Every finding on record at Altercare Post-Acute Rehab Center

Based on record review, staff interview, and facility policy review, the facility failed to timely notify the physician of a significant change in condition and failed to notify the physician when nursing staff independently held physician ordered medications. This affected one resident (#169) of three residents reviewed for notification of change. Findings include:Review of the closed medical record for Resident #169 revealed an admission date of 12/11/25 and a discharge date [DATE]. Diagnoses included hypervolemia (fluid overload), orthostatic hypotension, hypertension, dehydration, acute kidney failure, type II diabetes, anxiety, and depressionReview of Resident #169's physician's orders dated 12/11/25 revealed the resident had an order for Humulin, an intermediate acting insulin lasting 12 to 24 hours, to inject eight units subcutaneously at 8:00 A.M. and 4:30 P.M. In addition, an order to check her blood sugar, before meals and at bedtime; 7:30 A.M., 11:30 A.M., 5:30 P.M., 8:00 P.M. Additional notes stated to notify the physician for blood glucose levels over 400 or under 70. Morning medication included: Tylenol (analgesic) 1000 milligram (mg), Atorvastatin (lowers cholesterol) 20 mg, vitamin D3 (supplement) 20 microgram (mcg), vitamin B (supplement) 12 mcg, vitamin D2 (supplement) 1250 mg, levothyroxine (thyroid hormone) 50 mg, losartan (medication to treat high blood pressure and protect kidneys in type II diabetics) 50 mg, Protonix (stomach acid reducer) 40 mg, Lyrica (anticonvulsant and nerve pain medication) 150 mg used for nerve pain, Buspar (antianxiety) 5 mg used to treat anxiety.Review of the December 2025 Medication Administration Record (MAR) on 12/18/25 revealed the Tylenol, Atorvastatin, vitamin D3, vitamin B12, and vitamin D2 were signed off as administered, BuSpar and vitamin D2 were not signed off as administered. The resident's blood sugar result at 7:30 A.M. was 240 and 182 at 11:30 A.M. Humulin was not administered at 8:00 A.M. as ordered. Review of the nurse's progress notes dated 12/18/25 at 8:54 A.M. revealed the nurse was given report from the night shift nurse that Resident #169 was lethargic, breathing heavily, and slow to respond to voice command. Both nurses observed Resident #169 lethargic, breathing and slow to respond to stimuli. During morning medication administration, the nurse noted the resident was breathing heavily, lethargic and slow to respond to voice. The physician was called, and the nurse was waiting for response. There was no documentation that the resident's physician ordered medications, including insulin (blood glucose at 7:30 A.M. was 240) were held.Progress noted dated 12/18/25 at 11:59 A.M. stated Resident #169 was unresponsive. Blood pressure was 70/30, blood glucose level was 182, and respirations were 30 per minute. Resident #169 stirred in response to a sternal rub. The physician was called at this time. There was no return call at this time. Emergency Medical Service (EMS) was called, and Resident #169 wat transferred to the hospital.Interview with the Medical Director (MD) on 03/11/26 at 3:29 P.M. stated he was not informed that the medications were held on the morning 12/18/25 and did not recall speaking to the nurse to give orders to hold Resident #169 medication, including insulin with a blood sugar of 240. The MD stated he would only hold fast acting insulin not long-acting insulin. Interview on 03/11/26 at 4:24 P.M. with Certified Medication Aid (CMA) #600 stated Resident #169 was sleepy due to a new medication (Buspar). On 12/18/25 she was instructed by Licensed Practical Nurse (LPN) #516 to hold insulin if the resident did not eat her breakfast. CMA #600 stated Resident #169 was not awake that morning.Interview on 03/11/25 at 4:31 P.M. with LPN #516 stated in morning shift report, the night nurse informed her that Resident #169 was not doing well and was not eating. LPN #516 wanted to send Resident #169 to the emergency room (ER) immediately but was told by the night nurse and the Director of Nursing (DON) to continue to monitor the resident. LPN #516 instructed CMA #600 to hold the insulin if the resident did not eat her breakfast per nursing judgement. LPN #516 sent a message to the physician; however, there was no response. LPN #516 stated Resident #169 did not look well and was sent to the ER.Interview on 03/13/26 at 9:30 A.M. with the DON stated the nurse called the physician on 12/18/25 and waited for a call back with instructions. CMA #600 held morning medications including insulin per nursing judgement on 12/18/25. Review of the facility policy titled Preparation and General Guidelines, dated May 2020, stated if a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time an explanatory note is entered on the record. If a dose of vital medication is withheld, refused, or not available, the prescriber is notified unless otherwise instructed by the prescriber.Review of the policy titled Change in the Residents Condition or Status, dated 05/01/2025, stated nurses will immediately notify the resident: consult with resident's attending physician, nurse practitioner, physician assistant or clinical nurse specialist and notify the resident representative of a significant change in the resident deterioration in health in a life-threatening condition.This deficiency was an incidental finding identified during the complaint investigation.

Based on record review, review of the emergency transport report, review of hospital records, interview and facility policy review, the facility failed to ensure Resident #169's insulin was administered as prescribed and failed to ensure timely transfer to the emergency room when a significant change in condition was identified. This affected one (Resident #169) of three residents reviewed for medication administration. The facility census was 66.Findings include:Review of the closed medical record for Resident #169 revealed an admission date of [DATE] and a discharge date [DATE]. Diagnoses included hypervolemia (fluid overload), orthostatic hypotension, hypertension, dehydration, acute kidney failure, type II diabetes, anxiety, and depressionReview of Resident #169's physician's orders dated [DATE] revealed the resident had an order for Humulin, an intermediate acting insulin lasting 12 to 24 hours, to inject eight units subcutaneously at 8:00 A.M. and 4:30 P.M. In addition, an order to check her blood sugar, before meals and at bedtime; 7:30 A.M., 11:30 A.M., 5:30 P.M., 8:00 P.M. Additional notes stated to notify the physician for blood glucose levels over 400 or under 70. Review of the [DATE] Medication Administration Record on [DATE] revealed Resident #169's blood sugar result at 7:30 A.M. was 240 and 182 at 11:30 A.M. Humulin insulin was not administered between 7:00 A.M. to 11:00 A.M. as ordered by the physician.Review of the nurse's progress notes dated [DATE] at 8:54 A.M. revealed the nurse was given report from the night shift nurse that Resident #169 was lethargic, breathing heavily, and slow to respond to voice command. Both nurses observed Resident #169 lethargic, breathing and slow to respond to stimuli. During morning medication administration, the nurse noted the resident was breathing heavily, lethargic and slow to respond to voice. The physician was called, and the nurse was waiting for response. There was no documentation that the resident's physician ordered medications, including insulin (blood glucose at 7:30 A.M. was 240) were held.Progress noted dated [DATE] at 11:59 A.M. stated Resident #169 was unresponsive. Blood pressure was 70/30, blood glucose level was 182, and respirations were 30 per minute. Resident #169 stirred in response to a sternal rub. The physician was called at this time. There was no return call at this time. emergency medical service (EMS) was called, and Resident #169 wat transferred to the hospital.Review of the emergency transport report dated [DATE] revealed EMS was called at 11:31 A.M., arrived on scene at 11:32 A.M., transferred to the emergency room at 11:45 A.M. and arrived at the emergency room at 11:57 A.M. The resident was unresponsive and hyperglycemic with a blood glucose level too high to register on the glucometer (over 600). (The significant change in condition began on night shift).Review of the hospital records dated [DATE] revealed Resident's glucose in the emergency room was 951, and she was admitted with diagnoses including diabetic ketoacidosis, septic shock, altered mental status, and hypotension. The resident expired in the hospital on [DATE].Interview with the Medical Director (MD) on [DATE] at 3:29 P.M. stated he was not informed that the medications were held on the morning [DATE] and did not recall speaking to the nurse to give orders to hold Resident #169's medication. The MD stated he would only hold fast acting insulin not long-acting insulin. Interview on [DATE] at 4:24 P.M. with Certified Medication Aid (CMA) # 600 stated Resident #169 was sleepy due to a new medication. On [DATE] she was instructed by Licensed Practical Nurse (LPN) #516 to hold insulin if the resident did not eat her breakfast. CMA #600 stated Resident #169 was not awake that morning.Interview on [DATE] at 4:31 P.M. with LPN #516 stated she received in morning shift report from the night nurse that resident was not doing well and was not eating. LPN #516 wanted to send Resident #169 to the emergency room immediately but was told by the night nurse and the Director of Nursing (DON) to continue to monitor. LPN #516 instructed CMA #600 to hold the insulin if the resident did not eat her breakfast per nursing judgement. LPN #516 sent a message to the physician; however, there was no response. LPN #516 stated Resident #169 did not look well and was sent to the emergency room.Interview on [DATE] at 9:30 A.M. with the DON stated the nurse called the physician on [DATE] and waited for a call back with instructions. CMA #600 held morning medications including insulin per nursing judgement on [DATE]. Review of the facility policy titled Preparation and General Guidelines, dated [DATE], stated If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time an explanatory note is entered on the record. If a dose of vital medication is withheld, refused, or not available, the prescriber is notified unless otherwise instructed by the prescriber.This deficiency represents non-compliance investigated under Master Complaint Number 2713937.

Based on observation, interview, and record review, review of manufacture's guidelines and facility policy review, the facility failed to ensure a medication error rate of less than 5%. Four errors were observed in 34 opportunities resulting in a 11.76% medication error rate. This affected one (Resident #114) of four residents observed for medication administration. The facility census was 66.Findings include:Review of the medical record for Resident #114 revealed an admission date 02/24/26 with diagnoses including respiratory failure, malnutrition, embolism of right upper extremity and bilateral lower extremities, anemia and hypotension.Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #114 had moderate cognitive impairment and required substantial assistance with activities of daily living.Review of the physician orders for March 2026 revealed orders for Brinzolamide ophthalmic drops 1% (reduces high pressure in the eye) one drop twice a day. The order did not clarify if the drop were to be instilled in right eye, left eye or both. Brimonidine 0.2% ophthalmic drop (reduces high pressure in the eye) to be administered one drop in each eye twice a day. Atropine 1% ophthalmic drop (used to dilate pupils) to be administered one drop in right eye. Prednisolone Acetate 1% ophthalmic drop (corticosteroid) to be administered in the right eye once daily.Observation of medication administration on 03/12/26 at 8:56 A.M. with Licensed Practical Nurse (LPN) #593 revealed she prepared Residents #114's morning medication including Brinzolamide, Brimonidine, Atropine, and Prednisolone eye drops. LPN #114 at 9:12 A.M. administered Atropine in both eyes, at 9:14 A.M. administered Prednisolone in both eyes, at 9:15 A.M. administered Brimonidine in both eyes, at 9:17 A.M. administered Brinzolamide in both eyes.Interview with LPN #593 stated the facility policy for administering eye drops is to wait five minutes before administering another eye drop. LPN #593 verified she did not wait five minutes between administering eye drops. LPN #593 verified she administered Atropine, Prednisolone and Brinzolamide in both eyes because the resident requested the drops in both eyes. LPN #593 verified the Brinzolamide order did not identify what eye to instill the drops, and the order was not clarified with the physician.Review of the manufactures instruction for Atropine Ophthalmic stated if you are to use more than one drop in the same eye, wait at least five minutes before instilling the next drop.Review of the manufacturer's instructions for Brimonidine stated if more than one topical ophthalmic product is being used, the products should be administered at least five minutes.Review of manufacturer's instructions for Prednisolone stated if you are to use more than one drop in the same eye, wait at least five minutes before instilling the next drop.Review of the manufacturer's instructions for Brinzolamide stated if you are using another medication in the eye, use it 10 minutes before or 10 minutes after you use Brinzolamide eye drops.Review of the facility policy titled Preparation and General Guidelines, dated May 2020, stated medications are administered in accordance with orders of the prescriber. If a dose seems excessive considering the resident condition or a medication order seems to be unrelated to current diagnoses or conditions, the nurse calls the pharmacy for clarification prior to the administration of the medication or contacts the prescriber for clarification.Review of the facility policy titled Specific medication administration procedures, dated May 2020, stated if another drop of the same or different mediation is prescribed for administration in the same eye at the same time, wait five minutes or the specified length of time recommended per manufacture's instruction or pharmacy labeling.This deficiency represents non-compliance investigated under Master Complaint Number 2713937.

Based on record review, staff interviews and facility policy review, the facility failed to ensure a complete and accurate medical record for Resident #169. This affected one (Resident #169) out of nine residents' records reviewed during a complaint investigation. The facility's census was 66.Findings include:A review of Resident #169's medical record revealed an admission date of 12/11/25 with diagnoses including type II diabetes mellitus with hyperglycemia, cognitive communication deficit, orthostatic hypotension, dehydration, depression, generalized anxiety disorder and acute kidney failure.A review of Resident #169's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required partial to moderate assistance with bathing and with personal hygiene. A physical therapy note dated 12/17/25 revealed the resident required maximum assistance with sit-to-stand transfers and stand-by assistance with bed mobility. A Basic Interview for Mental Status (BIMS) was not conducted, but documentation throughout the chart revealed the resident was alert and oriented to person and place.Further review of Resident #169's medical record revealed a physician's order for Humulin N NPH Insulin (a crucial hormone that regulates blood sugar levels and plays a vital role in energy metabolism) KwikPen 100 units per milliliter (mL) (3 mL) 8 units; subcutaneous (beneath the skin) twice a day at 8:00 A.M. and 4:30 P.M. Further review of the medical record revealed an additional order for insulin Aspart U-100; 100 unit/mL (3 mL); 5 units; subcutaneous twice a day to be administered between 7:00 A.M. - 11:00 A.M. and 4:30 P.M. - 6:30 P.M.Further review of Resident #169's medical record revealed a nurse's progress note from 12/18/25 at 8:54 A.M. and authored by Licensed Practical Nurse (LPN) #516 stating this nurse was given report from the night shift nurse that the resident was lethargic, breathing heavily, slow in arousing to voice commands. This nurse and the night shift nurse walked up to the resident's room, this nurse observed the resident in with bed labored breathing and slowly responding to stimuli. During morning medication pass, this nurse noted resident breathing heavily, lethargic, slowly responding to voice commands, and vitals within normal limits (WNL). The physician was called, waiting for advice. The resident's daughter was updated about the resident's condition. The plan of care was ongoing.A review of Resident #169's Medication Administration Record (MAR) for December 2025 revealed she did not receive her insulin on 12/18/25.Further review of Resident #169's physician's orders revealed no order to hold her insulin.An interview with Medication Aide #600 on 03/11/26 at 4:24 P.M. revealed Resident #169 was sleepy on the morning of 12/18/25 due to a new medication (Buspar, and antianxiety medication). She was told by LPN #516 to hold the resident's insulin if the resident didn't eat breakfast. She stated Resident #169 did not eat breakfast, so the insulin was not given per LPN #516's instructions.An interview with LPN #516 on 03/11/25 4:31 P.M. revealed she received report on 12/18/25 at 7:00 A.M. from the overnight nurse that Resident #168 wasn't doing well and wasn't eating. LPN #516 further stated she instructed Medication Aide #600 to hold the resident's insulin if the resident didn't eat her breakfast per nursing judgement. LPN #516 further stated her progress note should contain information regarding her decision to hold Resident #169's insulin and her rationale for her decision. LPN #516 also stated the resident's vital signs should be in the medical record or in her progress note, not just stating vital signs were WNL.An interview with the Director of Nursing (DON) on 03/12/26 at 9:20 A.M. verified no notes or documentation about the nurse's decision to hold medications or a rationale behind that decision were present in Resident #169's medical record. The interview with the DON further verified the lack of vital signs in the medical record or the nurses' notes on 12/18/25. The DON further verified no order to withhold insulin was ever received from the physician, and no such order was present in Resident #169's medical record.Review of the facility's policy titled Change in the Residents Condition or Status, updated 05/01/25, revealed the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status (e.g. assessment, appropriate notifications, interventions, and response).This deficiency is an incidental finding identified during the complaint investigation.

Based on record review and staff interview, the facility failed to ensure catheter care was provided to Resident #7. This affected one (Resident #7) of one resident reviewed for urinary catheter care. The census was 64. Findings include: Review of Resident #7's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included pleural conditions-hydropneumothorax, hemiplegia/hemiparesis, difficulty walking, muscle weakness, chronic atrial fibrillation, constipation, hypertension, dysphagia, ataxia, vertigo, major depressive disorder, hypothyroidism, anxiety, insomnia, restlessness/agitation, and cerebrovascular disease. Review of Resident # Minimum Data Set (MDS) assessment dated revealed the resident was alert and oriented. Review of Resident #7's physician orders revealed an order for catheter care with a start date of 04/19/23. Review of Resident #7's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for June, July, and August of 2023 revealed no evidence of catheter care being done. Review of Resident #7's Point of Care history from 07/17/23 to 08/17/23 revealed no evidence of catheter care being done. Interview on 08/14/23 at 12:49 P.M. and on 08/15/23 at 11:15 A.M. with Resident #7 revealed his catheter was not cleaned very often and he was very upset about it. Interview on 08/15/23 at 11:20 A.M. with Licensed Practical Nurse (LPN) #227 revealed Resident #7 was ordered catheter care every shift and as needed. Interview on 08/16/23 at 12:48 P.M. with Regional Nurse Consultant #315 confirmed there was no evidence of catheter care being done for Resident #7. Interview on 08/16/23 at 1:32 P.M. with Administrator also confirmed there was no evidence of catheter care being done for Resident #7.

Based on observation and interview, the facility failed to ensure Resident #10's medications were not left unsecured at the bedside. This affected one of five residents observed for medication administration. Findings include: Observation was completed on 11/03/21 at 7:29 A.M. with Licensed Practical Nurse (LPN) #811 passing morning medications to Resident #10. Resident #10 was sitting in a chair by the bed upon entry into the room. A plastic medication administration cup contain one small pink table was observed on Resident #10's bedside table. LPN #811 proceeded to administer medications to Resident #10 and then discarded the medication in the plastic cup found on the bedside table. Interview on 11/03/21 at 7:35 A.M. with Resident #10 revealed she could not recall what the small pink medication tablet was or when it was placed in the plastic cup at her bedside, but she said she thought it was from when the nurse passed her medication during the night time. Interview on 11/03/21 at 7:36 A.M. with LPN #811 confirmed an unsecured medication was found on Resident #2's bedside table. LPN #811 verified she did not administer that medication and she could not determine what the medication was or when it was administered. Review of Medication Administration Policy, dated 05/20, indicated residents were always to be observed after administration to ensure that the dose was completely ingested. If only a partial dose was ingested, this would be noted on the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] This deficiency substantiates Complaint Number OH 440.

Based on observation and staff interview, the facility failed to ensure medication carts for two out of six medication carts observed in three medical units were secured when unattended. The census was 70. Findings include: On 10/22/20 between 8:08 A.M. and 10:25 A.M., the surveyor observed the medication cart on the 100 hall was not secured and was left unattended. Observation of the medication cart on the 300 hall verified it was not secured and was left unattended. Registered Nurse (RN) #101 and RN #103 were instructed that medication carts should be secured when left unattended. The above finding was verified with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 10/22/20 at 10:30 A.M.

Based on observation, interview and record review the facility failed to ensure Resident #20 was properly assessed for the safe use of a remote-controlled lift recliner to prevent a fall. This affected one of three residents reviewed for falls. Findings include: Review of the medical record for Resident #20 revealed the resident was admitted on [DATE] and discharged to another facility on 02/07/19. [DIAGNOSES REDACTED]. Review of the baseline care plan dated 01/18/19 revealed the resident was at risk for falls with interventions including orientation to his room and call light system, encouragement of call light use, and fall prevention as indicated. The baseline care plan also included the care area of chronic back pain. Review of a skilled nursing note dated 01/20/19 revealed the resident required extensive physical assistance of one person for bed mobility, transfers and toilet use. A Physical Therapy (PT) care plan dated 01/20/19 revealed the resident was unable to ambulate at that time and standing balance was absent. The resident was unable to safely transfer from the bed to a wheel chair or to safely transfer from a sitting to a standing position, requiring 100% assist for the latter. An Occupational Therapy (OT) care plan dated 01/21/19 revealed the resident reported chronic pain but could not identify specific locations. Review of a Fall investigation dated 01/22/19 revealed Licensed Practical Nurse (LPN) #105 was called by State tested Nurse Aide (STNA) #204 to Resident #20's room at approximately 11:45 A.M. STNA #204 responded to the resident calling out for help and found the resident lying on the floor in front of the remote-controlled (RC) lift recliner. This occurred about 10 to 15 minutes after Resident #20 received a shower and was placed in the RC lift recliner. LPN #105 assessed the resident. Vital signs and neurological checks were within normal limits. The resident reported a headache and back pain. The physician and significant other were notified. The physician gave orders to monitor the resident and notify him if there was any change. The resident was sent to the hospital approximately six hours later per his significant other's request. Review of hospital examination notes dated 01/22/19 and results of a computed tomography (CT) scan revealed no acute findings in the brain or cervical spine. The resident returned to the facility the same day. Interview on 05/29/19 at 12:03 P.M. with STNA #204 revealed Resident #20 was placed in the facility provided RC lift recliner after he was given a shower. STNA #204 reported she demonstrated the use of the remote control to the resident and left him in a reclined position with his call light and the remote control within reach. About five minutes later STNA #204 heard Resident #20 calling for help and found him on the floor in his room in front of the recliner. STNA #204 reported the resident must have pressed the remote control repeatedly and was thrown from the chair. STNA #204 called for the nurse who assessed the resident and assisted STNA #204 with returning the resident to his bed. STNA #204 did not know if Resident #20 had been assessed by therapy for the use of the RC lift recliner. On 05/29/19 at 2:11 P.M. interview with Physical Therapy Assistant (PTA) #302 revealed she completed Resident #20's initial evaluation on 01/20/19. At the time of the initial assessment Resident #20 was in a lot of pain and did not have adequate trunk control to use a wheelchair. PTA #302 verified the resident was not assessed for use of the RC lift recliner. Interview on 05/29/19 at 3:03 P.M. with the Administrator and observation of a facility provided RC lift recliner like the one used by Resident #20 revealed pressing the up button on the RC lifted a person to a standing position. The Administrator verified the resident should not have been placed in the chair and given the RC to operate it prior to being assessed for safe use of the RC chair. This deficiency substantiates Complaint number OH 403.

Based on interview and record review, the facility failed to ensure the physician was notified that an antidepressant medication was not obtained and administered to one resident for nine days. This affected one (Resident #131) of five residents reviewed for unnecessary medications. The facility census was 64 residents. Findings include: Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Comprehensive Assessment had not been completed at the time of the survey. Review of the physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Continued review of the MAR indicated [REDACTED]. Documentation revealed on 04/14/19 at 1:33 P.M. stated Not Administered: Drug/Item unavailable; on 04/14/19 at 9:07 P.M. Not Administered: waiting for delivery; 04/15/19 10:06 A.M. Not administered: drop ship; 04/15/19 1:26 P.M. Not Administered: patient care; 04/16/19 Not Administered: drop shipment; on 04/17/19 Late Administration: Charted late: pt care. Review of the progress notes dated 04/08/19, 04/09/19, 04/15/19, 04/16/19, and 04/16/19 did not indicate the residents' physician was notified of the omitted medication. Further review of the nurse practitioners' notes dated 04/09/19 or 04/15/19 did not document she had been informed of the medication omission. Interview 04/17/19 at 10:34 A.M. with the Assistant Director of Nursing (ADON) revealed she would have to check into why the resident didn't get [MEDICATION NAME] timely and get back to me. Interview 04/17/19 at 12:18 P.M. with the Director of Nursing (DON) revealed she wasn't sure why the facility didn't have the medication and why nursing would not have documented on the missing days. The DON reviewed the resident record and verified the physician had not been notified of the medication omission.

Based on interview and record review, the facility failed to ensure an antianxiety medication was obtained for one (Resident #131) of five residents reviewed for unnecessary medications. The facility census was 64 residents. Findings include: Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Continued review of the MAR indicated [REDACTED]. Documentation revealed on 04/14/19 at 1:33 P.M. stated Not Administered: Drug/Item unavailable; on 04/14/19 at 9:07 P.M. Not Administered: waiting for delivery; 04/15/19 10:06 A.M. Not administered: drop ship; 04/15/19 1:26 P.M. Not Administered: patient care; 04/16/19 Not Administered: drop shipment; on 04/17/19 Late Administration: Charted late: pt care. Further review of the nurse practitioners' notes dated 04/09/19 or 04/15/19 did not document she had ben informed of the medication omission. Interview 04/17/19 at 10:34 A.M. with Assistant Director of Nursing revealed she would have to check into why the resident didn't get [MEDICATION NAME] timely and get back to me. Interview 04/17/19 at 12:18 P.M. with the DON she stated she wasn't sure why the facility didn't have the medication and why nursing would not have documented on the missing days.

Based on observations and interview the facility failed to maintain sanitary procedures when providing catheter care for Resident #3, this affected one of four residents reviewed for catheter care. Findings Include: Observations on 04/05/18 at 2:15 P.M. were made. State tested Nurse Aide (STNA) # 36 was observed providing catheter care for Resident #3. Observations revealed that STNA#36 started washing from the perimeter (outside) of the perineal (area between the pubic bone and the coccyx) washing toward the penis (center), an interview with STNA #36 after the treatment revealed that washing procedures include washing from the penis (center) and work outward toward the perimeter, this prevents bacteria from entering the urethra (opening at tip of the penis). Review of catheter care policy/procedures revealed that washing should start from the penis (center) and work outward toward the perimeter to prevent bacteria from entering the urethra. A review of the medical record for Resident #3 revealed that Resident #3 was given antibiotics 02/25/18 through 03/04/18 to treat a urinary tract infection [MEDICAL CONDITION]. This deficiency substantiates Complaint Number OH 986

Based on record review and interview the facility failed to ensure injuries of unknown origin were reported to the State agency as required and thoroughly investigated for Resident #22 and Resident #256. This affected two residents (Resident #22 and #256) of 3 residents reviewed for falls. Findings include: 1. Review of Resident #22's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was moderately cognitively impaired. The assessment revealed the resident required the extensive assistance of two staff for bed mobility, transfers and toileting and the extensive assistance of one staff member for dressing, hygiene and bathing. Record review revealed the resident was at risk for falls and had a care plan for falls dated 10/27/16 and updated through 02/01/17. The resident was at risk for falls due to impaired vision, impaired sitting balance and unsteadiness while walking or standing. Record review revealed on 11/26/16 at 7:56 P.M. the resident was found on the floor. She was lying on her back in front of her chair,with her head propped up on the wheelchair. She did not have an injury and Dycem, a non-skid material, was placed on her wheelchair to prevent sliding. She denied pain or discomfort from the fall as documented by staff on 11/26/16 at 8:15 P.M., on 11/28/16 at 8:02 P.M. and 11/27/16 at 4:09 P.M. A nursing note dated 01/11/17 at 3:00 P.M. revealed the resident was observed lying on the floor on her back in front of the recliner, which was in the highest stand up position. The note indicated the resident had been to the bathroom at 2:00 P.M. Her range of motion was assessed and within normal limits, as were her vital signs. Neurological checks were initiated and the note indicated an intervention was put in place to place the remote for the recliner in the side pocket while the resident was in the recliner, and to ensure the call light was within reach. Review of nursing notes dated 01/12/17 at 3:23 P.M., 01/13/17 at 10:40 A.M., 01/13/17 at 10:52 P.M. and 01/14/17 at 2:36 A.M. all revealed no complaints of pain or discomfort related to the fall. Review of a nurse practitioner note dated 01/16/17 revealed abnormal labwork had been reviewed and the resident had increase in [MEDICAL CONDITION] and lethargy, although she was afebrile. The nurse practitioner examined her with plus one [MEDICAL CONDITION] to her bilateral feet and ankles. The nurse practitioner continued the [MEDICATION NAME] (diuretic) dose as previously ordered and also ordered Ted hose (compression hose) to be worn during the day. Lab work was ordered for 01/19/17 and an appointment was made with a nephrology office for worsening [MEDICAL CONDITION]. Review of the record revealed occupational therapy was ordered to assess the resident for the use of the lift chair after the fall on 01/11/17. The occupational therapy notes for 01/16/17 through 01/19/17. revealed the resident with varying levels of participation in the occupational therapy lift chair transfers, including transfers from wheelchair, toilet and shower seat. There was no indication of pain or swelling,until the note on 01/19/17 which indicated the resident had significant swelling of right lower extremity on that date and new non weight bearing precautions. Interview with the certified occupational therapy assistant COTA #41 on 03/02/17 at 11:35 A.M. confirmed the resident was able to participate in therapy until 1/19/17. She stated the resident did not have any complaints of pain during her therapy sessions on 01/16/17, 01/17/17 and 01/18/17. A nursing note dated 01/18/17 at 12:23 P.M. revealed the resident was observed with [MEDICAL CONDITION] and had pain in the right ankle and foot. The physician was notified, with orders given for an X-ray. Review of the X-ray report dated 01/18/17 revealed non displaced fractures of the distal right tibia and distal right fibula. Review of a nursing note dated 01/18/17 at 10:32 revealed the physician was notified of the results of the X-rays and an order was given for the resident to be non-weight bearing. Review of a nurse practitioner note dated 01/19/17 revealed the resident stated her leg hurt, but was not specific in the complaints of pain. The note verified the resident had had a fall approximately 1 week ago but had developed worsening pain and inability to bear wight. The note acknowledged the non-displaced distal tib/fib fracture and plan to make resident non weight bearing and place in walker boot until she could be seen by an orthopedic service. The note indicated the resident had been started on an antibiotic for a possible urinary tract infection starting 01/18/17. The resident's right ankle was noted to be bruised and swollen with her range of motion limited. The nurse practitioner note indicated the resident would be sent to the hospital after discussion with the power of attorney and she was discharged on [DATE]. An interview with the director of nursing on 03/01/17 at 3:15 A.M verified there was no investigation regarding the fracture found on 01/18/17. She stated she spoke with the nurses who had told her the resident had not had any other falls, but said she did not specifically talk with State tested nursing assistants or other staff and had no written statements from staff regarding care or observations of the resident prior to the complaints of pain and the confirmation of the fracture. A followup interview with the director of nursing on 03/02/17 at 10:15 A.M. revealed she had written a summary of the incident on 03/01/17 and showed the surveyor names of staff members she had interviewed. She stated she did not have actual statements from the staff. Another interview with the director of nursing on 03/02/17 at 11:20 A.M. verified there was no evidence in the resident's medical record including nursing notes and occupational therapy notes regarding pain of the right lower extremity until the nursing note dated 01/18/17 at 12:23 P.M Although the [MEDICAL CONDITION] was documented in the nurse practitioner note dated 01/16/17, the note indicated a more medical concern contributing to the [MEDICAL CONDITION], including abnormal lab work, [MEDICAL CONDITION] and possible worsening [MEDICAL CONDITION]. The director of nursing verified the record review did not reveal resident complaint or staff observation of pain to the right ankle after the fall on 01/11/17 until 01/18/17, which would indicate the pain was new. Since there was no indication in the record to correspond to the pain and fracture, the facility should have conducted a thorough investigation of the injury of unknown origin and reported the incident to the state agency. Resident #22 did not return to the facility after she was transferred to the hospital on [DATE] and was not in the building during the annual survey conducted concurrently with the complaint survey so she could not be interviewed or observed. Review of the facility abuse policy dated 2016 indicated injuries of unknown source were defined and an injury where the source was not observed or could not be explained by the resident and the injury is suspicious because of the extent of injury. The policy indicated the circumstances surrounding such injuries should be reported to the state agency and thoroughly investigated. 2. Review of Resident #256's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS 3.0 assessment, dated 01/03/17 revealed the resident was cognitively intact and required the extensive assistance of one staff member for bed mobility, transfers, and toileting. Review of her fall care plan dated 12/27/16 and updated through 05/31/17 revealed the resident was at high risk for falls due to impaired cognition, unsteady gait and interventions included encouraging resident to use call light for any assistance and assist resident with mobility as needed. Review of her nursing progress notes revealed Resident #256 sustained falls on 12/31/16, 01/17/17 and 01/18/17. She was not injured in the falls. A nursing note dated 02/02/17 at 2:05 A.M. revealed the resident was found on the floor. She was attempting to go to the bathroom. Review of the toileting grids revealed the last time the resident had been assisted to the bathroom prior to the fall at 2:05 A.M. was at 5:57 P.M. on 02/01/17. She was not injured. Review of the investigation of the incident revealed a deep perimeter mattress was ordered to alert resident to the edge of the bed. Review of the only nursing notes after the fall. dated 02/03/17 at 12:21 A.M., 02/03/17 at 4:54 A.M. and 02/03/17 at 7:28 P.M. all very brief, indicated the resident did not have complaints of pain or discomfort. The only other progress note after the fall was a pharmacist note dated 02/07/17. After the pharmacy note, the next nursing note in the record was dated 02/07/17 at 8:49 A.M. and revealed the resident had stated she had pain to her hip. The note indicated an X-ray ordered by the physician revealed an inferior and superior ramus [MEDICAL CONDITION] pelvis. After consultation with the physician and family revealed the resident would not be sent to the hospital, but would see an orthopedic physician as an outpatient. Review of a physician note dated 02/08/17 revealed the resident presented with complaints of pain after an injury from a fall on 02/07/17. The note indicated the Resident had no complaints of pain and remained with no restrictions to her weight bearing. An interview with the director of nursing (DON) on 03/02/17 at 10:15 A.M. revealed she did not have an investigation regarding the resident's fracture. She stated the resident's son had asked for an X-ray due to noting the resident was wincing when sitting down. She verified the record contained no documentation or assessment of this. She stated she talked with staff who all indicated the resident had had no falls, but verified she did not obtain written statements from staff regarding care or observations of the resident prior to the complaints of pain and the confirmation of the fracture. She stated that she felt the fracture occurred when the resident fell on [DATE], but verified the record did not support this conclusion, as all documentation indicated no concerns expressed by the resident. She stated she was unaware of the fall referred to in the physician's note on 02/08/17. The DON approached the surveyor later and stated the physician had been contacted and would be changing his documentation regarding the possible fall on 02/07/17. She further verified that even if the physician recanted the comment about the fall, the record review did not contain any evidence to indicate the injury came from the fall on 02/02/17 and the incident was not reported and thoroughly investigated. Review of the facility abuse policy dated 2016 indicated injuries of unknown source were defined and an injury where the source was not observed or could not be explained by the resident and the injury is suspicious because of the extent of injury. The policy indicated the circumstances surrounding such injuries should be reported to the state agency and thoroughly investigated.

Based on observation, record review and interview the facility failed to implement an effective bowel elimination program to prevent constipation and increased pain for Resident #278. This affected one resident (Resident #278) of two residents reviewed for pain. Findings include: Record review revealed Resident #278 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission physician order's revealed an order for [REDACTED]. On 02/20/17 the resident was ordered an additional over the counter laxative to be taken daily. On 02/27/17 the physician ordered an [MEDICATION NAME] twice daily as needed for abdominal cramps, a stool softener daily, increased the over the counter laxative and gave an order to administer two laxative suppositories. Review of the bowel elimination plan of care indicated to monitor the frequency, amount and consistency daily. Observe for signs and symptoms of constipation and address accordingly, report to the physician as needed. Review of the resident's progress notes revealed no evidence of any concerns or issues related to constipation. Review of the observational skilled nursing documentation since admission revealed beginning on 02/20/17 Resident #278 verbally expressed having moderate pain that was distressing/miserable. On 02/21/17 she verbally expressed having mild pain. On 02/27/17 Licensed Practical Nurse (LPN) # 32 documented at 1:32 P.M. Resident #278 had no pain and positive bowel sounds. Review of the 02/21/17 bowel assessment indicated Resident #278 was continent and no further assessment was necessary. Review of the 02/22/17 pain assessment indicated the resident had low back pain and an over the counter [MEDICATION NAME] was effective. Review of bowel records revealed the resident had bowel movements as followed: 02/18/17 small, 02/19/17 medium, 02/20/17 large, none until 02/24/17 medium, 02/25/17 small and 02/26/17 small. There was no evidence any interventions were provided for the four days she did not have a bowel movement. Review of Certified Nurse Practitioner (CNP) #34 note dated 02/20/17 revealed Resident #278 complained of constipation. The plan was to start an over the counter laxative powder daily. Review of CNP #34 note dated 02/27/17 and faxed to the facility at 3:42 P.M. indicated the resident's chief complaint was constipation with abdominal cramps. Complaints of constipation despite resuming the over the counter laxative powder as requested. She reported to CNP #34 having abdominal cramps because she could not get it out and she was straining. The plan was to increase the over the counter laxatives and begin a stool softener. Resident #278 was observed on 02/27/17 at 3:58 P.M. lying in bed. She had a pained facial expression, holding on to her stomach and grimacing at intervals. She said she was constipated and had not had a bowel movement in three days. She said she asked for a suppository but they offered her the over the counter laxative. She said she requested a suppository like she received when she was at the hospital because it worked. She said she was in horrible pain without relief. She said she reported this to the nurse and the nurse did not listen to her. She said the lady doctor that visited this morning between 9:00 A.M. and 10:00 A.M. agreed that she needed a suppository but she had yet to receive it. She said she had been waiting all day for a suppository that the doctor ordered. The surveyor asked Resident #278 to put her call light on to report her pain and constipation. Resident #278 activated her call light on 02/27/17 at 4:21 P.M. STNA #36 responded at 4:31 P.M. and LPN #37 responded at 4:37 P.M. Resident #278 told LPN #37 she was waiting for her suppository and was still cramping. LPN #37 said she was waiting for the medication to be drop shipped then said maintenance was working on the automated medication dispenser. Interview with LPN #33 on 02/28/17 at 2:55 P.M. indicated she was not made aware of any pain the resident was having. She reported Resident #278 had received two suppositories last night with large results. Interview with the occupational therapy assistant (COTA) #37 on 03/01/17 at 10:34 A.M., revealed Resident #278 complained of constipation during her treatment session on 02/27/17. Interview with CNP #34 on 03/01/17 at 1:48 P.M. revealed she arrived on 02/27/17 around 7:00 A.M. and saw 19 residents that day. CNP #34 recalled seeing Resident #278 who complained of abdominal pain and constipation. She said she informed LPN #33 of the new orders verbally. She said often she will verbally tell the nurse of new orders and provide the written order later. She said she prescribed two rectal suppositories because in her experience often one came out so the remaining suppository would be effective. She said the protocol was to provide interventions beginning after three days of no bowel movement. She said the suppositories should have been stored in house and not needed to be ordered. Interview with the administrator and corporate nurse on 03/01/17 at 1:06 P.M. indicated the facility did not have any policy/procedure related to bowel elimination but indicated usually after three days of not having a bowel movement an intervention would be initiated. This deficiency substantiates Complaint Number OH 541.

Based on record review and interview the facility failed to ensure interventions were in place and reevaluated to prevent falls for Resident #256. This affected one resident (Resident #256) of three residents reviewed for falls. Findings include: Record review revealed Resident #256 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, and required the extensive assistance of one staff member for bed mobility, transfers, and toileting. Review of Resident #256's fall care plan dated 12/27/16 and updated through 05/31/17 revealed the resident was at high risk for falls due to impaired cognition and unsteady gait. Interventions included encouraging resident to use call light for any assistance and assist resident with mobility as needed. Review of the nursing progress notes revealed Resident #256 sustained a fall on 12/31/16 at 6:45 P.M., when she got out of bed to close her blinds. She was not injured and was educated to use the call light. Review of the nursing progress note, dated 01/17/17 at 2:00 P.M. revealed the resident was found on the floor on that date. There was no injury noted. She was again provided education to use the call light. A nursing progress note dated 01/18/17 at 7:00 P.M. revealed the resident's family was helping her to the bathroom and she fell . She was not injured and the family was educated to ask staff for assistance. The investigation also indicated staff were to assist the resident to the toilet every two hours. A nursing note dated 02/02/17 at 2:05 A.M. revealed the resident was found on the floor. She was attempting to go to the bathroom. Review of the toileting grids revealed the last time the resident had been assisted to the bathroom prior to the fall at 2:05 A.M. was at 5:57 P.M. on 02/01/17. Review of the investigation of the incident revealed a deep perimeter mattress was ordered to alert resident to the edge of the bed. The investigation, including staff interviews, was not comprehensive to include any additional circumstances contributing to the fall or information as to when staff care had been provided to the resident in the time period before the fall. Review of a nursing note dated 02/25/17 at 12:12 P.M. revealed the resident was found on the floor. She stated she was trying to go to the bathroom and fell backwards. She hit her head on the bottom of her wheeled side table and had a golf ball sized hematoma on the top left of her head. She was sent to the hospital after standing up and feeling dizzy and returned on 02/25/17 at 5:04 P.M. with no new orders. Review of the plan of care toileting grids revealed the last indication of the resident using the bathroom prior to the fall on 02/25/17 at 12:12 P.M. was on 02/25/17 at 2:43 A.M. Review of the investigation of the incident revealed the resident was attempting to walk to the bathroom and fell . An intervention was written that the resident was to be toileted every two hours and the bed was to be in the lowest position when the resident was in bed. An interview with the director of nursing on 03/01/17 at 3:00 P.M. verified the resident was placed on an every two hour toileting plan after the fall on 01/18/17. She stated the resident was usually continent, but the plan was put in place as an intervention since the resident had been attempting to use the bathroom and she felt reminders would help decrease falls by giving her opportunities to use the bathroom with staff assistance. She verified the fall on 02/02/17 was due to the resident attempting to use the bathroom but the investigation did not indicate when the resident had last been toileted. She further verified the resident fell again on 02/25/17, again trying to go to the bathroom and sustained a large hematoma. The investigation did not reveal any documentation of when the resident was last assisted to the toilet, but an intervention was again written to indicated the resident was to be toileted every two hours. The director of nursing stated although she would expect the staff to ask the resident if she needed to use the bathroom, she would not necessarily expect staff to document every two hours that they had done so. However, she did verify the circumstance of the falls (resident falling when trying to get to the bathroom) and the facility investigational focus on asking if she needed to use the bathroom more regularly as an intervention to prevent further falls. She verified there was no indication in the investigations for 02/02/17 and 02/25/17 to indicated if the intervention of prompted toileting was being implemented by staff and the toileting grids did not indicate the resident had been prompted within several hours of the falls. This deficiency substantiates Complaint Number OH 541.

Based on observation, record review and interview the facility failed to ensure appropriate portion sizes of meals were served for Resident #73, Resident #60, Resident #77, Resident #47 and Resident #49. This affected five residents (Resident #73, #60, #77, #47 and #49) of six residents observed with mechanical ground meat during the lunch meal on 10/03/16. The facility identified 10 residents who resided in the facility and received mechanical soft diets. Findings include: On 10/04/16 observation of the lunch meal from 11:15 A.M. to 12:00 P.M. revealed the lunch meals being plated and served. At 11:30 A.M. Cook #10 placed a number 12 scoop in the mechanical soft chicken teriyaki. Cook #10 confirmed at this time the scoop size was a number 12. Cook #10 began plating the food. Cook #10 was observed to place one scoop full of chicken teriyaki on Resident #73, Resident #60, Resident #77, Resident #49 and Resident #47's plates. The State tested nursing assistants and Dietary staff were observed to take the plated food out of the kitchen to provide to the residents. At 12:00 P.M. the observation ended at which time Cook #10 and Dietary Manager #11 confirmed the spreadsheet indicated a number eight scoop was to be used for the mechanical ground meet. Review of the Spreadsheet for 10/03/16 revealed the mechanical soft ground meat required a number eight scoop. Review of the undated scoop size chart revealed the number 12 scoop was 3.25 ounces. Review of the chart revealed the number 8 scoop was four ounces. This deficiency substantiates Complaint Number OH 048.

Based on record review and interview the facility failed to ensure accurate medical record documentation for Resident #79 related to meal intakes and urinary assessments. This affected one resident (Resident #79) of three residents reviewed for dehydration. Findings include: Review of Resident #79's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review revealed the admission assessment dated [DATE] revealed Resident #79 did not have a catheter and was continent of bladder there was no indication the urine was blood tinged. Review of Resident #79's nursing assessments and progress notes from 08/15/16 through 08/19/16 revealed no evidence Resident #79 had any bleeding from the penis or blood in the residents urinary catheter. Review of the physical therapy plan of care dated 08/16/16 revealed underlying impairments included patient with some bleeding from his penis and nursing was made aware. Review of Resident #79's physical therapy progress notes dated 08/18/16 at 4:30 P.M. revealed Resident #79's had a little blood during the assessment of the penile meatus. Review of the nursing progress notes dated 08/19/16 at 9:19 A.M. revealed Resident #79 went out on a leave of absence with the family. There was no evidence the resident returned from the outing on this date. Review of Resident #79's intake record for 08/19/16 revealed Resident #79 had 480 milliliters of fluids during the lunch meal and ate 51-75 % of the meal. Review of Resident #79's intakes revealed Resident #79 took 76-100% of his meal for dinner and had 480 milliliters of fluid. Interview on 10/03/16 at 3:45 P.M. with Licensed Practical Nurse (LPN) #13 revealed Resident #79 did have blood in his urine during his stay. LPN #13 indicated that the bleeding had improved throughout the residents stay and should have been documented as improving in the resident's medical record. Interview on 10/04/16 at 10:38 A.M. with Receptionist #16 revealed she enters the intakes into the system per the documentation provided by the State tested nursing assistants. Receptionist #16 indicated she must have entered another residents intakes into the system as Resident #79's intakes. Receptionist #16 confirmed Resident #79 left with the family prior to lunch and dinner. Interview on 10/04/16 at 1:55 P.M. with the Director of Nursing confirmed there was no documentation in the nurse's notes or assessments indicating Resident #79 had blood in his urine. This deficiency is an incidental finding to Complaint Number OH 048.

Based on record review and interview, the facility failed to provide copies of a resident's medical record to his durable power of attorney (DPOA) upon written request. This affected one of three residents (Resident #2) identified by the facility as having made a request for copies from their medical record. Findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's information sheet listed one of his daughters as being his DPOA. Review of the authorization for release of health information revealed Resident #2's DPOA requested a copy of all of the resident ' s medical records pertaining to his care on 11/04/14. The director of nursing provided information on a piece of paper that said the medical record request for Resident #2 was denied as the health care POA was not binding since Resident #2 was not declared incompetent. Review of the comprehensive Minimum Data Set (MDS) assessment completed on 10/22/14 indicated Resident #2 could not complete a cognitive interview since he was rarely/never understood. This assessment indicated Resident #2 had short and long term memory impairment and was severely cognitively impaired for decision making abilities. This assessment indicated he was not able to be involved in his own care planning and that his family was involved. The DPOA papers on the chart completed on 07/25/11 indicated his POA had the right to request, review and receive any information, verbal or written, regarding his physical and mental health, including, but not limited to, all of his medical and health care records. The additional instruction section on the form indicated his agent, or any alternate agent named in this document, shall be treated as " my personal representative for all purposes relating to his protected health information as provided in the privacy rule under the Health Insurance and Portability Act of 1996. If this health care power of attorney becomes effective, my agent or any alternate agent is entitled to receive any and all protected health information about me that I would be entitled to receive. " The concern that the medical record request was denied was reviewed with the director of nursing (DON) on 12/11/14 at 11:05 A.M. The POA papers were reviewed with the DON and she verified the concern but stated she did not handle these requests and would check for additional information. The DON said she thought the resident had to be judged incompetent by his doctor in order for the DPOA to be in effect. The DON verified the information in the comprehensive assessment completed on 10/22/14. The DON said she knew the attorney had said to deny the request, and the check from the DPOA was returned because she had actually brought in a check to pay for the copies. On 12/11/14 at 1:25 P.M., the DON indicated the facility attorney indicated they would not release a resident's medical records until a physician documented that the resident was incompetent and could not make their own decisions. They needed more than the nursing comprehensive assessment to release medical records. The Corporate Administrator and the DON returned at 2:00 P.M. on 12/11/14 with the federal regulations and indicated the regulation said the medical records were to be released to the legal representative. The Corporate Administrator said the DPOA was not the legal representative as the physician had not documented in the medical record that the resident was incompetent. The DON verified the facility staff had allowed the DPOA to refuse a swallowing study and the administration of pain medications for Resident #2, and the DPOA was the participant in Resident #2's care planning as he was confused and unable to make decisions for himself. This deficiency substantiates Complaint Number OH 112.

Based on record review and staff interview, the facility failed to ensure siderails were properly secured to the bed resulting in a fall for one resident (Resident #74). This affected one of three residents reviewed for falls. Findings include: Review of Resident #74's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Minimum Data Set (MDS) 3.0 dated 07/07/14 revealed Resident #74 was moderately cognitively impaired and required extensive assistance of two staff members with bed mobility, transfers, dressing, toileting and personal hygiene. Review of the Nurses Progress notes dated 07/16/14 timed 1:00 A.M. revealed Resident #74 was lying on the floor after the state tested nurse aide (STNA) had provided care to the resident. The note indicated Resident #74 hit his head on the side table and had an abrasion to his knee. Resident #74 denied pain at that time. The physician was notified and ordered to send Resident #74 to the emergency room if the resident's wife consented. Resident #74's wife was updated and declined evaluation in the emergency room . Review of the facility fall investigation dated 07/16/14 revealed the nurse observed Resident #74 lying on the floor with two STNAs present. The investigation indicated Resident #74 had grabbed the side rail on the bed, the side rail came loose and Resident #74 fell to the floor. The report indicated the resident's knees came out of the bed and the STNA lowered the resident's top portion of the body to the floor. The other STNA went to get the nurse. The resident had an abrasion to his right knee without any other injuries and hit his head on the side table. On 08/06/14 at 8:25 A.M. interview with the Director of Nursing (DON) revealed the resident's bed was a rental bed provided by hospice. The DON described the side rail as a claw-like side rail that clamped onto the bed with a large black knob to secure the side rail. This deficiency substantiates Complaint Number OH 703.

Based on observation, interview and record review, the facility failed to ensure interventions were in place to enable Resident #31 to increase her protein intake and did not ensure that a care plan for dental needs was in place for Resident #130. This affected 2 of 17 residents reviewed for care plans, with a facility census of 74. Findings include: 1. Review of the record revealed that Resident #31 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. She was noted with [DIAGNOSES REDACTED]. Review of the minimum data set quarterly assessment dated [DATE] revealed the resident had moderate cognitive impairment. The record indicated that the resident was on a "low concentrated sweets, no added salt" diet, in a mechanical soft form and nectar thick liquids. Review of a dietary note dated 02/28/12 at 3:18 P.M. revealed that the resident did not like the ordered protein supplement and had a history of [REDACTED]." The note further stated that the level of 3.7 was "just slightly below where they (the [MEDICAL TREATMENT] center) prefers it to be for a [MEDICAL TREATMENT] patient." The note indicated that the dietician would recommend discontinuing the protein supplements and that she "encouraged the resident to consume protein-rich food/fluids. " A quarterly nutritional assessment dated [DATE] at 3:13 P.M. revealed that, "according to the [MEDICAL TREATMENT] center," the most recent [MEDICATION NAME] level was 3.7, which was "stable." The note indicated that a "desirable [MEDICATION NAME] for [MEDICAL TREATMENT] patients is 4.0 or above." The note indicated that the resident has a history of refusal of supplements. The note verified the resident's diet as ordered as "appropriate and tolerated," with "no recommendations. " Interview with Resident #31 on 04/17/12 at 1:00 P.M. revealed the resident in her room sitting up in a wheelchair. She had oxygen in place through nasal tubing. She verified that she went to [MEDICAL TREATMENT] three times a week. She was asked about any special diets or food that she should eat and she was not aware of any of these. Another interview with the resident on 04/19/12 at 1:15 P.M. again revealed her in her room in her wheelchair. She again denied any concerns or special recommendations related to her diet. Interview with the facility dietary manager (DM #4) on 04/18/12 at 9:20 A.M. revealed that the facility did not have a high protein diet that could be ordered. She stated that double meat portions could be ordered to increase protein, and that cottage cheese, yogurt and hard boiled eggs were offered on a "soup cart" that was available for the lunch meal. She stated that residents who would require high protein would have this indicated on their meal card and then would be offered the higher protein supplements for lunch. The dietary manager verified that the meal card for Resident #31 did not indicate that she was recommended a high protein diet. Interview with the corporate dietician, Dietician #5, on 04/18/12 at 9:45 A.M. revealed that the facility dietician was not in the building or available for interview. She stated that she had been told by the facility dietician that the resident had been educated as to increasing her protein consumption, but that the resident was cognitively impaired, and that there was no provision made for the resident to have access to high protein foods to increase her intake. She verified that the resident's diet did not indicate a high protein recommendation and that as it was ordered, would provide only a routine diet's amount of protein. She verified that the resident's care plans, including plans for [MEDICAL TREATMENT] and nutrition did not indicate the resident's [MEDICATION NAME] level, the [MEDICAL TREATMENT] center's recommendation for an [MEDICATION NAME] level of 4.0, or interventions to increase the resident's access to high protein foods, in addition to the protein that was currently in place for a regular diet, or interventions that could be taken by staff to increase the resident's protein. Dietician #5 approached the surveyor on 04/18/12 at 3:00 P.M. to provide a list of [MEDICATION NAME] levels which she had obtained from the [MEDICAL TREATMENT] center. The list indicated that the resident's [MEDICATION NAME] had been 3.9 on 01/11/11, 3.7 on 02/08/12 and 03/14/12 and was 3.8 on 04/11/12. Dietician #5 verified that the resident's [MEDICATION NAME] had been as high as 3.9 and that although it had increased slightly on the April level, the facility dietician had not indicated this in her note, that it was still not at the level desired by the [MEDICAL TREATMENT] center and that the record did not indicate interventions to increase the resident's protein intake or make high protein choices readily available to the resident. 2. Interview with Resident #130 on 04/16/12 at 2:34 P.M. revealed she had tooth and partial denture problems. She stated she needed some teeth pulled. She felt her teeth looked horrible when she did not wear her partial and said her partial had cracked and missing teeth. Further interview with Resident #130 on 04/18/12 at 9:00 A.M. stated she doesn't like the look of her teeth, she's embarrassed because they look like fangs. She growled and made a clawing motion. She stated she's told her aides about her broken teeth. She stated no one had approached her about seeing a dentist. She stated she would liked to have seen one. Observation of Resident #130's teeth during the interview revealed broken, missing, cracked, sharp and discolored teeth. The condition of her teeth put her at risk for oral complications and emotional decline because of how she felt about her appearance. Resident #130 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual comprehensive assessment (MDS 3.0) dated 03/24/12 and the quarterly MDS 3.0 dated 02/24/12 did not identify a broken partial and had no obvious broken teeth. However, review of the nursing admission assessment oral examination dated 01/28/12 indicated Resident #130 had obvious/likely cavity or broken natural teeth. The annual assessment nursing note dated 04/10/12 at 6:00 A.M. identified obvious or likely cavities or broken natural teeth. The assessment indicated the upper partial was in good condition. Review of the computerized clinical record lacked a plan of care related to dental status. The nutritional plan of care dated 03/31/11 also lacked indication of her dental status. Review of the activities of daily living plan of care dated 11/04/11 indicated an intervention was to consult dental services as needed. Interview with the director of nursing on 04/18/12 at 8:37 A.M. revealed Resident #130's teeth looked painful. She was not sure why her dental status was not reflected on the MDS 3.0. She stated the resident had not complained to her about her teeth. Interview with State tested Nursing Assistant (STNA) #1 on 4/18/12 at 8:26 A.M. revealed the resident had not complained about her broken teeth to her. Interview with the licensed social worker (LSW) on 04/18/12 at 8:45 A.M. stated the resident had not seen a dentist since she was admitted to the facility because she was private pay and the family did not want to pay for dental services. She reported the resident just became medicaid this month so she was placed on the list to see the dentist on 04/30/12. The LSW was unaware how the resident felt about her appearance and that she had cracked or broken teeth. The LSW reported later on 04/18/12 at 9:09 A.M. the resident saw a dentist on 08/30/11 for comprehensive oral evaluation, [MEDICATION NAME], intraoral-complete including bitewings. The receipt was signed by the resident. There was no identification of the need for restoration services at that time. Interview with the director of nursing on 04/18/12 at 10:30 A.M. verified no dental plan of care had been developed.

Based on observation, interview and record review, the facility did not ensure that the resident's need for fluid restrictions related to [MEDICAL TREATMENT] was reevaluated and updated on the plan of care for Resident #31. This affected one of 17 residents reviewed for care plans with a facility census of 74. Findings include: Review of the record revealed that Resident #31 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. She was noted with [DIAGNOSES REDACTED]. Review of the minimum data set quarterly assessment dated [DATE] revealed the resident had moderate cognitive impairment. The record indicated that the resident was on a " low concentrated sweets, no added salt " diet, in a mechanical soft form and nectar thick liquids. Review of a care plan for [MEDICAL TREATMENT] dated 11/01/10 and updated through 07/30/12 revealed the resident was on a 1500 cubic centimeter (cc) fluid restriction, that was ordered on [DATE]. Review of the resident's orders for April, 2012 did not indicate the resident was on fluid restrictions. Review of a dietary note dated 09/08/11 at 11:19 A.M. revealed the resident was on a 1500 cc fluid restriction. Review of a dietary note dated 10/06/11 at 11:37 A.M. revealed the resident had been to the hospital, returned on 10/21/11 and was taking all nutrition through a [DEVICE] (G tube) because of swallowing difficulties. Continued review of the record revealed that the resident's diet was advanced to taking nectar thick liquids by mouth on 12/13/11. The dietary note dated that day at 5:02 P.M. did not indicate fluid restrictions, although it did recommend " therapeutic diet as prior " to the time that the resident was not able to take fluids by mouth. Observation and interview with Resident #31 on 04/17/12 at 1:00 P.M. revealed the resident in her room sitting up in a wheelchair. She had oxygen in place through nasal tubing. She verified that she went to [MEDICAL TREATMENT] three times a week. She was asked about any special restriction on her fluids and she was not aware of any. Another interview with the resident on 04/19/12 at 1:15 P.M. again revealed her in her room in her wheelchair. She denied any concerns or special recommendations related to her fluid intake. Interview with the facility dietary manager (DM #4) on 04/18/12 at 9:20 A.M. verified that the meal card for Resident #31 did not indicate that she was on a fluid restriction. Interview with the corporate dietician (Dietician #5) on 04/18/12 at 9:45 A.M. revealed that the facility dietician was not in the building or available for interview. She stated that she had been told by the facility dietician that she would take direction from the [MEDICAL TREATMENT] center as to whether the resident needed fluid restrictions. She verified that the resident's orders did not indicate a fluid restriction order, although it was in the care plan. She further verified that the record did not contain any documentation related to the need for fluid restriction, even though it had been in place prior to the resident's gastrostomy tube and inability to take fluids, and that the resident was currently taking fluids with no restrictions.