interview on 07/27/26 at 9:59 A.M. with Resident #36 revealed she had a leg wound that she acquired while at the facility. Resident #36 stated the staff were to change her wound dressings daily, but it was not always done until recently.Interview on 07/29/26 at 1:56 P.M. with Registered Dietitian (RD) #605 revealed she was at the facility on Mondays and Wednesdays. RD #605 stated she typically was made aware of wounds or pressure injuries by running the wound report once weekly on Mondays. RD #605 stated at times ADON #550 would also notify her verbally while she was at the facility or via email. RD #605 stated she was not aware that Resident #36 had an unstageable pressure injury because she did not run the wound report when she was at the facility on 07/27/26 nor did ADON #550 inform her. RD #605 stated the last wound report she ran was on 07/13/26 and Resident #36 was not on it.Interview on 07/29/26 at 3:28 P.M. with ADON #550 and Regional Clinical Nurse (RCN) #600 revealed ADON #550 stated on 07/21/26 she saw Resident #36's wound and at that time it was an open area and the surrounding skin was red with a rash. ADON #550 stated she talked to the provider for oral antibiotic for cellulitis. ADON #550 stated there was a treatment in place for the wound to cleanse with normal saline and apply foam. ADON #550 stated the wound was on the right medial leg although the order indicated it was for the left lower leg. ADON #600 stated RD #605 was usually notified of wounds by running the wound report or she would let RD #605 know. ADON #550 stated she could not recall if she informed RD #605 of Resident #36's wound.Interview on 07/29/26 at 4:31 P.M. with RCN #600 verified when the wound treatment orders were changed on 07/20/26 there were no routine dressing orders put in place. RCN #600 verified there was no evidence that wound treatments were completed on 07/20/26, 07/21/26, and 07/22/26. RCN #600 was informed Resident #36 stated her wound dressing changes were not being done daily as ordered. RCN #600 stated those were possibly the days that Resident #36 was referring to. Interview on 07/30/26 at 9:30 A.M. with Wound Nurse Practitioner (WNP) #607 stated Resident #36's wound was improving from the previous week. WCP #607 stated that last week the wound was larger and was initiated from her sock. WNP #607 stated the redness surrounding the wound was gone and the wound itself had gotten smaller. WNP #607 stated she recommended a nutritional consult as it was a baseline recommendation across the industry. WNP #607 stated nutrition was beneficial, assuming Resident #36 was losing protein. WNP #607 stated Resident #36 had an unstageable pressure injury and nutrition was complementary, whereas if the wound was a stage three (deep, full-thickness skin loss) or greater or if the resident had poor appetite, nutrition would need to be on board.Review policy Pressure Injuries: Assessment, Prevention & Treatment, updated 05/01/26 revealed it was the facility's policy to identify residents at risk for developing pressure injuries, implement interventions to prevent the development of pressure injuries and provide care for existing pressure injuries. This deficiency represents non-compliance investigated under Complaint Number 2729946.

Based on closed medical record review, review of 911 communications, review of the American Heart Association (AHA) guidance for adult Cardiopulmonary Resuscitation (CPR), review of Ohio Revised Code related to pronouncement of death, facility policy review, and interview, the facility failed to ensure Resident #46, who had a Full Code status, received appropriate and timely emergency response (including CPR) consistent with the resident's advance directives, facility policy, professional standards of practice, and physician expectations. This resulted in Immediate Jeopardy and Actual Harm with subsequent death on [DATE] at 7:20 A.M. when Resident #46 was found unresponsive (without vital signs) and Licensed Practical Nurse (LPN) #509 discontinued cardiopulmonary recusation (CPR) without a physician order, without emergency medical services (EMS) present, and without the qualifications necessary to pronounce the resident deceased . Additionally, LPN #510 failed to ensure EMS response by canceling or miscommunicatingwith 911, resulting in EMS never arriving on the scene. This affected one resident (#46) of eight residents reviewed for change of condition. The facility census was 45. On [DATE] at 4:45 P.M. the Administrator, Director of Nursing (DON) and Corporate Regional Nurse (CRN) #603 were notified Immediate Jeopardy began on [DATE] at approximately 7:20 A.M., when Resident #46 was found unresponsive, and facility staff failed to follow the facility CPR policy requiring immediate initiation of CPR, activation of 911, and continuation of CPR until EMS arrival or physician instruction. Instead, CPR was stopped prematurely, EMS never entered the facility, and the physician did not authorize cessation of life-saving efforts. The resident was subsequently pronounced deceased at the facility. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 7:53 A.M. the Administrator notified CRN #603 and requested assistance with an investigation into the death of Resident #46. On [DATE] at 11 :00 A.M. immediate education was initiated for licensed nurses in the facility by CRN #603, regarding the facility policy titled Change in Condition, facility policy titled CPR, staff emergency response expectations, education related to physician was required to determine time of death/discontinuation of resuscitation efforts and the facility notification procedure. Education was completed on [DATE] at 6:00 P.M. when five of seven (5/7) Registered Nurses (RN) (one RN was out on leave and one RN was considered as needed (PRN) and would receive education upon return) and eight of eight (8/8) Licensed Practical Nurses (LPN) were educated. The facility also implemented a plan that upon hire, all new licensed nurses would be educated by the Director of Nursing (DON)/designee regarding the above information. Agency nurses and any PRN licensed nurse who were not actively working in the facility at that ti me would be educated by the DON on the information prior to their next working shift. On [DATE] at 12:00 P.M. CRN #603 audited 47/47 in-house resident charts to verify signed Advanced Directives were in place. The facility then implemented a plan forthe Administrator/designee to audit code status for incoming admissions daily for two weeks and PRN thereafter. On [DATE] at 2:00 P.M. CRN #603 audited crash carts located on each unit (Timberline and Wildwood) to ensure all necessary supplies were available and Automated External Defibrillator (AED) was centrally located. On [DATE] at 5:25 P.M. an Ad Hoc Quality Assurance meeting was held with the Administrator, DON/Interim IP, RNC #603 and Medical Director (MD) #606 related to event with discussion of plan including education, root cause, and audits. MD #606 agreed with the facility plan at that time. On [DATE] the Administrator and DON verified active CPR Certification for seven of seven RNs and eight of eight LPNs. On [DATE] at 7:00 P.M. CRN #603 completed an audit of medical records for all residents who had expired in the facility and had a full code for the past six months. On [DATE] the DON initiated interviews of three licensed nurses daily for one week and then three times a week for three weeks and then as needed to ensure the licensed nurse was able to identify when CPR was required for a resident as well as the correct procedure to initiate emergency response to the facility. Beginning on [DATE] the facility implemented a plan for the Administrator/designee to audit code status for incoming admissions daily for two weeks and as needed thereafter. On [DATE] the facility initiated mock code drills by the DON every shift for one week. The DON/designee would then continue these on one random shift three times a week for three weeks and then as needed to ensure licensed nurses were able to appropriately identify when CPR was required and appropriate initiation of emergency response protocols. Any concerns identified with the audits would be forwarded to QAPI committee weekly for four weeks and as needed for immediate follow-up. The Administrator would be responsible for ongoing compliance. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure on-going compliance. Findings include: Review of Resident #46's closed medical record revealed an admission date of [DATE] with diagnoses including ataxia (lack of muscle control), systemic inflammatory response syndrome, dysphagia (difficulty swallowing), communication deficit, weakness, abnormalities of gait, dysarthria (motor speech disorder), aphasia (impaired ability to communicate), heart failure, hypertension, atherosclerotic heart disease, type two diabetes, convulsions, Parkinsonism, and hyperlipidemia. Record review revealed Resident #46 expired in the facility on [DATE]. Review of medical record Face Sheet Advanced Directives revealed the resident had a code status of Full Code. No Do Not Resuscitate (DNR) was designated. Review of the Minimum Data Set (MOS) 3.0 Entry assessment dated [DATE] revealed Resident #46 entered the facility from a short-term hospital on [DATE]. Review of the medical record clinical admission documentation dated [DATE] at 4:45 P.M., authored by Registered Nurse (RN) #601, revealed Resident #46 had impaired short-term memory but intact long-term memory. Resident #46 was alert and oriented to self, place and time, sometimes understood others, and was limited to making concrete requests. Resident #46 had unclear speech but was able to understand others. Resident #46 was incontinent with bowel and bladder and wore a brief. Resident #46's mobility was limited to changing positions. Review of the baseline care plan dated [DATE] revealed Resident #46's Advanced Directives were not addressed. Review of the progress note dated [DATE] at 1:17 P.M. authored by the Administrator revealed the lnterdisciplinaryTeam (IDT) met with Resident #46 and family to discuss plan of care and discharge planning. Resident #46's code status was designated 'FULL CODE. Resident #46 planned to return home with his son. Review of the physician orders dated [DATE] to [DATE] revealed no physician orders regarding an Advanced Directive. Review the medical record revealed on [DATE] at 2:05 A.M. vital signs documented by LPN #510 revealed Resident #46's blood pressure was 130/60 millimeters of mercury (mmHg), oxygen saturation 96 percent, pulse 83 beats per minute, respirations 20 per minute and a temperature of 97.1 degrees Fahrenheit (F). Review offacility document titled Medication History authored by LPN #510 revealed on [DATE] at 2:07 A.M. Resident #46 refused Acetaminophen 325 milligrams (mg) (analgesic), Atorvastatin 80 mg (lowers cholesterol), Carvedilol 3.125 mg (treats high blood pressure and heart failure), and Keppra 100 mg/milliliter (ml) (antiseizure). Resident #46 refused to open his mouth to take medication. The note included Physician #600's team was paged and made aware. Review of the nursing progress note dated [DATE] at 4:28 A.M. authored by LPN #510 revealed Resident #46 refused evening medication. The previous nurse stated in report that Resident #46 had been refusing meals. Physician #600's team was paged, and the STAT labs (high [NAME] Blood Cell (WBC) count of 26.8 with the normal range being 4.5 to 10 thousand per cubic millimeter) were reported to Nurse Practitioner (NP) #610 who gave orders to obtain a urinalysis (UA) with culture and sensitivity (C&S) and an x-ray to rule out pneumonia due to a sudden increase in WBC and change in condition.Resident #46 remained afebrile (no fever) and vials signs within normal limits. The note included Resident #46 responded to physical stimulus when repositioned in bed and when vital signs were taken. Resident #46 was stable at this time with the plan of care continued. Review of the facility document titled Medication History authored by LPN #510 revealed on [DATE] at 6:52 A.M. Resident #46 refused Acetaminophen 325 mg because he was sleeping. Review of the nursing progress note dated [DATE] at 7:20 A.M. authored by LPN #509 revealed she entered Resident #46's room to obtain vital signs, and when the blood pressure cuff was applied, there were no signs of life present. The note included CPR was initiated with second nurse, prior nurse contacted EMS and Physician #600. Review of the nursing progress note dated [DATE] at 8:20 A.M. authored by LPN #509 revealed Resident #46's son and daughter arrived. LPN #509 updated the funeral home. The note documented the coroner arrived at 11:45A.M. to transport the resident. Review of the facility staffing schedule for [DATE] revealed there was no registered nursed on duty/working at the time of the incident involving Resident #46 being found unresponsive without vital signs. Review of a witness statement dated [DATE] (no time) authored by LPN #509 revealed she came on shift at 7:05 A.M. and received report from the night nurse (LPN #510) who stated Resident #46 had critical labs (WBCs were elevated) and Resident#46 had not been eating. Narcotics were counted. The statement included LPN #509 grabbed her blood pressure cuff to get Resident #46's vital signs. When attempting to get vital signs, LPN #509 noticed Resident #46 was blue, cold, hard, stiff with no signs of life. She called the other nurse to the room and asked the nurse resident's code status that was a Full Code. The night nurse (LPN #510) proceeded to text the Administrator about what to do. LPN #510 grabbed the crash cart and called 911 already since she stated she got an order to do so. 911 came in and left. LPN #509's statement included CPR was initiated but did not state if EMS was in the room or exited the room. Recusation was unsuccessful. Resident #46 was reported deceased , oxygen discontinued. Postmortem care started and comfort was provided to the family. Review of Call for Service document number 2604632 dated [DATE] revealed a call was received to the local 911 service at 7:45 A.M. but hung up. The call was received from [facility name]. A call back was performed and 911 dispatch spoke to Receptionist #576; she was to call back the nurses and call the police department back. At 8:05 A.M. 911 attempted to call the facility, the phone rang a few times then hung up. At 8:06 A.M. a police officer was dispatched to the facility. At 8:09 A.M. a police officer arrived at the facility. At 8:11 A.M. an all clear was given, checks okay, according to Receptionist #576. Review of audio recording of the 911 recorded call dated [DATE] revealed the 911 operator answered the call asking for the address. From 0:00:05 to 0:00:50 there was no response from the facility. At 0:00:53, the 911 operator called back, and a staff member answered, Thank you for calling [facility name], how can I help you? The facility was informed the [NAME] Village Police Department was calling regarding a recent 911 call from the facility directly, not a patient room. The staff member stated she would have to see who called. The staff member stated she would check if a nurse called and stated her name. The 911 operator requested a call back or otherwise the operator would have to send someone out. The 911 operator gave a call back number. Time stamp at 0:01:17 revealed a male voice stating, all clear, checked okay per [name], it was accidental. The Administrator and the DON listened to the audio and verified [name] who was Receptionist #576. Review of Body Camera footage dated [DATE] from 8:10 A.M. to 8:11 A.M., revealed a police officer entered the building, and LPN #510 standing at the front receptionist desk with Receptionist #576. The police verified with Receptionist #576 that the facility did not call the 911 dispatcher back regarding their situation. Receptionist #576 told the police officer that the nurse told her the emergency was canceled. The recording was shared with the Administrator and the DON who verified Receptionist# 576 and LPN #510 were in the video. Review of the Vital Statistics Certificate of Death revealed Resident #46 expired in the facility on [DATE] at 7:20 A.M. Cause of death was myocardial infarction and coronary artery atherosclerosis. No autopsy was performed. An interview on [DATE] at 12:50 P.M. with Registered Nurse (RN) #601 revealed Resident #46 was stable on admission during his admission assessment. A meeting was held with the family because Resident #46 was eating less, but Resident #46's family wanted Resident #46 to remain a Full Code status and was not ready to consider hospice. An interview on [DATE] at 1:14 P.M. with the Administrator revealed the facility had an interdisciplinaryteam (IDT) meeting (date not provided) with the family regarding Resident #46's functional decline, but the family was not ready for hospice or a code status change. Resident #46 was to remain a Full Code as a result of this meeting. An interview on [DATE] at 2:00 P.M. with LPN #509 revealed she worked [DATE] and her shift started at 7:00 A.M. She stated she received report from LPN #510 stating Resident #46's labs were not good, and Resident #46 was not doing good. During narcotic count at the start of the shift, Physician #600 called with an order to send Resident #46 to the hospital. When she walked into Resident #46's room to obtain vital signs for transfer, she stated Resident #46 was unresponsive and did not have a blood pressure. She stated she called for LPN #510. LPN #510 told her Resident #46 was a Full Code. LPN #509 stated she felt it was not medically appropriate to start CPR. LPN #509 stated Resident #46 had a hard chest, was blue, his extremities were stiff, and his mouth was stiff. She stated LPN #510 was to call 911 and LPN #510 called Physician #600 and Resident #46's family. LPN #509 also stated there was no RN in the building at that time and stated she did not know why EMS was not in the room. An interview on [DATE] at 4:30 P.M. with the DON revealed if a resident was a Full Code the nurse was to initiate CPR and wait for EMS to arrive so EMS could take over and call the time of death. A physician could also call the time of death, only a physician could determine if compressions could be stopped and sometimes the physician would speak with EMS to make these determinations. An interview on [DATE] at 6:59 A.M. with LPN #510 revealed Resident #46's baseline was a poor communicator, and he was becoming more lethargic. On [DATE], Resident #46 was still able to answer yes or no questions or squeeze her hand. She stated she called the on-call NP around 8:00 P.M. regarding Resident #46's decline in condition. At 2:00 A.M. vital signs were obtained again, and Resident #46 did not want to take his medications. She stated she called the NP again at 4:00 A.M. and received orders for a chest x-ray. As stated, she was putting in the x-ray orders, she received the results of Resident #46's labs. The NP was paged again. Physician #600 called back at 7:00 A.M. with an order to send Resident #46 to the hospital. LPN #510 stated LPN #509 went to the resident's room while she called 911 to set up a ride to the hospital. LPN #510 stated LPN #509 told her Resident #46 was unresponsive. LPN #510 stated she observed Resident #46 to be cold to touch, his back was still warm, and his brief was wet with urine and stated no rigor mortis had set in and there was no pooling of blood in extremities. The LPN indicated it was like Resident #46 had recently passed away. LPN #510 stated she had to dig for information to verify Resident #46's code status. LPN #510 verified the police came to the facility and verified she told the police there was no emergency. LPN #510 also stated CPR was stopped because LPN #509 decided to stop CPR. LPN #510 also stated she did not know why EMS never came to the facility. She stated the physician declared Resident #46 deceased after CPR was stopped. LPN #510 verified at no time was EMS in the room to assist with CPR or to pronounce Resident #46's death. LPN #510 statedthefacilitypolicywasto have EMS end the code and pronounce a resident deceased . An interview on [DATE] at 9:50 A.M. with LPN #509 revealed she observed Resident #46 to be blue, his mouth was stiff and he was in rigor mortis, with no blood pooling. However, the LPN stated rigor mortis was in his hands because his fingers were curled in. LPN #509 stated she was told Resident #46 was a Full Code, and she initiated CPR, but she thought Resident #46's sternum was too hard, so she stopped. LPN #510 was in the room when CPR was stopped. LPN #509 verified a police officer was never in the room, and EMS never entered the room. She was not sure if EMS ever came to the facility. LPN #509 stated the physician declared Resident #46 deceased after talking to LPN #510. LPN #509 verified the facility policy was to call 911 and continue CPR until the EMS arrived then call the physician and family while EMS had taken over. An interview on [DATE] at 10:06 A.M. with the DON revealed the facility policy if a resident was unresponsive the nurse was to check the resident's code status. If the resident was a Full Code, they were to call 911 and continue CPR until EMS arrived on the scene. EMS would take over; the nurse would present and gather information and start paperwork at that time. The DON stated only a physician could determine when to stop CPR, and usually EMS would call the physician. An interview on [DATE] at 11:13 A.M. with Physician #600 revealed he did call the facility at 7:00 A.M. on [DATE] with an order to send Resident #46 to the hospital. Physician #600 stated a nurse called him back and stated Resident #46 was blue. He stated he asked the nurse what Resident #46's code status was, but the nurse did not know. Physician #600 stated he told the nurse to start Advanced Cardiac Life Support (ACLS) until the advanced directives were verified. He stated the nurse told him EMS was on the scene; therefore, he waited for a call back from EMS but never received a call back. He verified he did not tell the nurses to stop CPR or call the time of death.During the interview, Physician #600 indicated facility staff did not act appropriately because the nurse called to tell him Resident #46 was cold and appeared deceased . The nurse was to initiate ALCS then call the physician when a resident was a Full Code. An interview on [DATE] at 11:37 A.M. with Resident #46's Emergency Contact, Responsible Party #602 revealed at no time did the family change Resident #46's code status. Resident #46 was to be a Full Code. She stated the facility called her on [DATE] at 7:45 A.M. stating her dad was found non-responsive; they gave CPR, but he did not respond. An interview on [DATE] at 11:45 A.M. with CRN #603 verified there were no additional telephone orders in the closed medical record for Resident #46 to indicate a change in code status had ever occurred from the resident's desire to maintain advance directives for a full code status. An interview on [DATE] at 12:00 P.M. with Fire Chief #604 revealed the facility called 911 on [DATE] but hung up. When the facility was reached, they stated there was no emergency; therefore, no EMS was sent to the facility. There was no run report because the facility declined service. An interview with the Administrator on [DATE] at 2:45 P.M. revealed according to her investigation Resident #46 did not have signs of distress during the night and when found in the morning, Resident #46 had the beginning signs of death. The Administrator also explained that the facility utilized an on-call system with the Cleveland Clinic NPs that were on-call until 6:00 A.M. then the NPs would call the physicians. The Administrator also stated an interview with the aide who performed postmortem care revealed Resident #46 was stiff, but they were still able to move his body. An interview on [DATE] at 8:50 A.M. with Funeral Home Employee #605 revealed the funeral home was to produce the original death certificate upon arrival to the facility and would fill out the vital information, the death certificate was then sent to the physician to sign and fill in the medical information. Either the funeral home could write the time of death if provided by the facility or the physician would write the time of death. The funeral home revealed they received a phone call from the facility on [DATE] at 9:15 A.M. and the facility stated the time of the resident's death was 8:20 A.M. The funeral home removed Resident #46's body at 11:35 A.M. An interview on [DATE] at 10:45 A.M. with Receptionist #576 revealed she did not call 911 on [DATE] but they called the facility, and she transferred the call to both nurse stations, but no one answered. She stated when she walked to the nurse's station, she was told the nurses were in Resident #46's room. She knocked on the door because the door was shut but when she opened the door the curtain was pulled, therefore she could not see Resident #46 or nurses and could not state which nurse told her to cancel the 911 call. By the time she came back to her desk, a police officer was walking in and asked if anyone needed help. She stated she told the police officer that no one needed help. Review of facility policy titled, CPR- CARDIOPULMONARY RESUSCITATION POLICY, dated [DATE], revealed it was the policy of the facility that basic life support would be provided, including CPR, when a resident required such emergency care prior to the arrival of emergency medical services, that was consistent with the advance directive. In the absence of a Do Not Resuscitate Form (DNR) or If the DNR status was unknown at the time, prompt initiation of CPR was essential as brain death begins four to six minutes following cardiac arrest if CPR was no initiated within that time. Protocol included nurses or other care staff educated to initiate CPR, as recommended by the American Heart Association, unless a valid Do Not Resuscitated form was in place, resident presented with obvious signs of clinical death such as rigor mortis (Rigor mortis starts with smaller muscles such as eyes and jaw then moves to larger ones, often peaking around 12-24 hours postmortem, and eventually dissipating as decomposition breaks down muscle tissue), dependent lividity (the reddish-purple discoloration of the skin caused by blood settling into the lowest (dependent) parts of a body due to gravity after circulation ceases. It begins within an hour of death, becomes fixed in six to eight hours), decapitation, or decomposition were present. CPR procedure included check resident for response, assess for pulse, shout for help and activate call light for help, activate the emergency response system (911) to delegate task if assistance was present, immediately retrieve the emergency equipment or delegate task, begin chest compressions until emergency equipment arrived. Validate code status, if no DNR form present resident was a full code. Check the upper airway, look for obstruction, if oxygen was available connect bag to oxygen, turn on oxygen and adjust flow rate to 15 liters. Hand off resuscitation to emergency personnel upon arrival, then call the resident family and physician. The following information was to be documented in the medical record: date, time, and location of event. Condition of resident at the start of the event. Interventions implemented and the resident response to the interventions. Date and time physician and resident representative notified. Date and time of EMS arrival and transport. Review of the American Heart Association (AHA) 2025 guidance for adult CPR included the following: Check for breathing, if the person is not breathing or only gasping, begin CPR; Chest compressions included to push down hard and fast at a rate of 100 to 120 compressions per minute; After every 30 compressions, give two rescue breaths; and make sure the person is on a firm surface. In 2008, after the publication of several studies looking at the rates of bystander CPR and public attitudes toward it, the AHA updated their guidance and decided to take out rescue breathing (mouth to mouth) for untrained or lay responders as a way to encourage and focus on hands only CPR. This updated guidance did not apply to trained healthcare professionals. AHA guidelines clearly state that CPR must continue until a licensed provider with higher authority assumes care, the patient shows signs of life, the rescuer is physically unable to continue or an advanced directive/valid do not resuscitate (DNR) is present. Conditions under which CPR should not be started included decapitation, dependent lividity (pooling of blood in the lowest parts of the body) and rigor mortis (post-mortem muscle stiffening typically beginning two to four hours after death). Review of the State of Ohio requirements at Ohio Revised Code 4723.26 Determination of Death revealed no indication an LPN was qualified to make this determination. In addition, the Ohio Board of Nursing provides guidance indicating LPNs cannot officially pronounce death. They may assess and report the absence of vital signs to a physician, who then technically pronounces the resident/patient deceased . This deficiency represents non-compliance investigated under Complaint Number 2998478.

Based on medical record review, staff interview, resident interview, and facility procedure review, the facility failed to ensure medications were ordered and available in a timely manner for newly admitted residents. This affected one (Resident #41) of three residents reviewed for timely medication administration. The census was 42. Findings Include: Review of the medical record for Resident #41 revealed she was admitted to the facility on [DATE]. Her diagnoses were chronic kidney disease (stage IV), spinal stenosis, weakness, need for assistance with personal care, difficulty walking, obstructive and reflux uropathy, schizophrenia, spondylosis, migraine, schizoaffective disorder, and major depressive disorder. Review of Resident #41's progress note dated 12/11/24 revealed she was admitted to the facility on [DATE] at approximately 8:14 P.M. Review of Resident #41's progress note dated 12/12/24 revealed information that some medications needed to be clarified with the physician and faxed to the pharmacy. The note also stated that the medications were drop shipped, which was expedited shipping from the pharmacy, so she could get all of her medications in the facility. Within the same note, the nurse documented that Resident #41's family was upset that the resident's medications had not been sent to the facility in a timely manner. Review of Resident #41 hospital discharge documents dated 12/11/24 revealed a comprehensive list of medications she was taking in the hospital, and then a comprehensive list of medications she was to take when she was admitted to the nursing facility. The medications listed to be ordered at the nursing facility included Tizanidine four milligrams (mg) three times daily for muscle spasms and Oxycodone five mg every six hours as needed with instructions to give one tablet for a pain level of one to four and two tablets for a pain level of five to ten (on a pain scale of zero to ten, zero indicating no pain and ten indicating the worst pain). Review of Resident #41's Medication Administration Records (MAR) for December 2024 revealed the following medications were unavailable and not included in the initial medication shipment on the morning of 12/12/24: Tizanidine four mg three times daily for muscle spasms (due at three separate ranges of time from 7:00 A.M. to 11:00 A.M., 1:00 P.M. to 2:30 P.M., and 7:00 P.M. to 11:00 P.M.) and Oxycodone five mg every six hours as needed with instructions to give one tablet for a pain level of one to four and two tablets for a pain level of five to ten. These medications were not shipped to the facility or administered to the resident until the afternoon of 12/12/24. Interview with the Administrator on 12/21/24 at 10:35 A.M. revealed she was aware of Resident #41's issue with not having medication in the facility when she was first admitted and the family not being happy with that. Based on the information she received from the floor nursing staff, Resident #41's medications (all except for two) had arrived and been administered as ordered. They were waiting for the Tizanidine and Oxycodone from the pharmacy, which with being drop shipped, those medications arrived later in the afternoon of 12/12/24 and were then administered. Interview with Licensed Practical Nurse (LPN) #101 on 12/21/24 at 12:35 P.M. confirmed she was the morning nurse on 12/12/24. She received shift change report from LPN #102, who was the admitting nurse the night before. She was told the medications could not be drop shipped the night before because there were too many, so they were going to be delivered that morning when the pharmacy could bring them. She confirmed she received all the medications except for Tizanidine and Oxycodone, which the pharmacy needed hard copy prescriptions for. She looked through the hospital discharge paperwork and found a sealed envelope with the hospital stamp on it. She stated she opened the envelope and found the hard copy prescriptions for those two medications. She sent them to the pharmacy and had those medications drop shipped, the medications arrived in the afternoon of 12/12/24 and were administered as ordered. She confirmed it was odd for the hospital to send the hard prescriptions in a sealed envelope; she had not seen that before, but as soon as she was made aware the pharmacy did not have the two medications that needed the hard copy prescriptions, she immediately started addressing it so Resident #41 could have all of her medications in the facility. Interview with LPN #102 on 12/21/24 at 1:04 P.M. confirmed Resident #41 arrived to the facility on [DATE]. She confirmed she verified all the medications and orders from the hospital documentation with the physician and the pharmacy. She stated the pharmacy could not drop ship all of the medications because there were so many, so they would get them to the facility as soon as they could. She confirmed by the time she left on 12/12/24 at around 7:00 A.M., the medications had not arrived to the facility. Also, she confirmed she did not have a hard copy prescription for the Tizanidine or Oxycodone from the hospital, so she contacted the facility physician, who had the ability to send an electronic prescription to the pharmacy for them to be filled. She confirmed she did not follow up with the physician or pharmacy to ensure the prescription for Tizanidine and Oxycodone were filled; she assumed the physician had taken care of that. Interview with Resident #41 on 12/21/24 at 1:20 P.M. confirmed she was in pain due to not getting her Oxycodone medication when she needed it. She stated she didn't understand why the facility didn't have this medication in the facility already for her. She confirmed she got her Oxycodone in the afternoon on 12/12/24 and she had received it everyday since. She stated she had constant pain. She stated she was in pain due to not having the Oxycodone after she was discharged from the hospital on 12/11/24 into the afternoon on 12/12/24, but she could not say she was in any more pain than normal. Review of facility Nursing Admission Workflow for Admitting Nurse procedures, undated, revealed the staff tasked with a new resident admission should complete the following: print the Physician Orders Report, (located under the resident tab in the electronic medical records) for providers to sign, orders would be delivered to the pharmacy via the ePrescribe (electronic prescription) interface. Staff were to manually fax any controlled substances. This deficiency represents non-compliance investigated under Complaint Number OH00160656.

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #30 had a comprehensive care plan regarding interventions to maintain her peripherally inserted central catheter (PICC) (a catheter inserted through the arm vein and passed through to larger veins near the heart) line and monitor her intravenous (IV) antibiotics. This affected one resident (#30) out of three residents reviewed for care plans. The facility census was 41. Findings include: Review of the medical record for Resident #30 revealed an admitted [DATE] with diagnoses including endocarditis (serious infection of the heart's inner lining), cognitive communication deficit, hypotension, and heart failure. Review of the undated comprehensive care plan revealed Resident #30's care plan only included areas related to activities and nutrition. There was nothing in her care plan related to interventions to maintain the PICC line or the IV antibiotic use due to endocarditis. Review of the November 2024 physician orders revealed Resident #30 had the following orders: an order dated 11/01/24 for ceftriaxone (antibiotic) two grams per IV every 24 hours, an order dated 11/01/24 vancomycin (antibiotic) 750 milligram (mg) IV every 12 hours, an order dated 11/08/24 to flush the PICC line before and after each dose of IV antibiotic with a normal saline flush (sodium chloride) 0.9 percent 10 cubic centimeter (cc) twice a day, an order dated 11/08/24 to check the PICC line site every shift, an order dated 11/08/24 to change intermittent IV tubing every 24 hours, and an order dated 11/08/24 to change right arm PICC line dressing every seven days. Review of the November 2024 Medication Administration Record (MAR) revealed Resident #30 received IV antibiotics beginning 11/02/24 as ordered, but she did not have documented evidence that the PICC line was flushed before and after antibiotic therapy. There also was no documented evidence that the PICC line site was assessed and the IV tubing changed prior to 11/08/24. Review of the November 2024 Treatment Administration Record (TAR) revealed an order dated 11/08/24 to change Resident #30's right arm PICC line dressing every seven days. It was documented as completed on 11/08/24 by Agency Registered Nurse (RN) #610 and on 11/15/24 by Licensed Practical Nurse (LPN) #604. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 had intact cognition and received IV antibiotics. Interview on 12/03/24 at 8:25 A.M. with Resident #30's daughter revealed Resident #30 was displaying increased confusion on 11/17/24, and the physician ordered her to go to the hospital. While in the emergency room , it was discovered that her PICC line dressing was dated as being last changed on 10/29/24 (18 days). The hospital staff told her PICC line dressings were to be changed at least every seven days to prevent infection, and she was concerned especially since her mother already was being treated for a heart infection (endocarditis). Interview and observation on 12/03/24 at 8:31 A.M. revealed Resident #30 had a PICC line to her right upper arm with a dressing over the site dated 12/01/24. She stated that she was unsure how often she had the dressing changed and/or who changed her dressing. Interview on 12/03/24 at 10:46 A.M. and 1:07 P.M. with the Director of Nursing (DON) and Regional Nurse #603 revealed Resident #30 was admitted to the facility with a PICC line and IV antibiotics on 11/01/24. Regional Nurse #603 revealed she was in the facility on 11/08/24 and had completed a chart audit and noticed that Resident #30 did not have flush orders to flush the PICC line before and after the antibiotics, to change her IV tubing every 24 hours or to change her PICC line dressing. She brought this to the attention of the DON and the orders were obtained on 11/08/24. They verified from 11/01/24 till 11/08/24 Resident #30 did not have flush orders to flush the PICC line before and after antibiotics and did not have an order to change the IV tubing every 24 hours. The DON verified that the Administrator received a call from Resident #30's daughter concerned that when Resident #30 went to the emergency roiagnom on [DATE] they had discovered that her PICC line dressing was dated 10/29/24 (18 days). The DON revealed she educated the nurses regarding changing PICC line dressings. They also verified there was nothing in Resident #30's care plan related to interventions to maintain the PICC line or to monitor the IV antibiotics. Interview on 12/03/24 at 12:58 P.M. with MDS/RN #609 verified that the comprehensive care plan did not include anything related to the care and maintenance of Resident #30's PICC line and/or the IV antibiotics for endocarditis. Interview on 12/03/24 at 1:38 P.M. with Agency RN #610 revealed she only had worked at the facility twice and that she had never changed an IV dressing while at the facility, including Resident #30's PICC line dressing. She stated that she must have accidentally signed off that she completed the dressing change on 11/08/24 for Resident #30. She stated that she was not familiar with the electronic documentation system that the facility used as it was different than what she was used to and felt that was the reason that she signed off the dressing being changed in error. Review of the facility policy labeled; Care Planning, dated 2024, revealed the facility interdisciplinary team was responsible to develop an individualized comprehensive care plan for each resident. The policy revealed a comprehensive care plan was to be developed within 21 days of admission to the facility and would be updated by a member as changes in resident's condition occurred. There was nothing in the policy in regards what was to be included in the care plan. This deficiency represents non-compliance investigated under Master Complaint Number OH00160056.

Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #30's peripherally inserted central catheter (PICC) (a catheter inserted through the vein in the arm and passed through to larger veins near the heart) line dressing changes were changed as ordered, and failed to ensure physician's orders were obtained to maintain the PICC line, including flushing before and after intravenous (IV) antibiotic therapy and changing of IV tubing timely. This affected one resident (#30) out of one resident with an IV. The facility census was 41. Findings included: Review of the medical record for Resident #30 revealed an admitted [DATE] with diagnoses including endocarditis (serious infection of the heart's inner lining), cognitive communication deficit, hypotension, and heart failure. Review of the undated comprehensive care plan revealed Resident #30's care plan only included areas related to activities and nutrition. There was nothing in her care plan related to interventions to maintain the PICC line or the IV antibiotic use due to endocarditis. Review of the November 2024 physician orders revealed Resident #30 had the following orders: an order dated 11/01/24 for ceftriaxone (antibiotic) two grams per IV every 24 hours, an order dated 11/01/24 vancomycin (antibiotic) 750 milligram (mg) IV every 12 hours, an order dated 11/08/24 to flush the PICC line before and after each dose of IV antibiotic with normal saline flush (sodium chloride) 0.9 percent 10 cubic centimeter (cc) twice a day, an order dated 11/08/24 to check the PICC line site every shift, an order dated 11/08/24 to change intermittent IV tubing every 24 hours and an order dated 11/08/24 to change the right arm PICC line dressing every seven days. Review of the November 2024 Medication Administration Record (MAR) revealed Resident #30 received IV antibiotics beginning 11/02/24 as ordered, but she did not have orders and/ or documented evidence that the PICC line was flushed before and after IV antibiotic therapy. There was also no document evidence that the PICC line site was assessed and the IV tubing changed prior to 11/08/24. Review of the November 2024 Treatment Administration Record (TAR) revealed an order dated 11/08/24 to change Resident #30's right arm PICC line dressing every seven days. It was documented as completed on 11/08/24 by Agency Registered Nurse (RN) #610 and on 11/15/24 by Licensed Practical Nurse (LPN) #604. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 had intact cognition and received IV antibiotics. Review of the nursing note dated 11/16/24 at 11:50 P.M. and authored by LPN #800 revealed Resident #30 had a change in mental status as she had increased confusion. Physician #950 was notified and ordered Resident #30 to be evaluated at the hospital. Review of the Emergency Department Provider Note dated 11/17/24 and authored by Physician #900 revealed Resident #30 was evaluated as over the past day she felt more confused than usual. She had been receiving IV ceftriaxone and vancomycin due to endocarditis. She was discharged back to the facility without any abnormal findings on evaluation and/or lab testing. Physician #900 ordered to continue the current antibiotics. Observation of photo taken by Resident #30's daughter when Resident #30 was at the hospital revealed a PICC line to Resident #30's right upper arm with a dressing covering the PICC line site dated 10/29/24. (Resident #30's daughter stated she took the photograph 11/17/24 at 1:57 A.M. of Resident #30 right arm). Review of the grievance form dated 11/18/24 revealed Resident #30's daughter called the Administrator with a concern regarding when Resident #30 was at the hospital, it was discovered that Resident #30's PICC line dressing was outdated. The form revealed on 11/18/24 the Director of Nursing (DON) interviewed all involved staff and educated the staff on the importance of checking the dressing daily and changing the dressing according to the physician's order and as needed to ensure standard of care was provided. Interview on 12/03/24 at 8:25 A.M. with Resident #30's daughter revealed Resident #30 was displaying increased confusion on 11/17/24, and the physician ordered her to go to the hospital. While in the emergency room , it was discovered that the PICC line dressing was dated as last changed on 10/29/24 (18 days). The hospital told her PICC line dressings were to be changed at least every seven days to prevent infection, and she was concerned especially since her mother was being treated for a heart infection (endocarditis). Interview and observation on 12/03/24 at 8:31 A.M. revealed Resident #30 had a PICC line to her right upper arm with a dressing over the site dated 12/01/24. She revealed that she was unsure how often the dressing was changed and/or who changed the dressing. Interview on 12/03/24 at 10:46 A.M. and 1:07 P.M. with the Director of Nursing (DON) and Regional Nurse #603 revealed Resident #30 was admitted to the facility with a PICC line and IV antibiotics on 11/01/24. Regional Nurse #603 revealed she was in the facility on 11/08/24 and had completed a chart audit and noticed that Resident #30 did not have flush orders to flush the PICC line before and after the antibiotics, to change her IV tubing every 24 hours or to change her PICC line dressing. She brought this to the attention of the DON and the orders were obtained on 11/08/24. They verified from 11/01/24 till 11/08/24 Resident #30 did not have flush orders to flush the PICC line before and after antibiotics and did not have an order to change the IV tubing every 24 hours. The DON verified that the Administrator received a call from Resident #30's daughter concerned that when Resident #30 went to the emergency roiagnom on [DATE] they had discovered that her PICC line dressing was dated 10/29/24 (18 days). The DON revealed she educated the nurses regarding changing PICC line dressings. Interview on 12/03/24 at 12:58 P.M. with MDS/ RN #609 verified that the comprehensive care plan did not include anything related to the care and maintenance of Resident #30's PICC line and/or the IV antibiotics for endocarditis. Interview on 12/03/24 at 1:10 P.M. with the Administrator revealed she had received a call from Resident #30's daughter on 11/18/24, and she voiced a concern that when Resident #30 was at the hospital on 11/17/24, the hospital noticed that Resident #30's PICC line dressing was last changed on 10/29/24, and that the dressing was to be changed every seven days. She apologized to Resident #30's daughter and brought the concern to the attention of the DON who provided education to the nursing department. Interview on 12/03/24 at 1:38 P.M. with Agency RN #610 revealed she only had worked at the facility twice and that she had never changed an IV dressing while at the facility, including Resident #30's PICC line dressing. She stated that she must have accidentally signed off that she completed the dressing change on 11/08/24 for Resident #30. She stated that she was not familiar with the electronic documentation system that the facility used as it was different than what she was used to and felt that was the reason that she signed off the dressing being changed in error. Review of the undated facility policy labeled, Dressing Change and Care of PICC revealed the purpose was to reduce the risk of system infections and minimize the contamination of the catheter system. The policy revealed dressings were to be changed every seven days using a sterile technique and immediately if the integrity of the dressing was in anyway compromised. The policy revealed the dressing was to be labeled with date, time and nurse's initials and the procedure was to be documented. Review of the undated facility policy labeled, Flushing PICC Line revealed the purpose of the policy was to prevent blood clot formation in the catheter or at the tip and decrease the possibility of any drug interaction in the catheter. The PICC line was to be flushed every 24 hours with 10 cc of .9 percent sodium chloride when not in use and before and after each intermittent medication. The policy revealed the procedure included verifying the physician order and documenting the procedure. Review of the undated facility policy labeled; Tubing Set-Up revealed the purpose of the policy was to maintain sterility of the intravenous set-up. The tubing was to be set up by using an aseptic technique. The policy revealed the nurse was to verify the order and label the tubing with date, time and nurse's initials. The policy revealed the nurse was to document the procedure. This deficiency represents non-compliance investigated under Master Complaint Number OH00160056.

Based on observation, interview, record review, and facility policy review the facility failed to change Resident #38's PICC (peripheral inserted central catheter) line dressing as ordered. This affected one resident (#38) of three residents reviewed for PICC line dressings. The facility census was 41. Findings include: Review of the medical record for Resident #38 revealed an admitted [DATE]. Diagnoses included osteomyelitis of vertebra, discitis, dorsalgia, diabetes mellitus type 2, and chronic kidney disease stage 3. The Admission Minimum Data Set (MDS) assessment completed 03/28/24 indicated Resident #38 had no cognitive impairment. Observation and interview on 04/17/24 at 8:39 A.M. with Resident #38 complained the facility nurses were not changing her right arm PICC line dressing as ordered. It had been about two weeks since the last change and finally it was completed the day prior, 04/16/24. The PICC dressing on Resident #38's right arm was dated 04/16/24. Review of Resident #38's physician orders revealed an order dated 03/26/24 to change PICC line dressing every seven days and an order dated 03/27/24 to change PICC line dressing to right arm as needed (PRN). Review of Resident #38's Treatment Administration Record (TAR) from 03/22/24 to 04/17/24 revealed the routine PICC line dressing change was scheduled to begin on 03/28/24 and then be completed every seven days thereafter. On 03/28/24, Resident #38's PICC line change was documented as not completed due to it being completed on 03/26/24, again on 04/04/24, it was not completed due to the previous shift, and then on 04/11/24, it was not completed due to resident care. The PRN order reflected the PICC line dressing was changed on 04/16/24. There was no documented evidence Resident #38's PICC line dressing was changed between 03/26/24 and 04/16/24. Review of the progress notes from March 2024 to April 2024 revealed no documented evidence Resident #38's PICC line dressing was changed between 03/26/24 and 04/16/24. Interview on 04/17/24 at 12:43 P.M. with Assistant Director of Nursing (ADON) #100 verified there was no documented evidence Resident #38's PICC line dressing was changed between 03/26/24 and 04/16/24, and confirmed it was not changed every seven days as ordered. Review of the undated facility policy, Dressing Change and Care of PICC revealed to reduce the risk of systemic infections and minimize contamination of the catheter system, dressings were changed every seven days or immediately if the integrity of the dressing was compromised. This deficiency represents non-compliance investigated under Complaint Number OH00152974.

Based on interview, record review and review of facility policy the facility did not ensure State tested Nursing Assistant (STNA) #602 received 12 hours of formal in service education within the last year. This affected one STNA out of three STNAs (#602, #604, and #605) whose personnel files were reviewed for formal education/training. This had the potential to affect 36 residents. Findings include: Review of the personnel file for STNA #602 revealed a hire date of 07/15/03. Review of STNA #602's education transcript revealed in the last 12 months STNA #604 had 0.75 total hours of training. Interview on 11/02/23 at 12:20 P.M. with Regional Staff Coordinator #603 verified STNA #602 had only completed 0.75 hours of training in the last 12 months. Review of facility policy labeled, Inservice Training dated April 2013 revealed employees must complete all assigned course work and attend mandatory in-services. The policy revealed each STNA annually must complete at least 12 hours of formal in-service education.

Based on record review and interview, the facility failed to ensure staffing data was submitted appropriately to the Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all residents in the facility. The census was 36. Findings include: Review of the CMS staffing data report for quarter three of the 2023 fiscal year (from April 1 to June 30 2023) revealed the facility did not submit staffing data for the affected quarter. Interview with the Administrator on 10/31/23 at 8:37 A.M. confirmed the above findings.

Based on record review and interview, the facility failed to ensure the drug regimen of each resident was reviewed at least once a month by a pharmacist and ensure pharmacy recommendations were acted upon. This affected four of five residents reviewed for unnecessary medications (Resident #26, #30, #13, and #33). The total census was 36. Findings include: 1. Record review of Resident #26 revealed she was admitted to the facility on [DATE] and had diagnoses including atrial fibrillation, peripheral vascular disease, heart failure, and cardiomegaly. Record review of pharmacy communications regarding Resident #26 revealed she had a recommendation from pharmacy dated 01/03/23 for a digoxin lab with the next blood draw and every six months thereafter. The recommendation was marked as accepted, however no evidence was found of any digoxin lab draw being done until 09/05/23. Additionally, a recommendation dated 05/01/23 asked for a comprehensive metabolic panel on the next lab draw and to be repeated every 12 months thereafter. The recommendation was marked as accepted, however no evidence was found of a comprehensive metabolic panel for the resident until 09/15/23. Interview with the Interim Director of Nursing on 11/01/23 at 2:00 P.M. confirmed the above findings. 39973 2. Review of the medical record for Resident #33 revealed an admitted [DATE] and diagnoses included diabetes, major depression, hypertension, gout, and dementia with behavioral disturbance. Review of lab work in the medical record revealed there was no evidence of a Hemoglobin AIC (HGAIC) (a blood test that reflects an average blood glucose level) or an uric acid level (blood test to check the level of uric acid which often causes gout). Review of pharmacy recommendation dated 11/02/22 revealed Consultant Pharmacist #606 recommended a uric acid level and HGAIC with the next lab draw and repeat both labs in six months. The recommendation had a check mark by the recommendation that Primary Care Physician (PCP) #608 was in agreement with the recommendation but with no date. Review of pharmacy recommendation dated 01/03/23 revealed Consultant Pharmacist #606 recommended Resident #33's sliding scale be discontinued and to obtain a HGAIC on the next available lab date and repeat the HGAIC in three months. The Interim Director of Nursing (DON) placed a X by the recommendation, check blood sugar twice a day times one week and call if blood sugar below 70 and/or above 250. There was no date on the form. Review of pharmacy recommendation dated 03/07/23 revealed Consultant Pharmacist #606 recommended Resident #33 to have a trial dose reduction of duloxetine (anti-depressant) 20 milligram (mg) by mouth everyday and monitor for symptoms. Nurse Practitioner (NP) #607 checked that he agreed to the trial and signed and dated the recommendation for 09/07/23 (six months after the recommendation was made by the pharmacist). Review of pharmacy recommendation dated 07/03/23 revealed Consultant Pharmacist #606 recommended Resident #33's sliding insulin be discontinued and obtain HGAIC next available lab date and repeat HGAIC in three months. The recommendation had a check mark by the recommendation and was signed by PCP #608 without a date. Review of physician order completed by PCP #608 dated 09/08/23 revealed Resident #33's duloxetine was decreased to 20 mg once a day (per pharmacy recommendation). Interview on 11/01/23 at 2:52 P.M. with the Interim Director of Nursing verified there was no evidence Resident #33 had received an HGAIC or uric acid level despite pharmacy recommendations dated 11/02/22, 01/03/23, and 07/03/23. She also verified Resident #33's pharmacy recommendation dated 03/07/23 for the duloxetine dose reduction was not addressed until 09/07/23. 37097 3. Review of the medical record for Resident #13 revealed an admitted [DATE]. Diagnoses included aphasia, anxiety disorder, altered mental status, vascular dementia, and other sequela of cerebral infarction. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #13 dated 08/14/23 revealed Resident #13 had severely impaired cognition. Medication Regimen reviews with no recommendations were completed for Resident #13 on 04/23, 05/23, and 07/23. Pharmacy recommendations were provided for Resident #13 on 03/07/23, 06/06/23, and 08/02/23. No Medication Regimen reviews or Pharmacy Recommendations were provided for Resident #13 for 09/23 or 10/23. Interview on 11/02/23 at 2:30 P.M. with Licensed Practical Nurse/Assistant Director of Nursing (LPN/ADON) #600, verified there were no Medication Regimen reviews or Pharmacy Recommendations provided for Resident #13 for 09/23 or 10/23. 39969 4. Review of the medical record for Resident #30 revealed an admitted [DATE]. Diagnoses included localized edema, insomnia, glaucoma, gastro-esophageal reflux disease (GERD), muscle weakness, and type II diabetes mellitus. Review of the consultant pharmacist's medication regimen review for Resident #30, dated 10/02/23, revealed to please add an ICD-10 diagnosis to the diagnosis tab of the electronic medication administration record (eMAR) to support the use of the following medications: amitriptyline (antidepressant), Eliquis (anticoagulant), furosemide (diuretic), Januvia (antidiabetic), Lumigan (antiglaucoma), melatonin, insulin degludec (antidiabetic), and pantoprazole (reduces levels of stomach acid). Further review of the consultant pharmacist's recommendation form revealed nothing documented under the area titled Follow Through indicating the recommendation was addressed. Review of the eMAR for October 2023 revealed a blank space under the diagnosis tab for amitriptyline, Eliquis, furosemide, Januvia, Lumigan, melatonin, insulin degludec, and pantoprazole. Interview on 11/02/23 at 8:56 A.M. with Minimum Data Set (MDS) Nurse #608 verified there was diagnosis added to the diagnosis tab of the eMAR for each medication identified. Review of the facility policy titled Medication Regimen Review, dated May 2020 revealed findings and recommendations were to be reported to the Director of Nursing (DON), the attending prescriber, the Medical Director, and if appropriate, the Administrator. Responses were to be made readily available to he consultant pharmacist for follow-up. Under item G: The consultant pharmacist medication regimen review (MRR) and Nursing Documentation Review reports were to be processed as follows and were to be provided in a written or electronic format: 1) Medication Regimen Review Recommendations to Prescriber a.) the consultant pharmacist or facility was to provide the report to the responsible prescriber and DON within seven working days of the review. b.) A copy of the report was to be kept by the facility until the prescriber's signed response was returned. c.) The prescriber was to accept and act upon recommendations or reject and provide an explanation for disagreeing. d.) The facility was to maintain copies of signed reports and make them readily available for the consultant pharmacist for follow-up. 2) Nursing Documentation Review a.) The report was to be provided by the consultant pharmacist within seven working days of the review. b.) A copy of the report was to be kept by the facility until the nurse's response was returned.

Based on interview, observation, medical record review and policy review the facility did not ensure Resident #48 was free of a significant medication error. This affected one resident (Resident #48) out of one resident reviewed for insulin administration. This had the potential to affect eight residents (Resident #6, #10, #20, #18, #30, #33, #47, and #48) that had orders for insulin. Findings include: Review of medical record for Resident #48 revealed an admitted [DATE] and diagnoses included diabetes, hypertension, and chronic kidney disease. Review of care plan dated 10/16/23 revealed Resident #48 had an alteration in blood glucose metabolism related to her diagnosis of diabetes. Interventions included to administer diabetic medications per physician orders and observe for signs of hypoglycemia/ hyperglycemia. Review of November 2023 physician orders for Resident #48 revealed she had an order for lispro (a rapid acting insulin) insulin pen to administer three units subcutaneously (SQ) with meals scheduled at 7:30 A.M. and an order for insulin lispro insulin pen to be administered SQ per sliding scale including if blood sugar was 301 to 350 to administer eight units of insulin before meals and at bedtime (the morning dose was scheduled for 7:30 A.M.) Observation on 11/01/23 at 9:02 A.M. revealed Resident #48 was lying in bed when Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON) #600 entered her room to take her blood sugar and administer her insulin. Resident #48 did not have a breakfast tray in her room. Resident #48 stated to LPN/ADON #600 that she was upset as she did not understand why LPN/ADON #600 was taking her blood sugar so late as she had already eaten her breakfast. LPN/ADON #600 took her blood sugar, and it was 306 and LPN/ADON #600 stated that Resident #48 would require sliding scale insulin coverage with her routine insulin because the blood sugar was elevated. Resident #48 stated to LPN/ADON #600 that her blood sugar would be high since she ate almost an hour ago and stated that she should not have to get coverage just because the nurse was late on checking her blood sugar. Observation on 11/01/23 at 9:17 A.M. revealed LPN/ADON #600 administered Resident #48 her routine lispro insulin three units and eight units sliding scale lispro insulin to equal 11 units to her left deltoid (arm). Interview on 11/01/23 at 9:40 A.M. with LPN/ADON #600 verified Resident #48's routine insulin was scheduled for 7:30 A.M. and her routine lispro insulin was to be administered with meals and her sliding scale lispro insulin was also scheduled for 7:30 A.M. before breakfast. She verified she obtained her blood glucose level and administered her insulin at 9:17 A.M. after she had already eaten her breakfast. Interview on 11/01/23 at 9:55 A.M. with State tested Nursing Assistant (STNA) #601 revealed breakfast trays arrived to Resident #48's hall approximately between 7:40 A.M. and 7:50 A.M. everyday. STNA #601 passed Resident #48's breakfast tray between 7:40 A.M. to 8:00 A.M. today, 11/01/23. Interview on 11/01/23 at 10:10 A.M. with Resident #48 revealed when she was at home, she always used to take her blood sugar and administer her insulin right before she ate her meal. She revealed she was upset as frequently the nurses did not check her blood glucose level and/or give her insulin until after she ate. She revealed on 11/01/23 she had received her breakfast tray at approximately 8:00 A.M. and ate Cheerios and a breakfast croissant sandwich before LPN/ADON #600, had come in to check her blood sugar and administer her insulin which was after 9:00 A.M. Review of the undated facility policy labeled; Insulin Administration revealed it was the facility's policy to provide guidelines for safe administration of insulin to residents with diabetes. The policy revealed to check the blood glucose per physician order. Review of facility policy labeled, Medication Administration- General Guidelines dated May 2020 revealed medications were administered in accordance with orders of the prescriber. The nurse was to follow the five rights including right time.

Based on interview, record review and review of facility policy the facility did not ensure State tested Nursing Assistant (STNA) #602 received 12 hours of formal in service education within the last year. This affected one STNA out of three STNAs (#602, #604, and #605) whose personnel files were reviewed for formal education/training. This had the potential to affect 36 residents. Findings include: Review of the personnel file for STNA #602 revealed a hire date of 07/15/03. Review of STNA #602's education transcript revealed in the last 12 months STNA #604 had 0.75 total hours of training. Interview on 11/02/23 at 12:20 P.M. with Regional Staff Coordinator #603 verified STNA #602 had only completed 0.75 hours of training in the last 12 months. Review of facility policy labeled, Inservice Training dated April 2013 revealed employees must complete all assigned course work and attend mandatory in-services. The policy revealed each STNA annually must complete at least 12 hours of formal in-service education.

Based on review of the medical record, review of facility investigation, and interviews with facility staff and residents, the facility failed to ensure food served to the residents was free of mold. This affected one resident (Resident #24) of three residents reviewed for palatable food. The facility census was 45. Findings included: Review of the medical record revealed Resident #24 was admitted to the facility on [DATE]. Diagnoses included right tibia fracture, chronic obstructive pulmonary disease, hemiplegia right dominant side, Hepatitis C, osteomyelitis, depression, traumatic brain injury, post-traumatic stress disorder, liver disease, alcohol abuse and cocaine abuse. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #24 had moderately impaired cognition. Review of the progress notes dated 09/13/23 revealed Resident #24 was upset about the food on his tray, the nurse did not see his tray because the resident had already eaten his meal. Resident #24 came out of his room, walked very hastily to the kitchen, opened the door and was yelling at the kitchen staff. Resident #24 threatened to knock out the staff member's teeth. The kitchen staff was very calm and redirected Resident #24. Resident #24 complained of a stomachache and then he went outside and threw up. His wheelchair was brought out to him and he eventually wheeled himself back to his room. He was encouraged to drink fluids. The Administrator was informed. Review of the Meal Substitution log revealed on 09/13/23 sliced ham was substituted with sliced turkey for dinner. Review of the facility alert form dated 09/14/23 revealed a family concern was called in to the facility. On 09/13/23 at 4:45 P.M. the Executive Director (ED) received a call from facility nursing staff stating the sandwiches served for dinner had mold on them (they sent a picture). The ED attempted to call the Food Service Director (FSD) to instruct the kitchen staff to take back the trays and reserve the food. The FSD returned the call and stated all trays were being returned to the kitchen to be remade. However, one resident, Resident #24, had eaten his sandwich. The resident alleged he was sick and had vomited as a result of eating the sandwich. No other resident had consumed their sandwiches. Review of the unsigned witness statement dated 09/14/23 revealed STNA #107 was passing meal trays and noticed mold on the sandwiches. She immediately removed the tray and alerted the kitchen staff. She stated none of her residents ate any of the food. The kitchen remade the food and they served it. She stated there were no more visibly moldy sandwiches. Review of the signed witness statement dated 09/18/23 revealed Dietary #102 had made the sandwiches and wraps after lunch and at the time of making the sandwiches he saw no visible mold until the nursing assistant came and showed a moldy sandwich to him. He stated he stopped the tray line and made turkey and cheese sandwiches and the dietary aide pulled all the meal carts back into the kitchen and they changed out the sandwiches on the trays. On 10/11/23 at 10:10 A.M. an interview they Resident #24 revealed he stated he received a ham sandwich that was moldy. He stated it was dark in his room, he started eating the sandwich and it had tasted funny so he took a closer look and that was when he saw the mold on it. The aide told him they were picking up all the ham sandwiches because they had mold on them. He stated he got sick and threw up once outside and once in his toilet after eating the sandwich. On 10/11/23 at 11:10 A.M. an interview with Licensed Practical Nurse #100 revealed about three weeks ago a nursing assistant brought a sandwich to her that had visible moldy green lunch meat in it. She stated she was not sure what room she got it from. On 10/11/23 at 11:50 A.M. an interview with Food Service Manager (FSM) #101 revealed she had never had any complaints of spoilage of food except about three weeks ago it was brought to their attention during the evening meal a resident stated his ham sandwich did not taste right. She stated they had just sent the first cart out so Dietary #102 made the decision to not serve the ham and replace the sandwiches with turkey. She stated all the ham sandwiches were retrieved and thrown away. She stated they never tried the ham so she does not know if it was bad or not and Resident #24 had eaten his so they were not able to see it. On 10/11/23 at 4:10 P.M. an interview with State tested Nursing Assistant (STNA) #103 revealed she had been working the evening the residents received moldy ham and cheese sandwiches. She stated there were several residents who received them but Resident #24 was the only one who ate the sandwich before realizing it had been moldy and he was very upset. He went to the kitchen and started yelling at the kitchen staff. She stated they did take all the sandwiches back to the kitchen and threw them out and gave the resident a non-moldy sandwich. She stated she took a picture of one of the sandwiches she seen with the mold. On 10/12/23 at 12:20 P.M. an interview with STNA #107 revealed she had been working on the 100-hall and she got her meal trays first. She took the trays to Resident #19 and Resident #37 in their room. She stated Resident #37 got a bologna sandwich but Resident #19 got the ham sandwich. She stated Resident #19 liked her sandwiches cut up so she began to cut it up and noticed it had mold on it. She told the resident she could not eat it because it was moldy and took the tray away for her. She stated she went back out to the meal cart and looked at all the residents' sandwiches and all the ones with ham on them were moldy. She stated she told everyone working to check their sandwiches and took the cart to the kitchen. She stated she told Dietary #102 and he took the sandwich from her, ripped the moldy part off and said it was fine. She stated she told him she was not feeding those sandwiches to the residents. She stated he did not do anything and sent out the 200-hall meal cart with the same sandwiches. She stated the nursing assistant working on that hall passed out the trays even after she told him they had mold on them. She stated she called the ED to tell her of the situation. She added Resident #24 had already eaten his sandwich by the time they went around to pick up the sandwiches to switch them out. She stated Resident #24 was furious. On 10/12/23 at 12:40 P.M. an interview with Resident #19 revealed last month she received a moldy ham sandwich from the kitchen. She stated she had seen the mold on it. She stated the aide took the sandwich before she could eat it. This deficiency represents non-compliance investigated under Complaint Number OH00146475.

Based on observation, resident interview, staff interview, review of facility concern logs, review of staff in-services, and review of Resident Council meeting minutes, the facility failed to ensure resident call lights were answered in a timely manner. This affected two (Resident #1 and #2) of seven residents reviewed for call lights. The facility census was 36. Findings include: 1. Review of Resident #1's medical record, revealed the resident was admitted to the facility on [DATE]. Diagnoses included osteoarthritis, rheumatoid arthritis, weakness, pain in left shoulder, tremor, Charcot's joint, right ankle and foot, muscle weakness, muscle wasting and atrophy, and anxiety. Review of Resident #1's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/15/23, revealed the resident was cognitively intact and required extensive assistance of two staff for bed mobility. No behaviors were noted within the assessment. Observation on 06/01/23 from 9:54 A.M. to 10:56 A.M. revealed Resident #1's call light had been activated for at least 62 minutes. Interview on 06/01/23 at 10:35 A.M. with Resident #1 revealed the resident was waiting on an aide to come and adjust the sheets and blankets underneath of her straightened out. The resident reported the aide was likely showering other residents and would come when she was able. Interview on 06/01/23 at 11:01 A.M. with Licensed Practical Nurse (LPN) #101 revealed LPN #101 had not realized Resident #1's call light was going off for so long. LPN #101 stated the aide who was assigned to the hall where Resident #101 resided had been on lunch break at that time, which is why LPN #101 went to check on the call lights that were activated. 2. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included weakness, respiratory failure, difficulty in walking, mild intellectual disabilities, cognitive communication deficit, unspecified psychosis, anxiety, need for assistance with personal care, and history of falling. Review of Resident #2's annual MDS 3.0 assessment, dated 05/10/23, revealed the resident was cognitively intact. The resident required extensive assistance of one staff for transfers and toileting. No behaviors were noted within the assessment. Observation on 06/01/23 from 10:28 A.M. to 10:50 A.M. revealed Resident #2's call light had been activated for at least 22 minutes. At approximately 10:37 A.M., Resident #2 began yelling and crying out someone please help me, ow, and help me. Resident #2 could be heard crying loudly from the nurse station located just off of the hall where the resident resided. Interview on 06/01/23 at 11:11 A.M. with Resident #2, revealed the resident had been in the bathroom waiting for assistance wiping and off of the toilet. Resident #2 reported it often took staff a long time to respond to her call light but could not relay an approximate amount of time. Interview on 06/01/23 at 11:01 A.M. with LPN #101 revealed LPN #101 had not realized how long Resident #2's call light was activated. LPN #101 reported whenever Resident #2 finished using the bathroom, she would begin crying out. LPN #101 stated the aide who was assigned to the hall Resident #101 resided on had been on lunch break at that time, which is why LPN #101 went to check on the call lights that were activated. Review of the concern logs for 03/01/23 through 05/31/23, revealed concerns regarding call lights were noted on 03/21/23, 03/29/23, 04/06/23, 04/07/23, and 04/11/23. The resolution provided for each occurrence was education and/or staff education. Review of the all-staff in-service dated 05/04/23 revealed staff were educated regarding call light response. Review of Resident Council meeting minutes dated 03/30/23, revealed a concern with call light response time was noted. This deficiency represents non-compliance investigated under Complaint Number OH00142463.

Based on record review and interview, the facility failed to notify the family when a change of condition occurred. This affected one (Resident #100) of three residents reviewed for notification of change. The census was 47 residents. Findings Include: Review of the medical record for the Resident #100 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included encephalopathy, type two diabetes and need for assistance with personal care. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 03/29/22, revealed the resident had impaired cognition. Interview on 03/15/23 at 10:15 A.M., Family Member #1 of Resident #100 stated the facility did not inform her of the wound Resident #100 had on the sacrum. Family Member #1 stated her sister (Family Member #2) visited Resident #100 on 05/11/22 and observed a wound on the sacrum. Family Member #1 stated she spoke with the the social worker, Administrator and State tested Nurse Assistant (STNA) #245 on 05/12/22 regarding the wound. Family Member #1 stated the Administrator stated he would educate the staff on wound care and reporting. Interview on 03/15/23 at 4:36 P.M., Family Member #2 stated she observed the wound on the sacrum when she provided incontinence for Resident #100. Family Member #2 stated the wound had a dressing on it. Review of the plans of care dated 03/22/22 through 06/01/22 revealed no documentation related to Resident #100 having a wound on the sacrum. Review of physician orders dated 03/22/22 through 06/01/22 revealed no documentation related to Resident #100 having a wound on the sacrum. Review of assessments dated 03/22/22 through 06/01/22 revealed no documentation related to Resident #100 having a wound on the sacrum. The assessment indicated Resident #100 had a wound on the left calf. Review of the nurse's notes dated 03/22/22 through 06/01/22 revealed no documentation related to Resident#100 having a wound on the sacrum or any notification to the family regarding a wound. Review of the treatment administration records dated 03/22/22 through 06/01/22 directed staff to cleanse the lateral buttocks with soap and water, pat dry, then apply a layer of EPC cream to prevent skin breakdown. There was not a treatment for a sacrum wound. Interview on 03/16/23 at 9:15 A.M., STNA #245 stated Resident #100 had a wound on the sacrum. STNA #245 stated family were aware of the wound when family observed it. Interview on 03/16/23 at 9:29 A.M., the Director of Nursing (DON) verified Resident #100's family was not notified timely of Resident #100's wound or the plan of care regarding the wound. This deficiency represents noncompliance investigated under Master Complaint Number OH00140897 and Complaint Number OH00132660.

Based on record review, observations and interview, the facility failed to maintain a sanitary resident environment. This affected one (Resident #15) of five residents reviewed for environment. Findings Include: Review of the medical record for the Resident #15 revealed an admitted [DATE]. Diagnoses included difficulty in walking, major depressive disorder colostomy status, and metabolic encephalopathy. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/10/23, revealed the resident had intact cognition. The resident required extensive assistance for toileting. Observations on 03/15/23 at 8:57 A.M. of Resident #15 lying in bed revealed feces located on the resident's bed sheet, on the floor and all over the bag lining the trash bag. There was also clothing, and a bed pad covered with feces lying in a pile on the floor. Interview with Resident #15 during the observation, revealed the resident's colostomy bag had leaked the night before around 9:00 P.M. Resident #15 stated he told staff about it, but staff did not clean it up. Resident #15 stated staff had brought in his breakfast tray this morning and didn't clean the feces up. Observation and Interview on 03/15/23 at 9:00 A.M. with State tested Nurse Assistant (STNA) #229 verified that feces was on Resident #15's bed sheet, garbage, and floor. STNA #229 stated he would get it cleaned up immediately. Interview on 03/15/23 at 9:10 A.M., Housekeeper #203 stated staff did not inform her of the feces in Resident #15's room. Interview on 03/15/23 at 9:38 A.M., STNA #257 stated she took Resident #15's breakfast tray in the room but did not observe the feces on the bed or floor. This deficiency represents non-compliance investigated under Complaint Number OH00137034.

Based on record review and interview, the facility failed to ensure Resident #100's wound was thoroughly assessed, care planned comprehensively, and treated properly. This affected one resident (Resident #100) of three residents reviewed for wound care. The census was 47 residents. Findings Include: Review of the medical record for the Resident #100 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included encephalopathy, type two diabetes and need for assistance with personal care. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 03/29/22, revealed the resident had impaired cognition. Interview on 03/15/23 at 10:15 A.M., Family Member #1 of Resident #100 stated the facility did not inform her of the wound Resident #100 had on the sacrum. Family Member #1 stated her sister (Family Member #2) visited Resident #100 on 05/11/22 and observed a wound on the sacrum. Family Member #1 stated she spoke with the the social worker, Administrator and State tested Nurse Assistant (STNA) #245 on 05/12/22 regarding the wound. Family Member #1 stated the Administrator stated he would educate the staff on wound care and reporting. Interview on 03/15/23 at 4:36 P.M., Family Member #2 stated she observed the wound on the sacrum when she provided incontinence for Resident #100. Family Member #2 stated the wound had a dressing on it. Review of assessments dated 03/22/22 through 06/01/22 revealed no evidence Resident #100's sacrum wound was assessed. Review of the plans of care dated 03/22/22 through 06/01/22 revealed no evidence of a care plan was developed to address Resident #100's sacrum wound. Review of physician orders dated 03/22/22 through 06/01/22 revealed no evidence of treatment orders to Resident #100's wound on the sacrum. Review of the nurse's notes dated 03/22/22 through 06/01/22 revealed no documentation related to Resident#100 having a wound on the sacrum. Review of the treatment administration records dated 03/22/22 through 06/01/22 directed staff to cleanse the lateral buttocks with soap and water, pat dry, then apply a layer of EPC cream to prevent skin breakdown. There was not a treatment in place for a sacrum wound. Interview on 03/16/23 at 9:15 A.M., STNA #245 stated Resident #100 had a wound on the sacrum. STNA #245 stated family were aware of the wound when family observed it. Interview on 03/16/23 at 9:29 A.M., the Director of Nursing (DON) verified the lack of evidence related to assessment, care planning, and treatment of Resident #100's sacrum wound.

Based on record review and interview, the facility failed to ensure Resident #102's deep tissue pressure injury was comprehensively care planned and treated as ordered. This affected one (Resident #102) of three residents reviewed for wound care. The census was 47 residents. Findings Include: Review of the medical record for Resident #102 revealed an admitted [DATE] and discharge date of [DATE]. Diagnoses included displaced comminuted fracture of shaft of right femur, dementia and need for assistance with personal care. Review of the admission nursing assessment identified the Resident #102 was admitted with a surgical wound on right hip. There was no evidence of a pressure ulcer injury to the right heel. Review of the pressure ulcer risk assessment dated [DATE] revealed the resident was at moderate risk for the development of pressure ulcers. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 03/17/22, revealed the resident had impaired cognition. The resident required extensive assistance for bed mobility, transfers, ambulation. The assessment indicated the resident had no pressure wounds. Review of the plan of care dated 03/21/22 revealed the resident was at risk for pressure ulcers due to impaired immobility, cognition, and incontinence. Interventions included pressure reducing devices on wheelchair and bed, reposition frequently when in bed and chair, and float heels as tolerated. Review of the wound grid dated 03/23/22 revealed Resident #102 had a purple fluid filled intact blister (to the right heel) measuring five centimeters (cm) by eight cm by unable to determine depth (utd). Orders were for staff to cover with an abdominal bandage (ABD) and wrap with kerlix. The blister was identified as a deep tissue injury (DTI). Review of wound grid dated 03/30/22 revealed the blister had fallen off with a skin flap remaining around the perimeter of the wound, no infection was noted. New orders included to apply skin preparation to the surrounding intact skin, apply adaptic/serofoam to open area, cover with ABD and wrap with kerlix daily. The wound grid did not identify the wound type. Review of wound grid dated 04/06/22 revealed the right heel wound measured 3.3 cm by 3.2 cm by utd. The wound remained unchanged. New order was to paint wound with betadine, cover with ABD, and wrap with kerlix daily. The wound grid did not identify the wound type. Review of wound grid dated 04/13/22 revealed the right heel wound measured 2.9 cm by 3.6 cm by utd. The wound grid did not identify the wound type. Review of wound grid dated 04/20/22 revealed the right heel wound measured 3.1 cm by 3.3 cm by utd. The wound grid did not identify the wound type. Review of Resident #102's care plans revealed a comprehensive care plan was not developed to address Resident #102's right heel DTI. Review of progress notes from 03/11/22 to 04/25/22 revealed no documentation indicating Resident #102 had a DTI of the right heel. Review of the treatment administration record from 03/11/22 to 04/25/22 revealed no evidence of when and what treatment was provided to Resident #102's right heel DTI. Interview on 03/16/23 at 9:29 A.M., the Director of Nursing (DON) verified the lack of evidence a care plan was developed for Resident #100's right heel DTI and the lack of evidence of wound treatments being provided as ordered. The DON could not verify the treatments were completed as ordered. This deficiency represents noncompliance investigated under Complaint Number OH00131766.

Based on observation, record review, review of the facility policy and procedure related to medication administration and medication error and interviews with residents, family, and facility staff including Licensed Practical Nurse (LPN) #609, and Primary Care Physician #608 revealed the facility failed to administer Resident's #27, #19, #21, #24, and #10 their medications per physician orders when the facility failed to have sufficient nursing staff to administer medications on the 100 or 200 hall on 10/24/21 resulting in significant medication errors. This resulted in Actual Harm on 10/24/21 for Resident #27 as the facility failed to administer his cardiac and diuretic medications including his [MEDICATION(S)] (diuretic) that was ordered to treat Resident #27's fluid overload due to heart failure. This resulted in Resident #27 being sent to the hospital on 10/25/21 at 2:34 A.M. due to respiratory distress and was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Actual Harm affected one resident (Resident #27) of five residents reviewed for actual harm resulting from the significant medication errors, and the facility had significant medication errors that affected five residents (Resident #27, #19, #21, #24 and #10) of five residents reviewed for medication administration. This had the potential to affect all 28 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #12, #13, #14, #15, #17, #18, #19, #20 #21, #22, #23, #24, #25, #26, #27, #55, #56, #57, #58 and #59) residing on the 100 and 200 halls on 10/24/21. The facility census was 44. Findings include: 1. Review of the medical record for Resident #27 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 05/22/19 revealed Resident #27 had a potential for alteration in respiratory function related to history of respiratory failure and acute respiratory distress. Interventions included administer medications as ordered, elevate head of bed, obtain vital signs and oxygen saturation rate as ordered. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #27 had intact cognition and required two staff assist with bed mobility. Resident #27 received insulin, anticoagulant, antidepressant, and diuretic therapy daily during the seven-day assessment period. Resident #27 also received oxygen therapy. Review of the October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . These medications were to be administered between 7:00 A.M. to 11:00 A.M. every day. The MAR progress note authored by Licensed Practical Nurse (LPN) #609 revealed Resident #27's above medications were not administered due to short staffed and unable to complete. Also, Resident #27 was ordered to have his blood glucose level checked and administer [MEDICATION(S)] 100 units per milliliter per sliding scale at 7:30 A.M. and 11:30 A.M. The MAR progress note authored by LPN #609 revealed Resident #27's glucose level was not checked, and Resident #27 was not administered insulin per his sliding scale if needed due to short staffed and unable to complete. Review of the nursing note dated 10/25/21 at 2:34 A.M. and authored by LPN #611 revealed Resident #27 was sent to the hospital emergency room per emergency rescue squad as he was yelling out for help. Resident #27's oxygen saturation rate was 85 percent on three liters of oxygen. LPN #611 revealed Resident #27 was breathing with his abdominal muscles. Review of the nursing note dated 10/26/21 at 3:40 P.M. and authored by Registered Nurse (RN)/ MDS #605 revealed Resident #27's Primary Care Physician #608 was notified Resident #27 missed his morning medications on 10/24/21 and there were no adverse outcomes noted. Primary Care Physician #608 recommended no new orders. There was no documented evidence the resident and/ or responsible part were notified. Review of the hospital discharge records dated 10/28/21 revealed Resident #27 was hospitalized and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #27 was evaluated by a pulmonologist and had a thoracentesis to remove the extra fluid to help the resident breath better. The discharge paperwork also revealed Resident #27 received intravenous [MEDICATION(S)] (diuretic) to help get the extra fluid off his lungs. Resident #27 was stabilized and discharged back to the facility on [DATE]. Review of the care plan dated 11/2/21 for Resident #27 revealed he had an alteration in blood glucose metabolism. Interventions revealed administer diabetic medication per physician orders and observe for signs and symptoms of hyperglycemic and hypoglycemic. Interview on 11/05/21 at 11:17 A.M. with Resident #27 revealed he appeared slightly confused and unable to provide any details or information regarding his recent hospitalization . Resident #27 revealed he had no concerns related to getting his medications as ordered. Interview on 11/05/21 at 1:39 P.M. with Resident #27's Primary Care Physician #608 revealed Resident #27 was compromised especially related to his chronic renal failure, chronic respiratory failure, and his heart failure as he was in and out of hospitals. Primary Care Physician #608 revealed because of his fragile medical condition it was possible that missing even one dose of his medication, especially the [MEDICATION(S)], would cause the back up of fluid in his lungs. Primary Care Physician #608 revealed it was hard to say though if missing one dose of his medication would contribute or not with the buildup of that much extra fluid. He revealed in a regular healthy resident he would say it would not affect to that extent, but because Resident #27 was so compromised it was possible only missing one dose would cause a backup of fluid on his lungs. 2. Review of the medical record for Resident #21 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 10/21/21 revealed Resident #21 had cardiac impairment related to congestive heart failure, [CONDITION(S)], and coronary artery disease. Interventions included administer medications as ordered, and observe for shortness of breath, headache, dizziness, chest pain, and elevated vital signs. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #21's cognitive status was not assessed. She required extensive assist of one staff for bed mobility and extensive assist of two staff for transfers. She received five days of injections and five days of anticoagulant therapy during the assessment reference period. Review of the October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. to 11:00 A.M. The MAR progress note authored by LPN #609 revealed Resident #21's [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] was not administered due to short staffed and unable to complete. Review of the nursing notes for Resident #21 dated 10/24/21 to 11/05/21 revealed no adverse effects from missing the medications on 10/24/21. Review of nursing note dated 10/26/21 at 3:38 P.M. and authored by RN/ MDS #605 revealed Resident #21's Primary Care Physician #608 was notified Resident #21 missed her morning medications on 10/24/21 and there were no adverse outcomes noted. Primary Care Physician #608 recommended no new orders. There was no documented evidence the resident and/ or responsible part were notified. Interview on 11/05/21 at 8:11 A.M. with Resident #21 revealed it was difficult to communicate and understand as she spoke a different language, and she could not remember any issues with her medications and the nurses not giving medications as ordered. Interview on 11/05/21 at 9:30 A.M. with Resident #21's son revealed on 10/24/21 Resident #21 told him she did not receive any of her morning medications, and he was concerned especially because she received an anticoagulant and was on other medications for her heart. He revealed he was told by the facility that there was only one nurse in the facility for the other two units and that there was not a nurse on Resident #21's unit that was able to administer her medications on 10/24/21. 3. Review of the medical record for Resident #19 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 08/11/21 revealed Resident #19 had an alteration in blood glucose metabolism related to diabetes. Intervention included diabetic medications as ordered. Review of the care plan dated 08/26/21 revealed Resident #19 had cardiac impairment related to [CONDITION(S)]. Interventions included administer medication as ordered, observe for shortness of breath, headache, elevated blood pressure, and report any changes to the physician. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #19 had impaired cognition and required extensive assist of two staff with bed mobility and was totally dependent of two staff with transfers. She received daily insulin during the seven-day assessment period. Review of the October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. to 11:00 A.M. LPN #609 revealed per MAR progress note medications were not administered due to short staffed and unable to complete in timely manner. Also, on 10/24/21 Resident #19 did not have her blood sugar checked and [MEDICATION(S)] Regular insulin (diabetes) 100 units per milliliter per sliding scale if needed completed as ordered at 7:30 A.M. as LPN #609 revealed per MAR progress note medication was not administered due to short staffed and unable to complete in timely manner. Review of the nursing notes for Resident #19 dated 10/24/21 to 11/05/21 revealed no adverse effects from missing the medications on 10/24/21. Review of the nursing note dated 10/26/21 at 3:37 P.M. and authored by RN/ MDS #605 revealed Resident #19's Primary Care Physician #610 was notified Resident #19 missed her morning medications on 10/24/21, and there were no adverse outcomes noted. Primary Care Physician #610 recommended no new orders. There was no documented evidence the resident and/ or responsible party was notified. Interview on 11/05/21 at 1:08 P.M. with Resident #19 revealed she had no concerns regarding the facility administering her medications timely and as ordered. 4. Review of the medical record revealed Resident #24 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 03/19/20 revealed Resident #24 had a potential for alteration in comfort related to pain to bottom of feet due to [CONDITION(S)]. Interventions included medication per orders, and assess pain for possible cause, location, and duration. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #24 had intact cognition and required extensive assist of two people with bed mobility and transfers. He received daily insulin during the seven-day assessment period. Review of the October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. to 11:00 A.M. LPN #609 revealed per the MAR progress note medications were not administered due to short staff and unable to complete in timely manner. Review of the nursing notes for Resident #24 dated 10/24/21 to 11/05/21 revealed no adverse effects from missing the medications on 10/24/21. Review of the nursing note for dated 10/26/21 at 3:39 P.M. and authored by RN/ MDS #605 revealed Resident #24's Primary Care Physician #608 was notified Resident #24 missed her morning medications on 10/24/21 and there were no adverse outcomes noted. Primary Care Physician #608 recommended no new orders. There was no documented evidence the resident and/ or responsible party were notified. Interview on 11/05/21 at 11:22 A.M. with Resident #24 revealed no concerns regarding receiving his medications timely or as ordered. 5. Review of the medical record for Resident #10 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 11/26/18 revealed Resident #10 had an alteration in blood glucose related to diabetes. Interventions included administer medications as ordered, and finger stick blood sugars as ordered. Review of the October 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and administer glulisine insulin 100 units per ml per sliding scale. The MAR progress note authored by LPN #609 revealed she did not administer due to short staff and unable to complete in timely manner. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #10 had impaired cognition. She required extensive assist of one staff for bed mobility, dressing, toileting, and transfers. She received five days of insulin and anticoagulant therapy during the assessment period. Review of the nursing notes for Resident #10 dated 10/24/21 to 11/05/21 revealed no adverse effects from missing the medications on 10/24/21. Review of nursing note dated 10/26/21 at 3:35 P.M. and authored by RN/ MDS #605 revealed Resident #24's Primary Care Physician #900 was notified Resident #24 missed her morning medications on 10/24/21 and there were no adverse outcomes noted. Primary Care Physician #900 recommended no new orders. There was no documented evidence the resident and/ or responsible party were notified. Interview on 11/05/21 at 11:13 A.M. with Resident #10 revealed no concerns as she felt she received her medications timely and as ordered. Observation of medication administration on 11/05/21 from 8:13 A.M. to 8:40 A.M. completed by Registered Nurse (RN) #602 and LPN #603 for Resident's #27, #24, #25 and #34 revealed they administered their medications timely and as ordered. There were zero medication errors out of 28 opportunities. Interview on 11/05/21 at 9:53 A.M. with the Director of Nursing verified she was aware there was only one nurse in the facility on 10/24/21. The Director of Nursing revealed she was on medical leave and unable to cover as there was a call off leaving only one Agency LPN #609 in the facility to administered 43 residents their medications. She revealed she attempted to contact other nurses and agencies to cover the call off but was unable. She revealed she was aware LPN #609 felt she was unable to administer medications to all four units and revealed she had told LPN #609 to try her best to administer as many medications as she could. She verified the residents on the 100 and 200 units did not receive their morning medications. The Director of Nursing verified Resident #27 did not receive his morning medications that included [MEDICATION(S)] a diuretic and later was sent to the hospital on 10/25/21 at 2:34 A.M. and admitted with pleural effusion (fluid on his lungs). The Director of Nursing also verified the primary care physicians for the residents involved on the 100 and 200 hall that did not receive their medications was not notified until 10/26/21 by the RN/ MDS #605 including Primary Care Physician #608 for Resident #27 who was medically compromised. The Director of Nursing verified the residents or the resident's responsible parties were not notified that they did not receive their morning medications on 10/24/21. The Director of Nursing verified the facility did not fill out medication error forms per their facility policy. Interview on 11/05/21 at 11:38 A.M. with the Administrator verified he was notified on the morning of 10/24/21 that the facility had a call off and there was only one nurse on duty. He revealed he contacted the facility staff as well as all the agencies but was unable to cover the position. He verified he was aware LPN #609 felt she was unable to pass all the residents their medications for all four units. He was aware the residents on the 100 and 200 halls did not receive their morning medications on 10/24/21. The Administrator verified he had instructed RN/ MDS #605 to notify the residents Primary Care Physicians on 10/26/21, and the facility did not notify the resident's or the resident's responsible parties of not receiving their morning medications on 10/24/21 on the 100 and 200 halls. Interview on 11/05/21 at 12:11 P.M. with RN/ MDS #605 revealed on 10/26/21 the Administrator asked her to contact all the resident's primary care physicians on the 100 and 200 hall and notify them the residents had not received their morning medications on 10/24/21. She revealed she had contacted all the residents primary care physicians on 10/26/21 and received no new orders. She revealed she did not notify any of the residents or their responsible parties. Interview on 11/05/21 at 2:40 P.M. with LPN #609 revealed she worked on 10/24/21 and was the only nurse from 7:00 A.M. to approximately 3:00 P.M. for approximately 43 residents. She revealed she was only able to administer medication to the residents that resided on the 300 and 400 units. LPN #609 revealed she was unable to administer medications for the residents on the 100 or 200 units as there was not sufficient time to pass medications to the residents on all four units. She revealed during this time frame she also had two discharges and a resident on the 300/ 400 unit that required being sent to the hospital. She revealed she had spoken with the Director of Nursing who was aware she was the only nurse in the facility and was told to try her best to administer as many residents their medications as she could. She revealed she did not notify the physician, resident, or the resident responsible party that she was unable to administer their morning medications for the residents on the 100 and 200 halls. She revealed she was able to come over to the 100 and 200 hall a few times when the staff notified her to check a change in condition of a resident administer a few insulins and administer one as needed inhaler medication but could not remember who the residents were as she revealed she had only worked at the facility a few times and was not familiar with the residents. Review of the facility policy labeled Preparation a General Guidelines revealed the facility failed to implement the policy as written as the policy revealed medications were to be administered as prescribed as the facility was to ensure sufficient staff and medication distribution system was in place for safe administration of medications without unnecessary interruptions. Review of the undated facility policy labeled Medication Error Policy and Procedure revealed the facility failed to implement their policy as upon identification of a medication error the nurse would assess the resident to establish a baseline assessment. The policy revealed the nurse would notify the resident's physician of the medication error and obtain orders if needed. The policy revealed based on the medication the patient's condition should be monitored at least every two hours and the nurse would notify the physician if any changes post medication error. The policy revealed the nurse would complete the Medication Error Report Form. The policy revealed the medication error report would include notification to the family. This deficiency substantiates Complaint Number OH 955.

Based on observation, record review and interview, the facility failed to appropriately provide care and treatment to an injury following a fall, resulting in the worsening of the injury, for one resident (Resident #13) out of eight residents reviewed for accident hazards in a facility census of 49. Findings include: Resident #13 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nursing progress notes dated10/15/12 at 7:47 P.M. revealed Resident #13 was found sitting in her room, on the floor, in front of her wheelchair with daughter present. The notation indicated the fall was unwitnessed by staff but the daughter explained she accidentally pushed the wheel chair into the bed causing the wheel chair to tip forward and her mother to fall. The notation indicated a witness form and fall event was completed. A plan of care dated 10/17/12 for the resident being at risk for alteration in skin did not note the incident with the skin tear to the resident's right lower leg. A Wound Grid document dated 10/17/12 revealed skin tears that measured 0.8 centimeters (cm) by 0.9 cm and 0.9 cm by 0.9 cm on the resident's right leg shin. The information described the areas as "red with moderate sero-sangunous drainage." No physician order was found for the care and treatment of [REDACTED]. Physician orders dated 10/23/12 revealed to cleanse right shin skin tear with normal saline solution, gently pat dry, apply steri strips at area. The order was changed on 10/24/12 to cleanse the right shin skin tear inferior and superior aspect of right leg with normal saline, gently pat dry, cover with non-adherent dressing and wrap with a kerlix dressing. On 10/23/12 at 10:25 A.M. during interview with 400 unit charge nurse, Registered Nurse (RN) #235, she stated that Resident #13 had a fall in the facility approximately two weeks ago with no injury. She stated the resident's daughter was with her at the time of the fall. On 10/23/12 at 11:15 A.M. during observation of Resident #13, she was sitting in a high back wheel chair in a small television/lounge room across from the dining room with one daughter and her neighbor visiting with the resident. The resident was nicely dressed and somewhat confused and disoriented. Her daughter raised the resident's pant leg to show an old, frayed undated dressing on the resident's right lower leg. A large black boot was on the resident's right foot and lower leg almost covering the dressing. The daughter stated that the resident fell out of her wheel chair last week and the bar on the wheel chair "tore open her leg." She stated "when we arrived here after the fall the next morning there were steri strips on it, with no dressing and I asked them to put a dressing on the wound." The daughter stated, "I think the dressing on her leg is the same one that they put on that morning when I asked them to." During observation of Resident #13's right lower leg on 10/24/12 at 3:00 P.M. with RN #210 and the director of nursing (DON) assisting, a dressing on the resident's right leg (which was indicated as placed earlier that morning by RN #210) was removed to revealed two large wounds separated by a small scabbed area with a small amount of serous sanguineous drainage on the old dressing. The two open areas appeared approximately two to three cm wide with red weeping centers and a little scattered white material with in the posterior wound. Both wound areas had worsened. Both wounds were cleaned with a normal saline solution, a non-adherent pad was applied over the open wounds and all was wrapped with a Kerlix dressing. On 10/24/12 at 5:30 P.M. during interview with the facility corporate nurse, RN #230, she verified Resident #13's treatment administration record (TAR) and stated "they did a treatment on 10/17/12, but never wrote the order, so it was never done again until they saw the dressing yesterday 10/23/12."

Based on interview, observation and record review the facility failed to maintain a chair alarm for Resident #23 and Resident #19 who sustained a fall with injury, and failed to maintain a chair alarm for Resident #13 who had a history of [REDACTED]. This affected three of eight residents reviewed for falls of a sample of 12 residents Findings include: 1. Resident #23 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. An initial Minimal Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was moderately impaired in cognition for decision making and required extensive assistance by two staff members for bed mobility and one staff member for transferring and toileting. The MDS triggered assessment protocols in the area of falls. On 05/24/11 the resident was assessed as a high risk for falls. A plan of care for the resident dated 06/14/11 revealed the resident was at risk because of a history of falls, intermittent confusion, impaired balance with transitions (changing positions), functional decline and weakness. Interventions included "Do not leave alone on the toilet." Nursing notes dated 06/15/11 at 7:31 A.M. revealed that Resident #23 was sitting in his wheel chair in his room. A state tested nurse aide (STNA) went into the room and found the resident on the floor. The resident stated he was leaning over trying to put on his shoes. No injury was noted. The 06/15/11 physician orders [REDACTED]. During initial observation of Resident #23 on 07/19/11 at 10:50 A.M. the resident was found alone in the bathroom in his room with the bath room door closed (resident assessed to require assist of one staff member for toileting). A physical therapist (PT) #9 was standing in the resident's room waiting for the resident to finish. No information was provided to the surveyor as to who placed the resident in the bathroom and left him there or if the resident went into the bathroom by himself. At 2:30 P.M. the resident was found seated in a wheel chair facing the bathroom in his room. No alarm was noted on the resident's wheel chair. The resident was alone in his room. At 3:40 P.M. the resident was noted lying on the floor with his head near the wall and body extending out into the room. A moderate amount of bright red blood was noted on the floor under the resident's left elbow area where a laceration was noted. His wheel chair was across the room. The resident stated the wheel chair "got away from me". During interview with the state tested nursing assistant (STNA) #5 at 3:55 P.M. she stated that she was the first staff member to find the resident on the floor, and "the resident does not have an alarm". At 4:00 P.M. the facility assistant director of nursing, (ADON), was observed coming out of the resident's room. When asked about the alarm, she stated "I don't know where the alarm is." The facility did not have the ordered alarm device on the resident's wheel chair as ordered. On 07/21/11 at 9:00 A.M., review of the "Incident Reassessment Summary" dated 06/15/11 revealed the new intervention was to place an alarm to the wheel chair. The summary for the fall on 07/19/11 revealed the resident sustained [REDACTED]. The summary indicated "the chair alarm was not present." The summary further indicated that "staff inserviced about alarms." 2. Resident #19 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. An annual MDS 2.0 assessment dated [DATE] revealed the resident was moderately impaired in cognition for decision making and required extensive assistance by one staff member for activities of daily living events (ADL's) including bed mobility, transferring and toileting. The MDS triggered for protocols in the area of falls. The fall risk assessments dated 09/10/10 and 11/11/10 revealed the resident was a high risk for falls. A plan of care for Resident #19 dated 07/02/10 revealed that the resident had a history of [REDACTED]. Interventions and physician orders [REDACTED]. Nursing notes dated 12/06/10 at 4:05 P.M. revealed that Resident #19 was found on the floor by her wheel chair. The resident hit the left side of her forehead and left elbow. The notation indicated that the resident stated she was reaching for her papers on the chair. The resident was placed on oxygen, ice was applied to her head and an emergency medical squad (911) was called. The resident was sent to the hospital. No nursing notes were found regarding the resident's re-admission back into the facility. On 05/09/11 a significant change MDS for Resident #19 revealed the resident had declined and required extensive assistance by two staff members for bed mobility and transferring. The resident was also under hospice services. Nursing notes dated 07/16/11 revealed that at 8:05 A.M. a state tested nursing assistant (STNA) summoned the nurse on the unit to the resident's room. The STNA was transferring the resident from the bed to her geriatric chair and the resident could not stand and bear weight. The STNA lowered the resident to the floor with her back against the bed. The resident stated she "hurt all over" but her arm/chest area were sore since the fall. The resident had been assessed as a two persons assist with transfers. On 07/20/11 at 10:40 A.M., a review of the investigation "Incident Reassessment Summary" for all of the falls revealed the following: The fall of 12/06/10; the resident reached forward to pick up newspaper without locking her wheel chair and fell forward landing on her head with the wheel chair on top of her. The summary indicated that the resident's "head was wrapped" and ice applied. Staff was unable to determine the length of laceration due to "bleeding profusely". The new intervention was to remind the occasionally confused resident to lock the wheel chair. Hospital information revealed the resident had staples in her forehead for the laceration. The fall of 06/27/11; the resident had been resting in bed prior to the fall and had been declining in health and on hospice services. The new intervention was for the bed to be in low position and against the wall. Alarms were also to be placed on the resident on 06/30/11. The fall on 07/16/11; the STNA was pivoting the resident from her bed to the Broda chair when the resident felt weak and unable to support her weight. The new intervention indicated "two person transfer for all transfers" The resident was already assessed as requiring two person staff assistance for transferring following the decline in functional status and significant change MDS assessment of 05/09/11. During an interview with the facility Director of Nursing (DON) on 07/21/11 at 9:15 A.M., she verified that only one STNA transferred the resident. The surveyor asked the DON if the STNA who transferred the resident by herself was disciplined. The DON indicated that she had to check. No answer to the question was ever given to the surveyor during the survey. Resident #19 was observed on 07/19/11 at 10:50 A.M., 3:00 P.M. and 4:15 P.M., on 07/20/11 at 7:35 A.M. and 5:15 P.M. and on 07/21/11 at 7:40 A.M. and 9:00 A.M. sitting up in the Broda chair in the main dining room at a table or in the activity room area across from the dining room with no alarm device in place. At 9:00 A.M. on 07/21/11 Licensed Practical Nurse (LPN) #3 verified that the ordered alarm was not in place on the resident's chair and stated "she is supposed to have an alarm on." 3. Resident #13 was admitted into the facility on ,[DATE] with [DIAGNOSES REDACTED]. An annual 3.0 MDS assessment dated [DATE] revealed the resident had severe impairment for decision making and required extensive assistance by one staff member for bed mobility, transferring, and toileting. The MDS triggered protocols in the area of falls and the resident was assessed on 09/21/10 and 12/20/10 as a high risk for falls. A plan of care dated 03/28/11 revealed the resident was at risk for falls due to confusion, history of falls, incontinence, anti-depressant medications and unsteady gait. The interventions included the resident was to have a bed and wheel chair alarm to alert staff of unassisted ambulation. Resident #13's physician orders [REDACTED]. Nursing notes dated 04/11/11 at 11:00 P.M. revealed the resident was found lying on the floor next to her bed. The resident was unable to tell nursing what she was trying to do. No injury was noted. The notation indicated "new alarm." On 07/21/11 at 10:40 A.M. review of the investigation "Incident Reassessment Summary" dated 04/12/11 revealed the resident's bed alarm "did not sound, alarm box malfunctioned." Observation of Resident #13 on 07/20/11 at 8:00 A.M. revealed the resident was seated in her wheel chair in the main dining room. No alarm was noted on the resident's wheel chair. At 9:25 A.M. the resident was found sitting in her wheel chair, alone in her room. No alarm was found on the resident's wheel chair. LPN #8 was summoned to the resident's room. LPN #8 verified that no alarm was on the resident's wheel chair as ordered.