Every finding on record at Altercare Zanesville Inc.

Based on observation, medical record review and interview and policy review the facility failed to ensure personal protective equipment (PPE) was worn in Resident #6's room during meal delivery. This had the potential to affect the remaining 26 residents who resided on the 300-hall. (Resident #2, #5, #9, #12, #20, #21, #29, #31, #35, #39, #43, #44, #45, #47, #48, #49, #54, #59, #62, #63, #65, #67, #70, #76, #184 and #185). The facility census was 82. Findings Include: Review of Resident #6's medical record revealed an admitted [DATE] with diagnoses including infection following a procedure, acquired absence of right leg above knee, muscle weakness, and Methicillin Resistant Staphylococcus Aureus infection (MRSA) (a bacterial infection resistant to many antibiotics that is spread by skin to skin contact or contact with contaminated surfaces). Review of physician orders indicated Resident #6 required contact transmission-based precautions due to MRSA. Observation on 04/30/25 at 4:18 P.M. revealed the Director of Nutrition Services #425 entered a contact isolation room for Resident #6 during the evening meal tray delivery. A sign was posted outside of Resident #6's room indicating she was on contact precautions and a cart containing personal protective supplies was noted below the sign and outside the resident's room door. The Director of Nutrition Services #425 was not wearing PPE and did not wash/sanitize hands prior to entering or exiting the room. The Director of Nutrition Services #425 obtained a Styrofoam cup from another area in the hall and poured hot water in the cup for hot tea and took the hot tea into Resident #6's room. Interview on 04/30/25 at 4:22 PM with the Director of Nutrition Services #425 verified he did not follow the guidance for contact isolation and should have donned PPE before entering Resident #6's room and washed his hands after exiting the resident's room. Review of facility policy titled Isolation-Categories of Transmission Based Precautions, updated 11/2020 revealed Gloves and handwashing- In additional to wearing gloves, as outlined under standard precautions, wear gloves when entering room. Remove gloves before leaving room and wash hands immediately with an Antimicrobial agent or a waterless antiseptic agent. Gown- In addition to wearing a gown as outlined under standard precautions, wear a gown (clean, nonsterile) when entering the room.

Based on observation, medical record review and interview, the facility failed to follow insulin administration and blood glucose monitoring per physician orders. This affected one resident (Resident #79) of three residents reviewed for insulin use. The facility census was 82. Findings Include: Review of the medical record for Resident #79 revealed an admitted [DATE]. Diagnosis included type 2 diabetes, atherosclerotic heart disease of native coronary artery without angina pectoris and presence of aortocoronary bypass graft. Review of orders for March 2025 revealed Lantus (long acting insulin) insulin 42 units subcutaneous once a day started on 03/03/25, Insulin Lispro seven units three times a day before meals and per sliding scale dated 03/03/25. Review of the Minimum data Set (MDS) dated [DATE] revealed intact cognition. Resident #79 received insulin injections seven days during the assessment period. Review of medical record revealed Resident #79 was out of the facility to an endocrinology appointment on 03/26/25 at 9:00 AM. Review of the provider note dated 03/26/25 revealed continue lispro seven units before meals, two units for 50 points above 150 and lantus 42 units daily, will order freestyle libre. Review of the physician orders revealed Freestyle Libre 3 plus sensor (blood-glucose sensor) device apply once every 14 days started on 03/26/25. In addition, on 03/26/25 Insulin Lispro was discontinued, and blood sugars were not obtained. Review of the March and April 2025 Medication Administration Records (MAR) revealed Resident #79 stopped receiving Insulin Lispro routinely and as needed on 03/26/25 and monitoring blood sugars were not continued since 03/26/25. Resident #79 started the blood glucose monitor device on 03/28/25. Interview and observation on 04/28/25 at 12:07 PM with Resident #79 revealed her Freestyle Libre 3 plus sensor (glucose monitoring disc) came off and she stated she had to wait two weeks to get a new one. Resident #79 also stated staff have not been monitoring her blood sugars for some time. Observation at that time revealed Resident #79 did not have her glucose monitoring disc on. Interview on 04/30/25 at 11:42 A.M. with RN #300 from the endocrinologist's office revealed Resident #79 was seen in the office on 03/26/25 for diabetes management. RN #300 verified Resident #79 had orders for Lantus 42 units once daily and insulin Lispro seven units three times a day before meals and sliding scale two units for every 50 points above 150 (blood glucose level). Resident #79 also started on a blood sugar monitor device at that time. RN #300 stated the facility should have called and verified the orders if they did not understand them. Resident #79's blood sugar should be checked at least three times a day. RN #300 stated on the physician note, it said to continue to check blood sugars and continue insulin as ordered. Interview on 04/30/25 at 2:00 P.M. with the DON and Regional Nurse #439 verified the nurse that received the orders should have verified the orders with the physician. The DON verified Resident #79 did not receive monitoring of blood sugars from 03/26/25 through 04/30/25 except when she had a blood draw. DON verified on 03/26/25 Resident #79's fast acting insulin was discontinued and was not given per physician orders.

Based on closed medical record review, review of a resident communication log, review of visiting healthcare service orders, review of a customer alert form, hospital notes, policy review, medication instructions, and death certificate, and interview with family and facility staff the facility failed to ensure comprehensive monitoring and timely identification of a change in condition for Resident #94, who was incontinent of bladder with a diagnosis of Stage 3 chronic kidney disease. In addition, the facility failed to ensure Resident #94 received timely, necessary and appropriate treatment and services of a urinary tract infection (UTI). This resulted in Immediate Jeopardy, actual harm, and subsequent death beginning on [DATE] when Resident #94's daughter requested a urinalysis to be performed due to changes in the resident's cognition that was not completed by the facility. Resident #94's daughter again requested on [DATE] a urinalysis be performed as Resident #94 had increased confusion including visual hallucinations and two falls on [DATE]. On [DATE] the nurse practitioner (NP) was in the facility and ordered a urinalysis with culture and sensitivity for Resident #94, however, did not assess the resident. On [DATE] the physician ordered additional laboratory testing (a basic metabolic panel (BMP) and complete blood count (CBC). The urinalysis order was not entered into the computer system until [DATE]. The lab collected the BMP and CBC on [DATE] at 8:25 A.M., however the urine was not collected for the urinalysis. The urine specimen was finally collected and sent to the hospital lab on [DATE] for testing. On [DATE] the culture results were received indicating that the resident had Escherichia coli (E. Coli) (bacterial infection). The E. Coli infection had antibiotic susceptibility and was sensitive to Trimethoprim/Sulfa (antibiotic). The resident was started on Bactrim (antibiotic medication) orally. On [DATE] Resident #94's daughter requested the resident be transferred to the hospital due to her confusion. The resident was admitted to the hospital on [DATE] with diagnoses including sepsis secondary to UTI and met sepsis criteria. On [DATE] the resident expired at the hospital. The resident's death certificate dated [DATE] revealed the resident 's immediate cause of death was acute renal failure due to acute cystitis with an onset of days. This affected one resident (#94) of three residents reviewed for infections. The current census was 92. On [DATE] at 9:05 A.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when Resident #94 had a change in condition including confusion with visual hallucinations and increased episodes of falling, whereas the resident's family requested urinalysis twice due to the resident's change in condition, and the facility failed to complete the requested testing and failed to notify the medical provider of the family's concerns. In addition, the resident's urinalysis with culture and sensitivity was not collected timely, therefore delaying treatment for the UTI. Resident #94 was transferred and admitted to the hospital on [DATE] per the family's request due to increased confusion. The resident expired at the hospital on [DATE] due to acute renal failure due to acute cystitis. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 10:53 A.M. all 87 current in-house residents (continent and incontinent) medical records from [DATE] to [DATE] were reviewed by the DON and Regional Nurse, for any significant change in conditions and documented signs and symptoms of urinary tract infections and appropriate notifications have been made to obtain appropriate treatment for significant change in condition if needed. This was completed [DATE] at 1:29 P.M. On [DATE] the facility laboratory testing practice of completing labs per physician's orders on Monday, Wednesday, and Friday each week unless a STAT lab was ordered by a physician was reviewed with Medical Director (MD) #301 and approved. The facility was also in contact with a local hospital regarding the possibility of initiating a contract with them for labs, to increase available lab days, which was MD #301's preference when available to begin. It was the providers preference for facility nurses to be able to communicate scheduled lab days and facility lab capabilities upon on call physician notification. On call physician would then determine if STAT labs were a necessity or if lab could be ordered for next scheduled lab day. Scheduled lab days were posted for all nurses to reference at each unit's nurse's station. Nurses were aware of where to locate reference information regarding scheduled lab days and their responsibility to communicate lab capabilities and scheduled lab days to on call physician as needed. On [DATE] the facility implemented a plan in the event of a family request for medical intervention, in that nurses need to complete a comprehensive assessment of the resident to determine if there was a necessity for emergent care or treatment rendered. The comprehensive assessment would include new onset symptoms, vitals, mental status, respiratory status, pain status, and skin assessment. After assessment if it was deemed necessary for emergent care or treatment, then the nurse would immediately notify the resident; consult with the resident's attending physician, on call physician, nurse practitioner, physician assistant or clinical nurse specialist and notify the resident's authorized representative or interested family member. The following circumstances would constitute immediate notification as outlined above: a) An accident or incident involving the resident, which results in an injury and has the potential for requiring physician intervention b) A significant change in the resident's physical, mental, or psychosocial status (i.e. a deterioration in health, mental, or psychosocial status in either life-threatening condition or clinical complications) c) Lab, radiology, or other diagnostic testing results that fall outside of clinical reference ranges d) A need to alter the resident's medical treatment significantly (i.e. need to discontinue medication), or to commence a new form of treatment (e.g. refusal of treatment/medications (2) or more consecutive times) e) A need or family/resident request for transfer or discharge of the resident from the facility to a hospital/treatment center (this includes transfers to the hospital as well as discharges against medical advice) f) Beginning [DATE], the facility MedOne provider would receive immediate notification regardless of nurse's comprehensive assessments regarding family requests for medical treatment. The facility plan included, if upon assessment, a necessity for emergent care or treatment was not identified, nurses would add the concern to the Resident Communication Log. The Resident Communication Log would then be reviewed for needed follow up by the Medical Director, attending physician, or Nurse Practitioner on their next rounding day. On [DATE] at 12:06 P.M. the DON provided nurses education (either in person or by phone) on proper notification of significant changes in residents' conditions as outlined above. As of 5:34 P.M. on [DATE], 21 of 21 facility nurses have been educated on the above topics. No new nurses would be permitted to work until they have received education on the above topics. On [DATE] at 1:28 P.M. the DON provided nurses education (either in person or by phone) on signs and symptoms of UTIs per McGeer's criteria. On [DATE] at 1:30 P.M. an Ad hoc Quality Assessment Performance Improvement (QAPI) meeting was held with the Administrator, DON, Assistant Director of Nursing (ADON), Medical Director (MD) #301 and Regional Nurse in regard to proper notification of significant changes in residents' conditions and signs and symptoms of UTIs per McGeer's criteria. Review of Notifications of Change in Condition policy was completed at this time. MD #301 was in agreement with procedure for Notifications of Changes as outlined in this policy. Beginning [DATE] the DON or designee would conduct daily audits of all in-house resident records including the Resident Communication Log to ensure any significant change of condition has been reported to the appropriate personnel and treatment was obtained if deemed necessary by physician/CNP/On-Call service, for two weeks, then three times per week for two weeks, then weekly for two weeks and then as needed (PRN). Beginning [DATE], the DON or designee would conduct daily audits of all in-house resident records including Resident Communication Log to ensure documented signs and symptoms of urinary tract infections and the appropriate notifications have been made to obtain appropriate treatment if ordered daily for two weeks, then three times per week for two weeks, then weekly for two weeks and then as needed (PRN). Surveyor interviews completed on [DATE] at 9:32 A.M. and 10:02 A.M., with Licensed Practical Nurse (LPN) #190 and Registered Nurse (RN) #203 confirmed they were educated yesterday [DATE] on change of condition, documentation, and signs and symptoms of UTI. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #94's closed medical record revealed the resident was admitted to the facility on [DATE] following a hospitalization from [DATE] to [DATE] where the resident had back surgery. The resident's diagnoses included fusion of the spine, lumbar region, spinal stenosis, history of transient ischemic attack, atrial fibrillation, chronic diastolic heart failure, hypertension, type 2 diabetes, Stage 3 chronic kidney disease (mild to moderate loss of kidney function), anemia, depression, anxiety, sleep apnea, nonalcoholic steatohepatitis, tremor, hyperlipemia, and gastro-esophageal reflux. The resident was discharged to the hospital on [DATE] and did not return to the facility. The resident passed away at the hospital on [DATE]. Review of Resident #94's admission assessment dated [DATE] and completed [DATE] revealed the resident had short- and long-term memory impairment and was alert to self only. The resident was able to make needs known, understand others, and her speech was clear. The assessment revealed the resident was incontinent of urine at times. A baseline care plan indicated staff would observe (urine) for burning, odor, complaints of pressure, increase confusion, abdominal pain, fever and notify the provider as warranted. The resident's plan was to return home following her stay at the facility. Review of Resident #94's skilled note authored by Licensed Practical Nurse (LPN) #190 dated [DATE] revealed the resident was restless, confused/disoriented, only alert to self, incontinent of urine, and had mild pain (this was a check box on a form and did not describe the pain or specify the location of the pain). Review of Resident #94's history and physical note authored by Physician #301 dated [DATE] revealed the resident was seen for diabetes, diabetic fibrosis, and lumbar spinal stenosis post-surgery. The resident had a posterior lumbar interbody fusion that was performed on [DATE] and was stabilized and transferred to the skilled nursing facility for ongoing care and therapy. The resident was alert and oriented times three with mentation slightly slow. There were no new concerns per nursing staff. The resident stated her lumbar pain and leg pain was much improved since decompression. The note revealed the resident was incontinent and had no suprapubic tenderness. Staff reported the resident's memory was poor. Review of an incident reassessment summary (unauthored) dated [DATE] revealed the resident had fallen ambulating back from the bathroom. The resident was assisted times two (staff) to her feet and to the bathroom. No injuries noted. Immediate intervention was to encourage resident to use call light for transfers/ambulation assistance and therapy to screen for treatment as indicated. Review of Resident #94's orders dated [DATE] revealed laboratory testing orders for a Basic Metabolic Panel (BMP) (includes glucose, sodium, potassium. Chloride, carbon dioxide, creatinine, blood urea nitrogen (BUN), and calcium) and Complete Blood Count (CBC) (red blood cells, hemoglobin, hematocrit, white blood cells (also measure differentials which is the breakdown of different types of white blood cells, and platelets). However, there was no evidence the BMP or CBC were collected as ordered at this time. Review of Resident #94's skilled note authored by Registered Nurse (RN) #195 dated [DATE] revealed the resident was alert and oriented time three, no urine difficulties, however had severe pain. There was no additional information at this time related to the resident's severe pain, etiology of the pain and/or interventions to address the complaints of pain. Review of Resident #94's progress note dated [DATE] authored by Registered Nurse (RN) #195 revealed at 12:42 A.M. the resident was having general discomfort and non-pharmacological interventions (NPI) were ineffective. Medicated with two Norco's (schedule II opioid narcotic). At 6:43 A.M., resident complained of general discomfort and headache. NPI's not effective and medicated with two Norco's at 5:37 A.M. There was no evidence that the physician and/or nurse practitioner were notified at this time. Review of Resident #94's skilled note authored by RN #195 dated [DATE] revealed the resident was alert and oriented times three, no urine difficulties, or pain. Review of Resident #94's skilled note authored by RN #196 dated [DATE] revealed the resident was alert and oriented times three, no urine difficulties, or pain. Review of Resident #94's skilled note authored by RN #195 dated [DATE] revealed the resident was alert and oriented times three, no urine difficulties, or pain. Review of Resident #94's incident reassessment summary (unauthored) dated [DATE] at 2:45 P.M., revealed the resident had fallen in her room. Resident reported she was getting up to go to the bathroom and fell . The resident had no injuries noted and was assisted up times three to the bed and then to the bathroom. Intervention identified non-skid socks applied and the resident was educated to wear non-skid socks as tolerated. Review of Resident #94's progress note dated [DATE] authored by RN #195 revealed resident had complaints of back discomfort. NPI's ineffective. Resident was medicated at 8:43 P.M., with Norco. There was no evidence the physician and/or nurse practitioner were notified at this time. Review of Resident #94's incident reassessment summary (unauthored) dated [DATE] at 11:06 P.M., revealed the resident was found lying on the right side of the recliner. No injuries noted. The resident was assisted up times two (staff) and assisted to bed. New interventions implemented were bed in lowest position when in bed and bed against wall to promote spaciousness. (This fall is the second fall on this date). Review of a Resident Communication Log (log was to be used for non-emergent issues that could be addressed at next provider rounds) dated [DATE] to [DATE] revealed on [DATE] Resident #94's name was on the top of log and the concern indicated the resident's daughter wanted the resident checked for a urinary tract infection (UTI). On [DATE] Resident #94's name was listed again and the concern indicated resident was showing signs of restlessness. Resident noted getting out of bed/chair without assistance. Daughter wants a urinalysis (UA). At the bottom of the form there was a typed note (in all capital letters) ANY NEW ONSET SYMPTOMS OF COUGH, BLEEDING, CHANGE IN MENTAL STATUS, ABNORMAL VITALS, AND CRITICAL LABS NEED CALLED IMMEDIATELY! Review of Resident #94's skilled note authored by Licensed Practical Nurse (LPN) #165 dated [DATE] revealed the resident was restless, confused/disoriented, alert to self only, no urinary difficulties, or pain. Review of Resident #94's progress notes dated [DATE] and [DATE] revealed no evidence the resident's medical provider was updated on the family's request to have urine (UA) checked. In addition, there was no evidence the resident had been assessed by a medical provider since [DATE] when Physician #301 completed the resident's history and physical. Review of Resident #94's Admission Minimum Data Set (MDS) 3.0 dated [DATE] revealed the resident's brief mental status (BIMS) score was 11, reflecting she was moderately cognitively impaired. The assessment revealed the resident required partial/moderate (staff) assistance with toileting hygiene, dressing, putting on and taking off footwear, and personal hygiene. The resident had no impairment with range of motion. The assessment revealed the resident was occasionally incontinent of urine and not on a toileting program. Review of Resident #94's orders dated [DATE] revealed an order for laboratory testing for a Basic Metabolic Panel (BMP) and Complete Blood Count (CBC). However, there was no evidence that BMP or CBC was collected as ordered on this date. Review of Resident #94's skilled note authored by RN #195 dated [DATE] revealed the resident was alert to self, no urine difficulties, or pain. Review of Resident #94's progress note dated [DATE] at 6:40 A.M., authored by RN #195 revealed the resident had complaints of back pain. NPI's were ineffective and Norco was administered at 1:11 A.M. There was no evidence the physician and/or nurse practitioner were notified at this time and/or evidence the facility investigated to determine the etiology of the back pain. Review of a visiting healthcare service order sheet dated [DATE] revealed Nurse Practitioner (NP) #302 ordered Resident #94 to have a urinalysis (UA) with culture and sensitivity (C&S). (This is a note written by the medical provider to include the resident's name and orders which are then later entered into the electronic medical record) Review of Resident #94's orders dated [DATE] revealed an order for a Basic Metabolic Panel (BMP) and Complete Blood Count (CBC). However, there was no evidence that the BMP or CBC was collected and there was no evidence there was an order written for UA C&S. Review of Resident #94's skilled note authored by RN #196 dated [DATE] revealed the resident was alert and place, heart rate was irregular, no urine difficulties, and pain was rated six out of 10 (,d+[DATE] pain scale). There was no evidence the physician and/or nurse practitioner were notified at this time and/or evidence the facility investigated to determine the etiology of the resident's pain or irregular heart rate at this time. Review of a communication log from the on-call physician services dated [DATE] authored by NP #302 revealed the resident had chest pain with stable vital signs, pain seen left lateral (side) with deep breaths. Orders were provided for the medication, Maalox twice today and daily for three days and a chest x-ray. In addition, NP #302 order inhalation medication, DuoNeb every eight hours for 10 days. Review of Resident #94's physician orders dated [DATE] revealed NP #302 ordered a urine culture to be obtained (there was no diagnosis for the test). In addition, Physician #301 ordered a straight cath to obtain urine for culture and sensitivity with no indication or diagnosis listed, DuoNeb every eight hours with no diagnoses or indication noted, Maalox 30 milliliters (ml) now and 30 ml twice daily with no indication for use, and a STAT chest x-ray to rule out infection for symptoms of left side pain, decreased oxygen saturation levels, and increased confusion. Further review revealed no evidence Resident #94 was actually seen or assessed by a medical provider (physician or nurse practitioner from [DATE] through [DATE]. Review of Resident #94's medication administration record dated [DATE] to [DATE] revealed the resident received two doses of Maalox on [DATE], [DATE], and [DATE] which was different from the order on the communication log. The DuoNeb was started every eight hours on [DATE] at 8:00 A.M. (ordered on [DATE]). There was no indication for use/diagnoses. Review of Resident #94's BMP and CBC results dated [DATE] revealed the resident's blood was collected at 8:25 A.M., however the urine was not collected. The resident's sodium was 135 low (,d+[DATE] milliequivalents/liter (mEq/L)), chloride was 95 low (,d+[DATE] mEq/L)), red blood cells 3.76 low (3XXX,d+[DATE].40 million cells/microliter (mL), hemoglobin 11.4 low (,d+[DATE] grams/deciliter (g/dL) and hematocrit was 33.9 low (,d+[DATE] percentage (%)). (There was no documented evidence a medical provider was notified of the abnormal lab results until a resident progress note dated [DATE] at 2:45 P.M. authored by the DON which included the final lab results and chest x-ray results were reviewed by NP #302, there were no new orders at this time.) Review of Resident #94's progress note dated [DATE] at 12:15 P.M. (after labs were already obtained at 8:25 A.M., that morning) authored by RN #109 revealed he attempted to collect urine sample on resident via straight cath and was not able to collect. The resident was unable to follow directions for clean catch specimen. Other unit nurse to attempt urine collection when resident's daughter arrives to alleviate mental strain on resident. Review of Resident #94's skilled note authored by RN #195 dated [DATE] revealed the resident was alert and oriented times three, no urine difficulties, or pain. There was no documented evidence the resident had chest pain or low oxygen at this time. Review of Resident #94's chest x-ray dated [DATE] revealed no evidence of acute cardiopulmonary disease. Review of Resident #94's treatment administration record dated [DATE] to [DATE] revealed the resident's oxygen saturation via pulse oximetry was 93% to 99%. On [DATE] Resident #94 pulse ox was 95% and 97% (this note did not include if this was on room air or if the resident was receiving supplemental oxygen). Review of Resident #94's urinary incontinence plan of care dated [DATE] revealed the resident was incontinent of bladder and was at risk for altered dignity, skin breakdown, and urinary tract infections (UTI). Interventions included to observe/report any signs and symptoms of UTI such as resident complaints of pain or burning with urination, complaints of pressure, odor, discoloration of urine, and mood/behavior changes. Review of Resident #94's progress note dated [DATE] at 8:27 A.M. authored by Licensed Practical Nurse (LPN) #150 revealed Resident #94's urine was collected and sent to lab. (Five days after the resident's daughter had first requested the specimen be obtained). Review of Resident #94's skilled note authored by LPN #150 dated [DATE] revealed the resident was confused/disoriented, alert to self and place only, had frequent urination, and no pain. Review of Resident #94's skilled note authored by RN #196 dated [DATE] revealed the resident was alert and oriented time three, no urine difficulties, or pain. Review of a customer alert notice authored by the DON dated [DATE] revealed Resident #94's daughter had voiced concerns regarding the timeframe for lab testing at the facility. Preliminary lab results reviewed, and the daughter was informed the UA takes 72 hours to process per the lab. The resident's daughter was educated that lab draws and specimens were completed on Monday, Wednesday, and Fridays per the facility's services, but that the facility would send any cultures to the local lab as needed. A copy of the resident communication log and visiting healthcare service order sheet was attached to the notice. Review of Resident #94's UA results dated [DATE] revealed the urine was collected on [DATE] at 6:00 P.M., and received on [DATE] at 12:29 P.M. The diagnosis listed was dysuria (discomfort, pain or burning when urinating). The urine culture grew greater than 100,000 milliliters (ml) of Escherichia coli (E. Coli). The bacteria was sensitive to Trimethoprim/Sulfa. Review of Resident #94's progress note dated [DATE] authored by LPN #150 revealed final (urine) report received. New orders for antibiotic for urinary tract infection (UTI). Give first dose now and encourage fluids. Review of Resident #94's skilled note authored by LPN #150 dated [DATE] revealed the resident was alert to self and place, incontinent of urine and had no pain. Review of Resident #94's infection tracker with McGeer's criteria dated [DATE] revealed the resident had UTI that was a healthcare-associated infection. The resident had no indwelling catheter. The resident had acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis, or prostate and had at least 100,000 cfu/ml of no more than two species of microorganisms in a voided urine sample. The resident met criteria for McGeer's for non-catheter UTI. The resident had history of signs and symptoms of UTI including cloudy or dark urine, pain or burning, pain or burning during urination, and low-grade fever. The urine culture showed greater than 100,000 cfu/ml of E.Coli. Note- this information contained in Resident #94's infection tracker related to the resident's dysuria and cloudy dark urine was not included in the resident's medical record. Review of Resident #94's orders and medication administration records dated [DATE] revealed the resident was ordered Bactrim (sulfa antibiotic) 800 milligrams (mg) twice daily orally. The resident received one dose of Bactrim 800 milligrams (mg) on [DATE], two doses on [DATE], and one dose on [DATE]. Review of Resident #94's skilled note authored by LPN #140 dated [DATE] revealed the resident was alert and oriented time three, no urine difficulties, or pain. Review of Resident #94's skilled note authored by RN #196 dated [DATE] revealed the resident was confused/disoriented, alert to self only, incontinent of urine and denied shortness of breath and chest pain. Review of Resident #94's skilled note authored by RN #116 dated [DATE] revealed the resident was restless/confuses/delusional, alert to self, had irregular heart rate, and was incontinent of urine. Review of Resident #94's progress note authored by RN #116 dated [DATE] revealed at 1:45 P.M., the resident's family member requested the resident be sent to the hospital, for evaluation for confusion. This nurse educated the family that confusion was an expected symptom of urinary tract infection. The note revealed the family member insisted the resident be sent out to the hospital. At 1:50 P.M., NP #302 was notified, and an order was received to transfer the resident to the hospital per family's request. Review of Resident #94's medical provider notes revealed no evidence the resident had been seen by a medical provider from [DATE] to [DATE]. Review of Resident #94's observation report (transfer form) dated [DATE] and closed [DATE] revealed the resident's daughter was present at time of transfer. The daughter requested that the resident be sent to hospital. The observation report documented the resident's baseline mental status was confused and the resident was continent of bladder. However, review of medical record notes prior to this date included the resident had been alert and oriented times three and incontinent on various occasions. Review of Resident #94's progress note dated [DATE] at 8:46 A.M., revealed the resident was admitted to the hospital with sepsis (life threatening complication of an infection) secondary to UTI and met sepsis criteria. Review of Resident #94's hospital notes authored by Emergency Physician #401 dated [DATE] revealed the resident was in the emergency room for UTI. The resident had started Bactrim on Saturday after being diagnosed with UTI. Symptoms were worsening. Shaking possible rigors, chills, fever, back pain, and altered mental status. Review of Resident #94's hospital note authored by Hospitalist #402 dated [DATE] revealed the resident had acute cystitis and had tested positive on [DATE] for E. coli in the urine. The resident started on Bactrim on [DATE] with reported increased confusion. The resident was transitioned to the antibiotic Levaquin. The resident had acute kidney injury likely secondary to hypovolemia (low blood volume due to injury, illness, or underlying condition) and recent Bactrim. The note included the resident had acute metabolic encephalopathy in the setting of acute cystitis which was likely worsening due to Bactrim and hypovolemia. Review of Resident #94's discharge hospital note authored by Hospitalist #400 dated [DATE] revealed on [DATE] the resident presented to the hospital with altered mental status. She was admitted with a heart rate of 104, respirations were 24, lactate level 2.2, and positive UA. The resident was assessed to have acute cystitis and acute kidney injury (AKI) on chronic kidney disease 3. The AKI was likely secondary to hypovolemia and recent Bactrim use. Sepsis was secondary to acute cystitis. Although the acute metabolic encephalopathy etiology was unclear, the note included in the setting of acute cystitis complicated with Bactrim administration versus hypovolemia, versus polypharmacy, versus hypoglycemia. The resident was made comfort care only on [DATE] and expired on [DATE]. Review of Resident #94's death certificate dated [DATE] revealed the resident's immediate cause of death was acute renal failure due to acute cystitis and the onset was days. Interview on [DATE] at 2:27 P.M., with the DON, Administrator, and Corporate Nurse #300 confirmed the family had requested a urinalysis (UA) be obtained on [DATE] and [DATE], however nursing staff believed collecting a UA was not urgent and wrote the request on the resident communication log (for the practitioner to see when next in the building as opposed to contacting the provider at that time). The administrative staff verified the communication log was used for non-emergent issues that could be addressed at next rounds by the provider and indicated the nurse practitioner comes (to the facility) three days a week and the physician visits once a week. On Thursday, Saturday, and Sundays there are no medical providers in the facility. After 6:00 P.M. and on weekends the staff can call the on-call service to reach a covering medical provider. The DON confirmed there was no documentation that a medical provider was notified on [DATE] or [DATE] the family wanted a UA checked nor was there documented evidence the resident's urine was checked at the facility. The DON reported staff could have obtained a urine specimen (onsite) to check for infection prior to sending a urine to the lab. On [DATE] NP #302 reviewed the communication form and ordered a UA due to the family having requested it (although they believed the NP did not feel the testing was necessary). The administrative staff also verified on [DATE] Resident #94's daughter voiced concerns regarding the timeliness of UA and the DON reported she explained to the daughter that the lab only comes on Monday, Wednesday, and Fridays. The DON confirmed the UA was ordered on [DATE]; however, it was not collected until [DATE] and sent out on [DATE] to a local lab and not the facility's contracted lab. On [DATE] the urine C&S came back positive for the bacteria E. Coli and NP #302 ordered Bactrim DS twice daily. The administrative staff verified on [DATE] the family requested the resident be transferred to the hospital where she was admitted w [TRUNCATED]

Based on medical record review and interview the facility failed to ensure a resident received laboratory services per physician orders. This affected one resident (#65) of four residents reviewed. Findings included: Review of Resident #65's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including encephalopathy, atrial fibrillation (new onset), sleep apnea, hypertension, chronic kidney disease, Stage 4, bradycardia, transient cerebral ischemic attack, and bladder-neck obstruction. Review of Resident #65's orders dated 02/26/25 revealed the resident was to have a basic metabolic panel (BMP) every Friday until 03/15/25. There were no diagnoses or indications why the BMP was ordered. Review of Resident #65's treatment administration records (TAR) dated 02/22/25 to 03/13/25 revealed staff signed off the BMP was collected on 02/28/25 and 03/07/25. Review of Resident #65's medical record revealed no evidence a BMP was obtained on 02/28/25 or 03/07/25 per order. Review of Resident #65's physician note dated 02/25/25 revealed the resident had chronic kidney disease Stage 4 and coronary arteriosclerosis and to check BMP periodically. Interview on 03/13/25 at 2:27 P.M., with the Director of Nursing (DON), Administrator, and Corporate Nurse #300 confirmed there was no evidence the BMP was obtained on 02/28/25 or 03/07/25 per order for Resident #65. The DON confirmed there was no documented evidence why the BMP was not collected on 02/28/25 or 03/07/25. The surveyor asked the facility to provide additional information about why the BMP was ordered every Friday until 03/15/25. Interview on 03/13/25 at 4:58 P.M., with the DON revealed on 02/25/25 the physician had documented in the history and physical to check BMP periodically for coronary arteriosclerosis. Interview on 03/13/25 at 5:00 P.M., with the Administrator revealed the facility did not have a policy on laboratory services and the facility would just follow physician orders. This deficiency represents incidental findings of non-compliance investigated under Complaint Number OH00163321.

Based on observation, medical record review, policy review, national library glove use review guidance and interview, the facility failed to ensure a resident with an indwelling urinary catheter was provided appropriate care and services. This affected one resident (#2) of three residents reviewed for indwelling catheter use. The facility identified six residents with indwelling urinary catheters. The census was 93. Findings include: Medical record review revealed Resident #2 was admitted on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage, dementia, aphasia, congestive heart failure, urinary tract infection, hydroureteronephrosis, bladder outlet obstruction, pyelonephritis, ureteral stent, use of an indwelling urinary catheter, and Kennedy ulcer (a rapidly developing skin wound that appears in some people during their final weeks of life). Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #2 was severely impaired for daily decision-making, had no behavioral or rejection of care, bilateral impaired upper and lower extremity functional range of motion limitation, was dependent on staff for self-care, was always incontinent of urine and did not have an indwelling urinary catheter. Review of the hospital Infectious Diseases Progress Note dated 02/06/25 and hospitalist Inpatient Progress Note dated 02/06/25 revealed diagnoses included Escherichia coli (e. coli) cystitis with chronic retained right ureteral stent with greater than 100,000 col/mL urine culture for e. coli (a gram-negative bacteria commonly found in the lower intestine). Further review of the hospital records revealed a Discharge Summary dated 02/10/25 revealed the resident was admitted to the hospital on 02/05/25 with diagnoses including a urinary tract infection requiring treatment with antibiotics and discharged back to the facility on [DATE]. Review of the electronic Physician Orders dated 02/10/25 revealed the resident was ordered a 16 french indwelling catheter to straight drain. Review of the undated Baseline care plan revealed pain approaches included the following: encourage resident to report any pain; note pain by utilizing intensity, location and pain type; note verbal (vocal) complaints of pain and non verbal restless, grimacing, withdrawal; and to medicate for pain per order and indication by the resident verbal or non verbal. Coccyx wound approaches included to monitor for pain. On 02/18/25 between 10:42 A.M. and 11:03 A.M., observation of Resident #2's indwelling catheter care revealed the following: Certified Nurse Assistant (CNA) #222, CNA #224 and Registered Nurse (RN)#266 donned personal protective equipment, gathered supplies and entered Resident #2's room to perform catheter care. CNA #222 washed her hands at the sink, donned gloves after filling a single water basin with warm water and took soap and the single wash basin to the resident's bedside. CNA #222 informed the resident she was going to perform catheter care and CNA #224 was going to roll her onto her left side. Observation of the resident laying on her back in bed revealed the indwelling catheter tubing was positioned under her left leg and was pressed against the mattress. CNA #222 grasped a washcloth and placed it into the wash basin, applied soap to the wash cloth. The indwelling catheter shaft tubing from the external urethral orifice to the urine drainage port was cleansed in a downward motion while CNA #222 was securing the catheter at the resident's urethral opening and labia. CNA #222's gloved fingers and hand was observed pressing against the external urethra and labia while the indwelling catheter tubing was cleaned. The washcloth was placed into a trash bag being held by RN #266. CNA #222 grasped a new clean washcloth without changing her gloves and placed both the wash cloth and gloved hands in the washbasin CNA #222's gloved hands were observed and moved the washcloth around the washbasin to wet it and then wrung out the excess water. CNA #222 proceeded to rinse the indwelling catheter tubing and then placed the washcloth used to rinse the tubing into the trashbag. Using the same gloves, CNA #222 then grasped a clean dry washcloth, dried the catheter tubing and then placed the washcloth in the trashbag. CNA #222 went to the resident's bathroom, dumped the washbasin water into the toilet, removed her gloves and washed her hands at the sink. CNA #222 verified the above observation and she had not changed her gloves during the procedure. On 02/18/25 between 12:25 P.M. and 12:37 P.M., interview with RN #226 verified CNA #222 did not change her gloves during catheter care and were placed in the washbasin after used to clean and then rinse/dry the resident's indwelling catheter tubing. RN #226 stated the resident had been hospitalized recently for diagnoses including a urinary tract infection and residents with indwelling catheters were at higher risk for infections. On 02/18/25 between 12:43 P.M. to 12:46 P.M., interview with CNA #222 verified the above observation. Review of the undated Policy: Catheter Care, Urinary revealed it was the facility policy to prevent infection of the resident's urinary tract. Review of the National Library of Medicine, National Institutes of Health: Glove Use dated March 2010 revealed change gloves between tasks and procedures on the same patient, and after contact with material that may contain high concentration of microorganisms. This deficiency represents non-compliance investigated under Complaint Number OH00162399.

Based on observation, medical record review, policy review and interview, the facility failed to ensure Resident #74 and #87 were provided an individualized and comprehensive pain management program to adequately control pain. This affected two residents (#74 and #87) of three residents reviewed for pain management. The census was 94. Actual Harm occurred on [DATE] when Resident #87, who had an order for scheduled narcotic pain medication twice a day, was observed lying in bed, turning his head side to side, moaning and he verbalized his pain was a 10 out of 10 (a ,d+[DATE] pain scale is a way to measure pain intensity, where 0 represents no pain and 10 represents the worst possible pain imagined). The resident reported he had not received his scheduled pain medication and due to not receiving the medication timely, his pain level rating was severe. Findings include: 1.Medical record review revealed Resident #87 was admitted on [DATE] with diagnoses including end stage renal disease, non-pressure chronic ulcer of the right heel and midfoot with fat layer exposed, non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle, neoplasm of unspecified behavior of the bone, soft tissue and skin, dependence on renal dialysis, type 2 diabetes mellitus without complications, history of transient ischemic attack and cerebral infarction without residual deficits and Hodgkin lymphoma. Review of the care plan: Pain Actual, Alteration in Comfort related to ischemic feet, wounds, diabetes mellitus and decreased mobility dated [DATE] revealed goals to maintain a daily routine and verbalize comfort daily. Interventions included to administer pain medications as ordered/observe for effectiveness, Coordinate with therapy as needed to provide medications as ordered and as needed by resident, to promote comfort and encourage participation with therapy. Observe for episodes of breakthrough pain and medicate as ordered, or contact physician as needed. Offer additional non-pharmacological interventions: dim lights, soft music, position changes, music, TV, conversation, distraction. Remind resident that reporting pain early may improve effectiveness of pain medication, i.e., level 4 or less on pain scale or before pain becomes moderate. Review of the care plan: Resident has a Pressure Injury to the urinary meatus, diabetic ulcers to the left lower extremity, right calf and right heel; cellulitis to the right lower extremity; chronic ulcers of both the left and right foot and heel, and had Actual Wound pain (dated [DATE]) revealed interventions including to administer pain medication per physician's order, observe/report any adverse side effects, report/document if pain was noted or suspected and wound nurse/nursing work together to support resident. Provide support and encouragement during care and treatments, try non-medication relief measures such as repositioning, pillows, pad, support, diversion, if indicated and remind resident that reporting pain early may improve effectiveness of pain medication. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #87 was cognitively intact for daily decision-making and had received as needed pain medications and non-pharmacological interventions. The resident stated his pain was almost constant with an intensity of a 10 out of 10 that frequently affected his sleep and day-to-day activities. The resident had one unstageable pressure ulcer, diabetic foot ulcers and an infection of the foot. Review of the electronic physician orders revealed Resident #87 was ordered the following scheduled medications for pain management: OxyContin (opioid to treat moderate to severe pain) 10 mg extended release every 12 hours at 10:00 A.M. and 10:00 P.M. and Diclofenac cream (nonsteroidal anti-inflammatory) to affected joints as ordered every six hours. The last dose of Oxycontin was administered on [DATE] at 10:00 P.M. and the last dose of Diclofenac cream on [DATE] at 6:00 A.M. Further review of the resident's current electronic physician orders, dated [DATE], revealed Resident #87 had the following as needed (PRN) medications for pain management: acetaminophen (Tylenol) every six hours prn for complaints of pain rated ,d+[DATE] on a ,d+[DATE] pain rating scale and Oxycodone-acetaminophen (opioid) ,d+[DATE] mg one tablet every four hours prn for complaints of pain rated ,d+[DATE]. The resident received one dose of Oxycodone on [DATE] at 5:21 P.M. Pain assessments were ordered to be completed once a shift and with the administration of PRN medications. Review of the Wound Management assessment dated [DATE] revealed Resident #87 had six diabetic ulcers, a sacrum and a penile pressure ulcer. On [DATE] at 9:12 A.M. Registered Nurse (RN) #202 was observed to administer scheduled morning medications to Resident #87. At that time, a pain assessment was completed and the resident denied complaints of pain. The medications administered to Resident #87 did not include his scheduled Oxycontin. No additional information was provided from RN #202 during the investigation. On [DATE] at 11:30 A.M., while the surveyor was making observations on Resident #87's unit, a loud moaning sound could be heard and got louder when the surveyor walked toward Resident #87's room. Resident #87 was observed, lying in his bed, with his right hand pressed against his forehead with facial grimacing. He was moving his head side to side and moaning. Resident #87 complained of severe pain described as a radiating, constant, burning/aching/throbbing pain of both legs (the right was worse than the left leg), sacrum and feet. Resident #87 rated his pain a 10 out of 10 and stated he receives routine pain medicine because he has a lot of pain from his wounds but was not sure when he last received the medication. On [DATE] at 11:35 A.M. the surveyor reported to RN #201 that Resident #87 had complaints of severe pain and asked if the resident had received his scheduled 10:00 A.M. dose of Oxycontin. RN #201 reviewed the electronic Medication Administration Record (eMAR) and the controlled drug record for Resident #87 and verified the resident had not received his scheduled 10:00 A.M. dose of Oxycontin. RN #201 stated she arrived to work around 10:00 A.M. and was assigned to Unit 300 (Resident #87s unit) and began her assignment, which consisted of medication administration, around 10:10 A.M. RN #201 verified the resident had not received his Oxycontin because she was administering medications to other residents who had not received medications and they were late too (over an hour past the scheduled medication administration time and were indicated by red color coding in the computer system). Further observation at 11:39 A.M. revealed RN #201 dispensed OxyContin 10 mg into a medication cup, locked the medication cart and walked to Resident #87's room. Upon entrance to Resident #87's room, the resident was observed with facial grimacing and RN #201 asked the resident how he was doing. Resident #87 stated I am hurting and RN #201 replied good thing I brought this and handed the resident the medication cup containing the OxyContin 10 mg and a four-ounce glass of water. The resident took the medication and moaned. RN #201 told Resident #87 it would take 35 to 45 minutes for the pain medication to take effect, asked him if he wanted to keep the rest of the water provided with the medication and then exited his room. RN #201 did not assess the resident's pain and did not offer to reposition the resident or provide any non-pharmacological interventions to alleviate the resident's pain. Review of the electronic Medication Administration Record (eMAR) dated [DATE] revealed RN #201 documented Resident #87's 10:00 A.M. dose of OxyContin 10 mg was administered at 11:39 A.M. with comments including late administration: charted late with comment res (resident) care. On [DATE] at 12:07 P.M., observation of Resident #87 revealed he was in bed with his eyes closed. No moaning was heard coming from his room and he opened his eyes after obtaining permission to enter his room. Resident #87 stated that his pain lasts, once it starts, until the pain medicine starts to work. Resident #87 stated he still had pain in his legs, rated a six out of 10 and hoped the nurse would be returning to do the treatments to his legs. Review of the progress note dated [DATE] at 12:09 P.M. revealed pain medication administered at 11:35 A.M. and signed out at 11:39 A.M. Nurse Practitioner #200 notified of the late administration due to resident care. Interview with RN #201 on [DATE] at 4:15 P.M. for clarification as to why she documented 'charted late' when the medication administration was observed to be administered at 11:39 A.M. RN #201 stated that 'charted late' was just one option they have to document under. The RN verified Resident #87's OxyContin was administered greater than one hour after the scheduled administration time (considered late) and documented res care because she was providing care to other residents during the scheduled administration time (not that Resident #87 was receiving resident care to cause the late administration). The RN verified the resident did not receive his Oxycontin as scheduled, resulting in the resident moaning and complaining of severe pain. Review of the medical record revealed no evidence a comprehensive pain assessment was completed on [DATE] related to the late dose of scheduled pain medication. 2. Closed medical record review revealed Resident #74 was admitted on [DATE] with diagnoses including generalized osteoarthritis, spinal stenosis, lumbar region without neurogenic claudication, wedge compression fracture of T9-T10 vertebra, sequela-chronic T9 fracture, chronic pain syndrome, difficulty in walking, abnormal posture, need for assistance with personal care, displaced bimalleolar fracture of right lower leg, subsequent encounter for closed fracture with routine healing, congestive heart failure and peripheral vascular disease. Review of the care plan: Pain (dated [DATE]) revealed potential for pain related to odontoid fracture, right ankle fracture, osteoarthritis, lumbar spinal stenosis, chronic T9 fracture, chronic pain syndrome, muscle spasms, and restless leg syndrome. Interventions included to administer pain medications as ordered. Review of the care plan: Hospice (dated [DATE]) revealed Resident #74 was receiving hospice benefits for diagnoses including end stage congestive heart failure, pain, respiratory, dying process and coping/lifestyle/grieving. Goals included to promote comfort with care and daily routine. Pain was to be assessed for location and intensity, medicate per physician order and coordinate with hospice for pain control measures and consult with hospice for changes in resident's pain. Review of the significant change MDS 3.0 assessment (dated [DATE]) revealed Resident #74 was moderately impaired for daily decision-making, required assistance from staff at various levels to complete self-care, received scheduled, PRN (as needed) and non-pharmacological interventions for pain, complained of frequent pain that occasionally interfered with sleep and activities of daily living, described his pain as severe rated an eight out of 10 and had a life expectancy of less than six months. Review of Registered Nurse (RN) #205's hospice Progress Note dated [DATE] revealed Resident #74 was lying in bed upon arrival (between 9:05 A.M. and 10:00 A.M.) and was noted to be moving their arms/legs, grimacing and voiced pain to legs when asked. Nursing was notified and it was noted that Resident #74 had not received any PRN morphine since RN #205's visit on [DATE] but had received scheduled morphine. RN #205 documented concern for pain that was not being reported or recognized by staff, the resident has voiced pain to this nurse yesterday and today with visits. Morphine 10 mg every four hours schedule and prn to be ordered if family agrees. Nursing was encouraged to monitor closely for signs and symptoms of pain. Review of RN #205's hospice Progress Note dated [DATE] revealed (between 9:00 A.M. and 10:00 A.M.) Resident #74 was lying in bed with eyes closed, noted to be moving arms and legs frequently, moaning and moving mouth as if trying to speak, and appeared to be grimacing. Care coordinated with facility nurse who stated the resident had received two PRN doses of morphine in addition to his scheduled morphine in the last 24 hours. RN #205 updated family who stated Resident #74 was not comfortable when he was visited the previous night and would like morphine increased. Nurse Practitioner #206 was notified and agreed to increase morphine to 10 mg every four hours scheduled and to continue the PRN morphine dose as well. Review of the hospice RN #207 Progress Note dated [DATE] revealed (between 12:24 P.M. and 1:19 P.M.) facility nurse stated resident has been comfortable and family at bedside felt he was comfortable with current medications at this time. Resident #74 was unresponsive at the visit. Review of the Controlled Drug Receipt/Proof of Use/Disposition Form (dated [DATE] through [DATE]) and the Medication Administration Record dated [DATE] revealed the morphine sulfate was not administered as ordered at 8:00 P.M. on [DATE]. Review of Resident #74's progress notes date [DATE] at 10:00 P.M. [Recorded as Late Entry on [DATE] at 5:34 A.M.] revealed the resident was not breathing when the nurse walked into the room and the resident was without a pulse or heart rhythm. Review of LPN #204's Personnel Action Form and attached written Director of Nursing (DON) Statement dated [DATE] revealed the LPN #204 was issued a Disciplinary addressing non-compliance related to failure to comply with facility written policies & procedures and failure of time management techniques to complete assignments. Efficiently & effectively exhibits competent ability to perform job duties according to department specific job description. This violation was labeled as a medication error on [DATE] and was LPN #204's second offense. Review of the typed DON Statement revealed she interviewed LPN #204 via telephone on [DATE] regarding Resident #74's medication administration on [DATE]. LPN #204 stated that she was in a resident's room that required her attention early in the shift, after completing count and report. The outgoing nurse stated Resident #74 was stable and had been resting comfortably. LPN #204 was pulled over to another unit to help a charge nurse with an enteral feeding tube and when she returned, continued her medication pass. At that time, she was summoned to Resident #74's room, and he had expired. Attempts were made during the onsite survey to reach LPN #204 however; no return calls were provided. On [DATE] at 3:21 P.M., the Administrator verified Resident #74's dose of morphine sulfate was not given as scheduled on [DATE] at 8:00 P.M. Review of the policy: IIA2: Medication Administration-General Guidelines (dated [DATE]) revealed medications were administered within 60 minutes of scheduled time, except before, with, or after meal orders, which are administered based on standard, facility mealtimes. The individual who administered the medication dose records the administration on the resident's MAR/eMAR directly after the medication is given. Review of the undated policy: Pain Medication Administration revealed it was the facility's policy to provide guidelines for assessing the resident's level of pain prior to administering non-narcotic or narcotic analgesics. General guidelines the resident's experience of pain is highly individual and subjective. Pain was whatever the resident said it was. Intense pain could result from even minor procedures or surgery. Residents were not at risk for addiction to narcotic analgesics if used as prescribed for moderate to severe pain. Be familiar with the physiologic and behavioral signs of pain. (Note: Visible physiologic and/or behavioral signs of pain do not always accompany the experience of pain.) Residents may be reluctant to report pain due to the belief that pain is a normal part of the aging process or because of a reluctance to bother busy staff members. Acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated after analgesic relief is obtained. The pain assessment consists of gathering both subjective and objective data. Pain assessment tools, as indicated per facility protocol included the use of a one to 10-point pain intensity scale with word modifiers. Procedures included to provide resident privacy, explain the purpose of the assessment to the resident, and obtain subjective information from the resident including the following: a. Location. Ask the resident to point to the site(s) of pain. Utilize a drawing of a human body to assist in identifying the location(s) of pain. Pain Intensity. Provide the resident with ,d+[DATE]-point Pain Intensity Scale and ask the resident to choose the best description of his/her pain experience. Use the Wong-Baker FACES Pain Rating Scale with residents who are cognitively impaired, non-verbal, or who do not speak English. Encourage the resident to use adjectives to describe the quality of pain (sharp, piercing, dull, aching, shooting, burning, intense, agonizing, unbearable, etc.). Onset and Duration. Ask the resident about the time of onset and periods of relief {if any). Ask the resident if there are circumstances or activities that make the pain worse. Ask the resident if there are circumstances or activities that help reduce the pain. Ask the resident if there are accompanying symptoms such as nausea, vomiting, and sensitivity to light and sounds. Obtain objective information through assessment including behavioral responses to (acute) pain included facial wrinkling/grimacing and crying or moaning; evidence of depression, anxiety, fear or hopelessness; effect of pain on activities of daily living; and/or the condition of the site of pain, if appropriate. Evaluate the effectiveness of non-pharmacologic interventions (e.g., repositioning, warm or cold compresses, etc.), administer pain medications as ordered and place the call light within easy reach of the resident. If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them that they may now enter the room. Follow documentation guidelines in the procedure entitled Documentation of Medication Administration. This deficiency represents non-compliance investigated under Complaint Number OH00161035.

Based on observation, medical record review, controlled drug receipt review, policy review, and interview, the facility failed to ensure controlled medications were documented accurately to account for all controlled drugs. This affected two residents (#74, #87) of three residents reviewed for pain management. The census was 94. Findings include: 1. Closed medical record review revealed Resident #74 was admitted on [DATE] with diagnoses including congestive heart failure, wedge compression fracture of T9-T10 vertebra, displaced bimalleolar fracture of right lower leg, and subsequent encounter for closed fracture with routine healing. Resident #74 expired at the facility on [DATE]. Review of the care plan: Hospice (dated [DATE]) revealed Resident #74 was receiving hospice benefits for diagnoses including end stage congestive heart failure, pain, respiratory, dying process and coping/lifestyle/grieving. Goals included to promote comfort with care and daily routine. Interventions included to medicate per physician order, assess pain for location and intensity, and consult for changes with pain. Review of the significant change MDS 3.0 assessment (dated [DATE]) revealed Resident #74 was moderately impaired for daily decision-making, received scheduled, PRN (as needed) and non-pharmacological interventions for pain, complained of frequent pain that occasionally interfered with sleep and activities of daily living, described his pain as severe rated an eight out of 10, was receiving hospice services and had a life expectancy of less than six months. Review of Resident #74's Physician Order dated [DATE] revealed to administer hydrocodone acetaminophen (APAP) ,d+[DATE] milligrams (mg) every eight hours at 12:00 A.M., 8:00 A.M. and 4:00 P.M Review of Resident #74's electronic Medication Administration Record (dated [DATE] and [DATE]) and Resident #74's Controlled Drug Receipt/Proof-Of-Use/Disposition (Controlled Drug Form) labeled Hydrocodone/APAP ,d+[DATE] (mg) one tablet every eight hours (dated [DATE] through [DATE]) revealed the following: a. On [DATE], the electronic Medication Administration Record (eMAR) revealed one hydrocodone ,d+[DATE] tablet was administered at 4:00 P.M.;however, the entry on the Controlled Drug Form dated [DATE] did not reflect a dose of hydrocodone ,d+[DATE] (mg) was removed from the controlled drug card and administered at 4:00 P.M Further review of the Controlled Drug Forms revealed no documentation a dose was removed from the Controlled Drug card and given on [DATE] at 4:00 P.M. and the amount left in the drug card remained the same amount between the [DATE] dose at 8:00 A.M. and the next dose administered at 8:11 P.M b. On [DATE], the eMAR revealed one hydrocodone was administered at 12:00 A.M.; however, the entry on the Controlled Drug Form dated [DATE] at 12:00 A.M. entry was struck through and initialed by the nurse as an error. Further review of the Controlled Drug Forms revealed the drug count remained the same between the dose administered on [DATE] at 10:10 P.M. and the next dose given on [DATE] at 5:53 A.M c. On [DATE], the eMAR revealed one hydrocodone was administered at 4:00 P.M.; however, the entry on the Controlled Drug Form dated [DATE] did not reflect a dose of hydrocodone ,d+[DATE] (mg) was removed from the controlled drug card and administered at 4:00 P.M Further review of the Controlled Drug Forms revealed the drug count remained the same between the dose administered on [DATE] at 2:00 P.M. and the next dose administered at 4:00 P.M. on [DATE]. On [DATE] at 2:54 P.M. an electronic request was made to the Administrator and Director of Nursing (DON) for any additional information regarding the above controlled drug administration and documentation. On [DATE] at 4:08 P.M., an electronic interview with the Administrator referred to a performance improvement plan (dated [DATE]) for a relative facility-identified issue regarding Resident #74 not receiving pain medication as scheduled on [DATE] for an 8:00 P.M. dose and implemented this QAPI to correct. On [DATE] at 4:11 P.M., a second electronic request was sent to the Administrator and the DON to clarify the questions requested regarding the administration of oxycodone and the discrepancies found between documentation on the eMAR and the Controlled Drug Forms. On [DATE] at 4:22 P.M., the Administrator responded to the request stating the performance improvement plan encompassed the facility's previous failure to administer scheduled dose of pain medication as ordered, not any one specific pain medication. An education on timed medication administration and 5 rights to medication administration was initiated on [DATE] as part of this. The education included documentation of medication administration. As of [DATE] at 5:01 P.M., there was no additional information provided regarding the accuracy of the Controlled Drug Forms and documentation on the eMAR for the above examples found in Resident #74's medical record. 2. Medical record review revealed Resident #87 was admitted on [DATE] with diagnoses including end stage renal disease, paroxysmal atrial fibrillation, non-pressure chronic ulcer of right heel and midfoot with fat layer exposed, non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle, neoplasm of unspecified behavior of bone, soft tissue and skin, dependence on renal dialysis, type 2 diabetes mellitus without complications, and Hodgkin lymphoma. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #87 was cognitively intact for daily decision-making, received as needed pain medications and non-pharmacological interventions. The resident stated his pain was almost constant with an intensity of a 10 out of 10 that frequently affected his sleep and day-to-day activities. The resident had one unstageable pressure ulcer, diabetic foot ulcers and an infection of the foot. Review of the electronic Physician Orders (dated [DATE]) revealed Resident #87 was ordered OxyContin (opioid to treat moderate to severe pain) 10 milligrams (mg) extended release every 12 hours at 10:00 A.M. and 10:00 P.M On [DATE] at 11:39 A.M., observation revealed Registered Nurse (RN) #201 dispensed OxyContin 10 (mg) into a medication cup, locked the medication cart and started walking to the opposite side of the 300 unit to deliver the pain medication to Resident #87. The resident took the OxyContin at 11:41 A.M. RN #201 was not observed signing the Controlled Drug Form at the time the medication was dispensed or immediately after administration. On [DATE] at 11:48 A.M., observation of Resident #87's OxyContin 10 (mg) Controlled Drug Form with RN #202 verified RN #201 had not documented the removal of the OxyContin or administration of the medication. (RN #201 was administering medications to another resident during this observation). RN #202 verified controlled substances were to be signed out at the time dispensed on both the eMAR and the Controlled Drug Sheets. On [DATE] at 12:07 P.M., interview with RN #201 verified she had not documented the OxyContin on the Controlled Drug Form at the time of administration, stating she forgot. This deficiency represents non-compliance investigated under Complaint Number OH00161035.

Based on observation, medical record review, policy review, manufacturer guideline review and interview, the facility failed to administer medications as ordered. This affected three (#30, #64 and #270) of three residents observed for medication administration with five errors out of 33 opportunities resulting in an error rate of 15.15%. The census was 92. Findings include: 1. Medical record review revealed Resident #30 was admitted with diagnoses including glaucoma, chronic iridocyclitis left eye, and dry eye syndrome of bilateral lacrimal glands. Review of the careplan: Visual Function (revised 11/22/24) revealed impaired vision related to hypertension, diabetes, glaucoma, chronic iritis left eye and dry eyes. Interventions included to administer medications as ordered. Review of the electronic Physician Orders dated December 2024 included to administer brimonidine 0.2% one drop and dorzolamide-timolol drops 22.3-6.8 mg/mL to the left eye twice a day. On 12/09/24 between 9:29 A.M. and 9:45 A.M., observation revealed Licensed Practical Nurse (LPN) #401 prepared Resident #30's morning medications including brimonidine and forzolamide-timolol. LPN #401 was observed administering one drop of brimonidine to the left eye at 9:43 A.M. and one drop of dorzolamide-timolol to the left eye at 9:45 A.M On 12/09/24 at 10:18 A.M., interview with LPN #401 verified the above observation. Review of the Merative Drug Information: Dorzolamide and Timolol revised 02/01/24 revealed administration instructions including if your doctor ordered two different eye drops to be used together, wait at least five or 10 minutes between the times you apply the medicines. This will help to keep the second medicine from washing out the first one. 2. Medical record review revealed Resident #64 was readmitted on [DATE] with diagnoses including chronic atrial fibrillation, pneumonia and dry eye syndrome of bilateral lacrimal glands. Review of the careplan: At Risk for Impaired Vision (revised 11/04/24) related to aging and dry eye syndrome revealed interventions including to administer medications as ordered. Review of the electronic Physician Orders dated 12/10/24 revealed to administer Refresh Optive (carboxymethyl cellulose-glycern) 0.5-0.9 % one drop to left eye and GenTeal tears 0.1-0.3% one drop to both eyes four times a day. On 12/10/24 between 7:49 A.M. and 8:09 A.M., observation revealed Registered Nurse (RN) #402 prepared Resident #64's morning medications including systane ultra 0.4-0 3% and GenTeal tears 0.1-0.3% to the resident's bedside. RN #402 informed the resident of the eye drops and Resident #64 stated she took systane ultra to both eyes and Genteal Tears to the left eye only. RN #402 administered the eye drops per resident instructions versus the current physician order. Pressure was not observed being applied to the inner tear duct during the above observation. On 12/10/24 at 9:25 A.M., interview with RN #402 verified the above observation and administered what the resident told her instead of following or clarifying the physician order for Resident #64's ordered eye drops. Review of the Specific Medication Administration Procedures: IIB5: Eye Drop Administration (revised May 2020) revealed if multiple medications were prescribed for administration in the same eye at the same time, wait five minutes or the specified length of time recommended per manufacturer's instructions or pharmacy labeling, then repeat procedure. If administering medications to both eyes, use a different gloved finger to apply pressure to the inner tear duct. 3. Medical record review revealed Resident #270 was readmitted on [DATE] with diagnoses including Parkinson's disease, reduced mobility and unspecified constipation. Review of the careplan: Potential for Constipation related to use/side effects of medications, impaired mobility, and history of constipation revised 11/08/24 revealed interventions included to administer medications as ordered. Review of the electronic Physician Orders dated 12/10/24 revealed to administer Senna-S (laxative) two 8.6-50 (mg) tablets twice a day. On 12/10/24 between 8:15 A.M. and 8:27 A.M., observation revealed LPN #403 prepared Resident #270's morning medications including one tablet of Senna-S 8.6-50 (mg). On 12/10/24 at 8:27 A.M., interview with LPN #403 verified the above observation. This deficiency substantiates Complaint Number OH00160307.

Based on observation, medical record review, policy review and interview, the facility failed to maintain care and services for pressure ulcers. This affected one (#38) resident observed for a pressure ulcer dressing change. The facility identified five residents with pressure ulcers. The census was 92. Findings include: Medical record review revealed Resident #38 was admitted on [DATE] with diagnoses including paraplegia and Stage IV (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) pressure ulcer to the left ischium. Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #38 was cognitively intact for daily decision-making and had a Stage IV pressure ulcer. Review of the care plan: Pressure Injury (revised 10/10/24) revealed to complete treatments as ordered. Review of the electronic Physician Orders dated December 2024 revealed left gluteal cleft cleanse with Dakin's, apply Dakin's soaked kerlix gauze and cover with dressing. The treatment was to be completed daily. On 12/09/24 between 2:53 P.M. and 3:12 P.M. observation of Resident #38's left ischium pressure ulcer dressing change revealed the following: Registered Nurse (RN) #398 entered Resident #38's room with gathered pressure ulcer dressing change supplies. RN #398 prepared a clean field on the overbed table with prepoured Dakin's Solution 0.125%, kerlix, gauze, hand sanitizer and gloves. RN #398 removed a pair of bandage scissors from his scrub top pocket and cleaned the scissors with an alcohol swab. RN #398 used the bandage scissors to cut the kerlix and returned the bandage scissors to his scrub top pocket. Resident #38 was laying in bed and was assisted to his right side to expose the left ischium. The left ischium was not covered with a dressing, wound packing could be observed coming from the wound and a drainage collection bag with yellow urine was observed under the resident. RN #398 verified a dressing was ordered to cover the wound to absorb drainage, protect the wound and the resident should not have been laying on the drainage collection bag. RN #398 looked in the bed and through the linens and no dressing was found. RN #398 removed the packing from the wound and cleaned the wound. RN #398 removed his soiled gloves, used hand sanitizer, and applied new gloves. RN #398 soaked the cut kerlix roll in a cup of Dakin's solution and then packed the wound; however, there was an excess of Dakin's soaked gauze extending from the wound. RN #398 put his gloved hand into his scrub shirt pocket, removed the bandage scissors and used the scissors to cut the kerlix. At the time of the observation Assistant Director of Nursing #404 asked RN #398 if those were clean and he stated yes. RN #398 did not removed his gloves/hand wash after putting his gloved hand in his scrub shirt pocket to obtain the bandage scissors. RN #398 covered the wound with a dermaright dressing, assisted the resident in bed, moved the table next to the bed and gathered supplies with the same gloved hands. On 12/09/24 at 3:12 P.M., interview with RN #398 verified the above. On 12/09/24 at 3:25 P.M., interview with RN #400 verified RN #398 informed her no dressing was covering the wound and no dressing was found in the resident's bed. RN #400 verified nurse's bandage scissors were contaminated once he put them in his scrubs pocket and should have been cleaned prior to use. Review of the undated policy: Wound Care revealed the facility policy was to provide guidelines for the care of wounds to promote healing. Procedure included establishing a clean field and placing all items to be used during the procedure on the clean field, position the resident, cleanse hands, put on exam gloves, remove old dressing, discard old dressing, wash hands, put on gloves, cleanse wound per orders. wash hands, apply gloves, apply dressing per order, discard disposable items, and wash hands. This deficiency represents non-compliance investigated under Complaint Number OH00160319.

Based on observations, review of the medical record and interview with staff the facility failed to ensure the air mattress for Resident #26 was set at the proper setting for her weight and the treatment for Resident #55 was completed as ordered. This affected two residents ( #26 and #55) of four residents reviewed for wounds. The facility census was 99. Findings included: 1. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, muscle weakness, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypertension, stage four pressure ulcer of sacral region, neuromuscular dysfunction of bladder, arthritis, diabetes, (DM) hypothyroidism, moderate protein-calorie malnutrition, bladder-neck obstruction, dysphagia, pruritus, peripheral vascular disease (PVD), generalized anxiety disorder, anemia, bipolar disorder, major depressive disorder, restless leg syndrome, breast cancer and gastro-esophageal reflux disease (GERD). Review of the care plan dated 06/05/23 revealed Resident #26 had a pressure injury to her coccyx related to impaired mobility, PVD, diabetes, bowel incontinent, COPD, breast cancer, poor nutrition, friction concerns, and shearing concerns. Interventions included an air mattress to her bed. Review of the physician's order dated 07/07/24 revealed Resident #26 had on order for an air mattress to the bed, check the placement and function every shift. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had intact cognition. Review of Resident #26's weight dated 11/12/24 revealed a weight of 118.6 pounds. Review of the operations manual for the Drive alternating pressure low air loss mattress revealed on page seven, step six of the operation instruction revealed the resident's weight must be determined and to set the control knob to the weight setting on the control unit. Observation of the air mattress setting for Resident #26 on 11/12/24 at 2:40 P.M. revealed the air mattress was set at 300 pounds. During an interview at the time of the observations, Registered Nurse #504 confirmed the settings were incorrect and Resident #26 did not weigh 300 pounds. On 11/13/24 at 2:42 P.M. an interview with Resident #26 revealed she weighed 118 pounds the last time they weighed her. 2. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE]. Diagnoses included encephalopathy, displaced fracture of base of neck of left femur, dementia, osteoarthritis, tremors, hypertension, abdominal aortic aneurysm, benign prostatic hyperplasia, and chronic kidney disease. Review of the September 2024 physician's orders revealed Resident #55 had an order dated 08/28/24 to cleanse the buttocks with soap and water, pat dry, apply Venelex ointment (wound healing ointment) twice daily, cleanse coccyx with saline, an order dated 09/17/24 to apply Venelex ointment to the coccyx and apply a foam dressing once daily, an order dated 09/17/24 to clean the left hip with normal saline and apply a dry dressing once daily, and an order dated 09/17/24 to cleanse the right forearm with normal saline, pat dry and apply border foam every three days ( not due until 09/20/24). Review of the Customer Alert Notice dated 09/20/24 revealed the family of Resident #55 was concerned his treatments were not being completed as ordered. The resolution to the concern revealed an employee performance evaluation was completed per the facility policy. Review of the Personal Action Form dated 09/20/24 revealed Registered Nurse (RN) #520 was suspended pending investigation as of 09/20/24. The employee stated she got busy with a fall and forgot to complete Resident #55's treatments. The employer statement revealed RN #520 confirmed to the Director of Nursing she did not complete a treatment for Resident #55 and upon reviewing the Treatment Administration Record (TAR) for 09/19/24, RN #520 had signed off she had completed the treatments for Resident #55. Review of the September 2024 TAR revealed RN #520 had signed off Resident #55's treatments for 09/19/24 as being completed. Review of the Quarterly MDS dated [DATE] revealed Resident #55 has moderately impaired cognition. On 11/13/24 at 4:47 P.M. an interview with the Director of Nursing revealed on 09/20/24 she received a complaint from the family of Resident #55 that his treatments were not completed as ordered on 09/19/24. The Director of Nursing spoke to RN #55 and confirmed RN #55 had not completed the treatments for Resident #55 on 09/19/24. RN #55 said there had been a resident fall and another incident and she ran out of time. The Director of Nursing confirmed RN #55 signed the treatments off on the TAR as completed. This deficiency represents non-compliance investigated under Complaint Number OH00159414.

Based on record review, family interview, and staff interview, the facility failed to ensure a resident, who was known to have multiple dislodgements of his Percutaneous Endoscopic Gastrostomy (Peg) tube, had an abdominal binder in place as ordered to prevent any accidental dislodgements. This affected one resident (#4) of three residents reviewed for feeding tubes. Findings include: Review of Resident #4's medical record revealed he was admitted to the facility on [DATE] with the diagnoses of a traumatic brain injury due to a fall, cognitive communication deficit, hemiplegia (paralysis) and hemiparesis (weakness) following a stroke affecting the left non-dominant side, dysphagia, and gastrostomy status (surgical placement of a tube through the abdominal wall into the stomach for the purposes of providing nutritional supplements). Review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. He was not noted to have displayed any behaviors, nor was he known to reject care during the seven day assessment period. He had a functional limitation in his range of motion on one side of his upper and lower extremities. He was coded on the MDS as having the use of a feeding tube and received 51% or more of his calories through his feeding tube. Review of Resident #4's active care plans revealed he had a care plan in place for having the use of a tube feeding for the primary source of nutrition due to dysphagia. The interventions included the need for an abdominal binder to be in place related to frequent tube displacements. The intervention had been in place since 09/30/24. Review of Resident #4's progress notes revealed a nurse's note dated 09/26/24 at 1:00 P.M. that indicated the nurse entered the resident's room to administer his afternoon meds. His Peg-tube was noted to be dislodged and was lying on the resident's abdomen with the balloon deflated. The nurse attempted to reinsert a new Peg-tube unsuccessfully. The physician was notified and a new order was obtained to send the resident to the emergency room to replace his Peg-tube. He returned to the facility on [DATE] at 4:31 P.M., after his Peg-tube had been replaced. Review of Resident #4's progress notes revealed a nurse's note dated 09/28/24 at 2:35 P.M. that indicated the nurse went into the resident's room to administer medication to resident and flush his Peg-tube. The nurse noticed that the Peg-tube was not secured in place and was found out of placement. The physician was contacted and gave an order to transfer the resident to the emergency room . The resident returned to the facility on [DATE] at 9:00 P.M. with a new Peg-tube placed and an abdominal binder on. Further review of Resident #4's progress note revealed a nurse's note dated 10/13/24 at 6:17 A.M. that indicated the nurse was called into the resident's room by a nursing assistant and was notified that the resident's Peg-tube was not in place and was leaking all over his bed. The nurse assessed the resident's abdomen and noted the Peg-tube to be out of place. The nurse unsuccessfully attempted to place a sterile Foley catheter into the Peg stoma in an effort to maintain patency. A new order was received to send the resident out to the hospital. He did not return to the facility until 10/16/24 at 11:00 A.M. Review of the treatment administration records (TAR's) for October 2024 revealed the nurses were initialing to indicate the abdominal binder was in place every shift. The nurse working 10/13/24, when the Peg-tube was dislodged for the third time, indicated the abdominal binder was in place during the evening shift. On 10/22/24 at 10:08 A.M., an interview with Resident #4's representative revealed the resident has had his Peg-tube dislodged several times while in the facility. She stated they were supposed to use an abdominal binder, but she was told it had been misplaced when the Peg-tube was dislodged for the third time. On 10/22/24 at 1:25 P.M., an interview with Licensed Practical Nurse (LPN) #100 confirmed she was the nurse working the night of 10/13/24, when Resident #4's Peg-tube was dislodged for the third time. She stated, when she attached him to his enteral feeding that night at 8:00 P.M. and when she did most of her flushes through the night, everything was fine. It was not until she went in to do the last flush for the night that she noted it (Peg-tube) was out and the enteral feeding had leaked everywhere. She reported the Peg-tube was completely dislodged at that time and was not in place. She was asked what they did to try to prevent the Peg-tube from being dislodged. She stated they were supposed to have an abdominal binder on the resident, but he did not have one on that night. The abdominal binder was not in place when she started her shift. They could not find the abdominal binder anywhere in his room and she was not aware they had any others in the central supply room that could have been used. She just found out a couple of days ago that there were extra abdominal binders in the central supply room if needed. She reported the abdominal binder was effective when used to prevent an accidental dislodgement. She felt the resident's peg tube likely became dislodged due to him getting it caught under his arm when moving in bed. She did not feel it was intentional on the resident's part to pull it out. This deficiency represents non-compliance investigated under Master Complaint Number OH00158726.

Based on record review, observation, and staff interview, the facility failed to ensure a resident received the appropriate eating equipment and utensils as ordered during a meal to aid the resident in being able to feed himself. This affected one resident (#4) of three residents observed for eating/ feeding assistance. Findings include: Review of Resident #4's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included a traumatic brain injury secondary to a fall, hemiplegia (paralysis) and hemiplegia (weakness) affecting his left non-dominant side, dysphagia, cognitive communication deficit, muscle weakness, and need for assistance with personal care. Review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had unclear speech and was usually able to make himself understood and was usually able to understand others. He had moderately impaired vision without the use of corrective lenses. His cognition was severely impaired and he was not known to display any behaviors or reject care. He had a functional limitation in his range of motion on one side of his upper and lower extremities. Review of Resident #4's active care plans revealed he had a care plan in place for an impaired ability to perform or participate in daily activities of daily living (ADL) care related to a stroke, traumatic brain injury, left hemiparesis, dysphagia, and dysarthria. The goal was for the resident to participate with ADL's as much as possible and for him to be neat in appearance daily. He was also to maintain his current level of ADL's every day, without a decline by the target date. The interventions included the use of built-up foam utensils and a sip cup with handles for all meals. Review of Resident #4's physician's orders revealed he was on a low concentrated sweet diet at a pureed consistency with honey thick liquids. He was to receive a tray from the kitchen for lunch and supper. The orders also specified the use of built-up foam handled utensils and sip cups with handles for all meals. That order originated on 10/17/24. On 10/21/24 at 5:20 P.M., an observation of Resident #4 noted him to be sitting up in bed with his supper tray on the bedside table in front of him. He was served a pureed diet as ordered and had thickened liquids in two separate cups. He drank the liquids, but had not touched his food. He was noted to have regular eating utensils on his tray and not the built-up foam handled utensils as ordered. He was also noted to have been served his thickened liquids in regular cups and not two handled sip cups as ordered. His meal ticket on his tray specified he was to have black foam handled utensils and a two handed sip cup during for his meals. Findings were verified by Licensed Practical Nurse (LPN) #150. On 10/21/24 at 5:26 P.M., an interview with LPN #150 revealed Resident #4 was to be on a pureed diet with honey thickened liquids. He stated the resident received a tube feeding at night that ran from 8:00 PM to 8:00 AM. He was asked how much assistance the resident needed for eating and the nurse replied it was mixed. They encouraged him to do it himself, but the aides would help as needed. He has seen him eat and indicated the resident did have trouble getting food to his mouth and would make a mess. He also indicated the resident was supposed to have the use of heavy thick grip utensils, but stated the resident used regular cups. He was not aware that two handled sip cups were to be used for all his meals. He verified the resident's orders did include the need for built-up utensils and a two handed sip cup with meals. He had known the resident to not have received built-up utensils or a two handed cup at times in the past depending on who was working in the kitchen. He acknowledged the resident's meal ticket clearly specified the resident was to receive built-up utensils and a two handed sip cup for his meals. He further acknowledged the staff member passing the trays should be reviewing the meal ticket when the tray was delivered to ensure the resident received the appropriate diet and eating/ equipment and utensils were provided as needed. This deficiency represents incidental findings of non-compliance investigated under Master Complaint Number OH00158726.

Based on self-reported incident review, fire drill review, policy review and interview, the facility failed to submit a self-reported incident (SRI) for possible neglect after staff were observed sleeping on the night shift. This affected 27 residents (#65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #230) residing on Unit 3. The census was 91. Findings include: Review of the facility Self-Reported Incidents (SRIs) revealed no allegations of abuse, neglect or misappropriation had been reported to the Ohio Department of Health (ODH) since 08/20/24. On 09/19/24 at 5:07 A.M., interview with State tested Nurse Aide (STNA) #203 revealed she was not aware of staff sleeping while at work. On 09/19/24 at 5:09 A.M., interview with Licensed Practical Nurse (LPN) #200 (agency staff) stated she had discovered a STNA sleeping and had handled the situation stating she educated the staff member. The STNA stated she just had her eyes closed so she told the STNA not to close their eyes like that again. LPN #200 stated she did not remember the name of the STNA and did not report this to the nursing supervisor or the Administrator. LPN #200 stated this occurred about a month ago and she was not aware of staff sleeping since that time. On 09/19/24 at 5:29 A.M., interview with STNA #216 stated about a month or two ago she observed STNA #204 sitting in a chair on the night shift with her eyes closed and asleep. STNA #216 informed her nurse of the observation and the nurse also observed STNA #204 sleeping. On 09/19/24 at 7:10 A.M., interview with the Administrator revealed staff were not to be sleeping while on duty. The Administrator stated there had been an incident a few days earlier of staff reportedly sleeping. The Director of Nursing (DON) was notified and she had the nurses check the units and they reported to the DON that no staff were asleep. Review of a Facility Investigation Packet (undated) revealed the following: a. All Staff Meeting (STNAs) dated 09/17/24 included topics of sleeping on a shift. b. Two electronically written statements (undated) signed by the DON of interviews with LPN #200 and LPN #202 that stated at 1:00 A.M. it was reported that STNA's were sleeping on a unit but when they responded to the hallway, they did not see anyone sleeping. c. Review of the Fire Drill Form dated 09/17/24 at 2:00 A.M. revealed a silent fire drill was conducted. The simulation situation was smoke coming out of an outlet in the hallway on Unit 1. A head count was completed and resident doors were closed. No problems were noted on the Drill Overview. d. Review of the Event Statement Form - QAA Document (09/17/24) revealed Maintenance Assistant #205 was conducting a silent fire drill on 09/17/24 at 2:00 A.M. when he came on the 300 hall, STNA #203, STNA #204 and LPN #201 were asleep on the couch and he had to wake them up to sign the Fire Drill Form. Maintenance Assistant #205 stated there was also a resident still up walking around at the time of the observation. The statement did not indicate the name of the resident. e. There were no written staff statements including LPN #201, STNA #203 or STNA #204 in the packet for review. f. There was no documentation regarding residents residing on Unit 3 for any signs/symptoms of neglect after the discovery of staff sleeping. On 09/19/24 at 8:50 A.M., interview with the DON revealed Maintenance Assistant #205 had called off for today. At 9:05 A.M., a phone call was made to Maintenance Assistant #205; however, there was no answer. At 9:13 A.M., a phone call was made to STNA #204; however, there was no answer. On 09/19/24 at 8:59 A.M., interview with Maintenance Coordinator (MC) #208 revealed Maintenance Assistant #205 was stripping and waxing the floor in the therapy room on the night shift and was asked to complete a silent fire drill. Maintenance Assistant #205 had informed him that he had found staff sleeping at the time of the drill and that it had been reported to the DON. On 09/19/24 at 9:20 A.M., interview with the Administrator stated she interviewed Maintenance Assistant #205 since the incident but had not documented the interview but he stated the same story as in his written statement. He did add that LPN #201 and STNA #203 were asleep on one couch and STNA #204 was asleep on another couch and he had to wake them up to sign the fire drill sheet. The Administrator stated when staff went back to check on the Unit 3 (after Maintenance Assistant #205 observed the above staff sleeping), no staff were observed to be asleep; however, the Administrator did verify they had already been awakened by Maintenance Assistant #205 to sign the training sheet. The Administrator stated she had not filed a Self-Reported Incident (SRI) for the above incident because she felt this was an Employee Conduct concern and did not rise to the level of neglect. The Administrator verified she did not have her investigation completed to date and was unaware of other staff sleeping on the job. The Administrator verified the time of the DON's written statements was an hour prior to staff being found sleeping by Maintenance Assistant #205 and if staff were sleeping, they were not providing the care and services to residents. On 09/19/24 at 10:57 A.M., interview with the Administrator stated Maintenance Assistant #205 did not allege neglect of care or services and the facility had not received any complaints from family regarding neglect; therefore, she did not feel it needed to be reported as a SRI. Review of the policy: Abuse, Mistreatment, Neglect, Misappropriation of Resident Property and Exploitation (11/01/26) revealed to investigate all allegations, suspicions and incidents of Abuse, Neglect, Misappropriation of Resident Property and Exploitation, and injuries sustained by its residents. Facility staff should immediately report all such allegations to the Administrator and the ODH in accordance with the procedures in this policy. This deficiency represents incidental findings of non-compliance investigated under Complaint Number OH 00157767.

Based on observation, medical record review, policy review and interview, the facility failed to maintain infection control practices during incontinence care and failed to ensure staff wore face masks during a COVID-19 outbreak. This affected one resident (#70) of two residents observed for incontinence care and had the potential to affect 31 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30 and #31) residing on Unit 1 during the COVID-19 outbreak. The census was 91. Findings include: 1. On 09/19/24 at 4:58 A.M., observation of the facility front entrance door revealed a sign indicating the facility was currently under a COVID-19 Outbreak and masks should be worn. A box of face masks was available to use at the receptionist window. On 09/19/24 at 5:05 A.M., observation of Unit 1 revealed two licensed practical nurses (LPN's) (#200, #202) sitting at the nurses' desk and STNA (#203) walking down the hallway. Licensed Practical Nurse (LPN) #200 and #202 did not have a face mask on or within arms reach, State tested Nurses Aide (STNA) #203 was observed with a face mask looped around her ears; however the mask itself was positioned down around her neck. At the time of the observation, LPN #200, LPN #202 and STNA #203 verified staff were to be wearing face masks due to the current COVID-19 outbreak. On 09/19/24 at 7:10 A.M., interview with the Administrator verified staff should have been wearing face masks due to the current COVID-19 outbreak. 2. Medical record review revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and heart failure. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #70 was frequently incontinent of urine. On 09/19/24 between 5:34 A.M. and 6:02 A.M., observation of Resident #70's incontinence care revealed STNA #215 gathered supplies, washed her hands, and applied gloves. Resident #70's incontinence product was removed, observed to be urine soaked and STNA #215 put the incontinence product on the bare floor without a barrier. STNA #215 cleansed the resident with three disposable incontinence wipes and then placed them on the floor with the soiled incontinence product. STNA #215 placed a clean incontinence product on the resident, covered the resident with a blanket, picked up the soiled incontinence product and wipes off the floor and placed them into a trash bag. STNA #215 left the room with the trash bag, walked the trash to the central bath and removed her gloves. On 09/19/24 at 6:02 A.M., interview with STNA #215 verified she placed the urine soiled incontinence products on the floor without a barrier, did not change her gloves during incontinence care, and did not remove her soiled gloves prior to leaving the resident's room to dispose of the trash. On 09/19/24 at 7:10 A.M., interview with the Administrator verified soiled incontinent products should not be placed directly on the floor without a barrier. Review of the undated policy: Hand Washing/Hand Hygiene revealed the policy was to ensure proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infection. Hand washing was to occur after contact with blood, body fluids, secretions, mucous membranes, or non-intact skin and the use of gloves does not replace hand washing. This deficiency represents incidental findings of non-compliance investigated under Complaint Number OH00157767. This deficiency is evidence of continued non-compliance from the survey completed 09/13/24.

Based on review of the medical record, review of hospital discharge orders, policy review, and interview, the facility failed to ensure special respiratory equipment was available for resident use. This affected one resident (#94) of four residents reviewed for admission rights. The facility census was 93. Findings include: Closed record review revealed Resident #94 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, pulmonary fibrosis, and hyperlipidemia. Review of hospital records revealed Resident #94 had been identified as having significant risk for obstructive sleep apnea and discharge orders included but were not limited to CPAP machine with adult mask and tubing while sleeping. The order stated another medication with the same name was removed, continue taking this medication and follow the directions you see here. Review of an admission minimum data set (MDS)assessment completed on 08/13/24 revealed Resident #94's cognitive status remained intact. The resident had no behaviors, and had shortness of breath or trouble breathing with exertion and when lying flat. Review of the resident's medical record revealed Resident #94 received the CPAP on 08/19/24 although it was originally ordered on 08/06/24 at the time of the resident's admission to the facility. Review of orders revealed Resident #94 had an order in place (dated 08/19/24) to encourage her to wear CPAP when sleeping and during naps with CPAP settings of 10cm H2O and a full mask. The resident had an order dated 08/19/24 for prior to putting on, to check CPAP reservoir and fill with distilled water to max fill line, after removing in the morning cleanse mask and tubing with soap and water then allow to air dry. Review of the medical record revealed Resident #94 discharged to home from the facility on 08/22/24. Interview on 09/05/24 at 11:41 A.M. with Resident #94's family revealed early in her stay, they had informed Licensed Practical Nurse (LPN) #107 that Resident #94 required a CPAP and asked if they could bring her personal CPAP in from home, which was declined due to infection control concerns. Resident #94's family stated LPN #107 stated she would take care of it but Resident #94 did not receive a CPAP until she was about to go home. Interview on 09/10/24 at 2:04 P.M. with Director of Nursing (DON) revealed the referrals from the hospital are reviewed at the corporate level, then the information from the referral staff will need emailed to the DON to ensure items are ordered for residents. The DON stated in the email she received from corporate, there was not a request for Resident #94 to receive a CPAP. The DON stated once residents have been admitted from the hospital, she reviews the hospital after visit summary to ensure all items are in place. The DON confirmed the after visit summary had an order for Resident #94 to have a CPAP but the DON stated it was inaccurate and there was another after visit summary in the medical record somewhere and she would find it. The DON confirmed she was not able to locate the correct after visit summary. Review of an undated policy titled Admissions to the Facility revealed prior to the time of the admission, the resident's attending physician must provide the facility with the information needed for the immediate care of the resident, including orders for diet type, medication orders, and routine care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed interdisciplinary care plan. This deficiency represents non-compliance investigated under Complaint Number OH00157065, Complaint Number OH00157063, Complaint Number OH00157053.

Based on medical record review, observation, staff interview, and facility policy and procedure review, the facility failed to ensure proper infection control techniques were followed during pressure ulcer wound care. This affected one resident (#23) of three residents reviewed for pressure ulcers. The census was 93. Findings include: Review of Resident #23's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included Parkinson's Disease, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), high blood pressure and diabetes. Review of the quarterly MDS dated [DATE] revealed her cognition was intact, she had an indwelling urinary catheter and was incontinent of bowel. A Stage IV pressure ulcer was identified. Review of the Physicians orders dated 01/30/24 revealed an order to cleanse the wound with 1/4 strength Dakin's solution, pat dry, apply hydrofiber with silver, and cover with clean dry dressing once a day and when needed (PRN). On 09/09/24 at 11:05 A.M. observation of a dressing change to Resident #23 by Licensed Practical Nurse (LPN) #153 revealed the LPN washed his hands and put on gloves, he removed the old dressing with a small amount of serosanguineous drainage. LPN #153 them removed his gloves and washed his hands and put on new gloves. LPN #153 cleansed the wound with Dakins (a diluted bleach solution used to prevent and treat skin and tissue infections) soaked gauze, then patted dry with a clean gauze. LPN #153 then removed his gloves and without washing his hands put on new gloves. LPN #153 cleaned his scissors with an alcohol pad and cut the hydrofiber (absorbent material that transforms into a gel on contact with wound fluid. It locks in exudate, traps bacteria, contours to wound bed, and maintains moisture balance in the wound bed) and placed in the wound and covered with a foam dressing. LPN #153 then removed his gloves and gathered supplies and left the room. Interview with LPN #153 at 11:12 A.M. verified he had not washed his hands in between glove changes. Review of the Wound Care policy and procedure (not dated) revealed after cleansing the wound wash your hands and put on exam gloves prior to applying ointment/dressing per physician orders. This deficiency represents incidental findings of non-compliance investigated under Complaint Number OH00157065, Complaint Number OH00157063, and Complaint Number OH00157053.

Based on observations, review of the facility meal spreadsheet, interview with staff and review of the facility policy the facility failed to ensure the residents were served the proper portion size of meat. This had potential to affect all residents receiving meals from the kitchen except for nine residents (Resident #1, #5, #14, #51, #61, #80, #81, #86 and #88) the facility had identified as nothing by mouth, mechanical soft or pureed diets. The facility census was 96. Findings included: Review the spreadsheet for 08/05/24 revealed the residents were to receive a three-ounce slice of teriyaki pork. Observation of meal service on 08/05/24 from 11:15 A.M. to 12:00 P.M. revealed the facility was serving precooked teriyaki pork however the sliced pieces for the regular texture diets (diets that were not mechanical soft or pureed) looked smaller than a three ounce portion. Dietary Coordinator #300 weighed a piece of pork and it only weighed 1.5 ounces. She verified at this time the pork was not three ounces. [NAME] #301 checked all the meal trays on the already filled Unit 3 food cart and the pork slices only weighted between one ounce to 2.5 ounces. [NAME] #301 placed more teriyaki pork on the plates. Review of the facility policy titled, Therapeutic Diet Spreadsheet, dated 01/15 revealed a therapeutic diet spreadsheet would be available and followed at all meals. This would be used as a guideline for accurately serving all therapeutic and texture modified diets that havephysician's orders for the same. This deficiency represents non-compliance investigated under Complaint Number OH00154938 and OH00155452.

Based on review of the medical record and interview with the staff the facility failed to ensure a wound vacuum (vac) for Resident #58 was changed as ordered, and medications were administered in a timely manner for Resident #96. This affected one resident ( Resident #58) of three reviewed for wounds and one resident ( Resident #96) of three reviewed for medications. The facility census was 96. Findings included: 1. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. Diagnoses included acute osteomyelitis to the left ankle and foot, left foot fracture, thoracic aortic aneurysm, diabetes, right foot amputation, and Charcot [NAME] Tooth Disease. Review of the Five-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #58 had intact cognition. Review of the August 2024 physician's order revealed Resident #58 had an order to cleanse the left heel. Apply black foam as primary dressing, apply the wound vac at 125 millimeters of mercury (mmHg) as the outer dressing once a day on Tuesday, Thursday and Saturday from 7:30 A.M. to 7:30 P.M. dated 07/13/24. Review of the August 2024 treatment administration record revealed on 08/01/24 Resident #58's wound vac to his left heel was not change as scheduled. The comment note indicated the previous shift was to complete. Review of the progress notes from 07/31/24 to 08/02/24 revealed no documentation as to why the wound vac of Resident #58 was not completed as ordered on 08/01/24. On 08/05/24 at 2:50 P.M. an interview with Resident #58 revealed this was the second time he had been at the facility. He stated the first time the facility was great, very attentive. He stated this time he cannot get any care. He stated they are supposed to change his wound vacuum on Tuesday, Thursday and Saturday but they did not change it on Thursday. He stated he asked first shift three times to change it and they did not. He stated the day shift nurse told him he would be in later to do it but then he came in and stated he would not have time and he would let the second shift know they needed to do it. He stated the second shift nurse came into give him medication and he asked her if they told her she needed to change his wound vac and she stated they did and she would be back later to completed it but she never did. He stated he was leaving today because he was not staying at the facility another day. On 08/06/24 at 10:16 A.M. an interview with Registered Nurse #305 confirmed on 08/01/24 he did not get the wound vac for Resident #58 changed due to running out of time. He stated he was training a new hire, had two new admissions, and did not anticipate how long it was going to take to complete the dressing change for a different resident, which it took almost an hour to complete. He stated he spoke to Resident #58 and he was okay with second shift changing his wound vacuum. He stated when he came in the next day his wound vacuum still had not been changed so he changed it. He verified he ran out of time 08/01/24 to change it and there was no documentation he had changed it on 08/02/24. 2. Review of the medical record revealed Resident #96 was admitted to the facility on [DATE]. Diagnoses include fracture of the left femur, heart failure, hypertension, polyneuropathy, chronic pain, osteoporosis, major depressive disorder, hypothyroidism, hyperlipidemia, gout, cognitive communication deficit, and muscle weakness. She was discharged to home on 06/18/24. Review of the Admission MDS 3.0 assessment dated [DATE] revealed Resident #96 had intact cognition and received scheduled pain medications. Review of the daily pain assessments from 05/25/24 to 06/15/24 revealed Resident #97's pain level ranged from zero to eight. Review of the physician's orders revealed Resident #96 had an order for oxycodone-acetaminophen 3/325 milligrams every six hours at 8:00 A.M., 2:00 P.M., 8:00 P.M., and 2:00 A.M. dated 05/25/24. Review of the June 2024 Medication Administration record revealed the oxycodone-acetaminophen 3/325 milligrams (mg) every six hours was administered late on 05/26/24 3:05 P.M. for 2:00 P.M. and on 05/30/24 at 3:27 A.M. for 2:00 A.M. Review of the July 2024 Medication Administration record revealed the oxycodone-acetaminophen 3/325 mg every six hours was administered late on 06/05/24 at 9:57 P.M. for 8:00 P.M., on 06/06/24 at 3:02 A.M. for 2:00 A.M., at 06/07/24 at 12:57 A.M. for 06/06/24 at 8:00 P.M. (almost five hours late), on 06/07/24 at 3:03 A.M. for 2:00 A.M., on 06/07/24 at 9:56 P.M. for 8:00 P.M., on 06/08/24 at 3:23 A.M. for 2:00 A.M., and on 06/15/24 at 3:42 A.M. for 2:00 A.M. On 08/06/24 at 8:45 A.M. an interview with the Director of Nursing confirmed the oxycodone-acetaminophen 3/325 mg for Resident #96 was documented as administered late of several days. This deficiency represents non-compliance investigated under Complaint Number OH00155452 and OH00156251.

Based on review of the medical record, review of the Self-Reported Incident (SRI), interview with staff, and review of the facility policy the facility failed to prevent the misappropriation of medication for Resident #66 by facility staff. This affected one resident ( Resident #66) of three reviewed for medications. The facility census was 96. Findings included: Review of the medical record revealed Resident #66 was admitted to the facility on [DATE]. Diagnoses included dementia, chronic obstructive pulmonary disease, cerebral infarction, atrial fibrillation, polymyalgia, bipolar disorder, personality disorder, opioid disorder, generalized anxiety disorder, restless leg syndrome, Crohn's disease, malignant neoplasm of the colon, migraines, and xerosis cutis. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #66 had moderately impaired cognition. Review of the August 2024 physician orders revealed Resident #66 had an order for sumatriptan 100 milligrams as needed for migraines. The original order was from 11/30/23. Review of the SRI date 05/01/24 revealed Staff Coordinator #310, reported an allegation of possible misappropriation of resident medication by a facility nurse. The Administrator was notified and the allegation was reported to the Ohio Department of Health. The alleged perpetrator was immediately suspended and another alleged perpetrator identified through interviews was suspended immediately upon discovery. The alleged victim was interviewed, her documents and records were reviewed with no concerns identified. Resident #66 remained at her baseline. The in-house residents were interviewed with no concerns identified. All staff were educated on Abuse, Neglect and Misappropriation policy. All nurses were required to complete education on how to prevent medication errors and ethics/corporate compliance. Review of the signed witness statement from Staff Coordinator #310 dated 05/01/24 revealed Registered Nurse (RN) #311 came into her office around 7:30 A.M. regarding another issue. Staff Coordinator #310 asked RN #311 how her headache was from the day before and RN #311 told her she still had it. RN #311 indicted to her she thought about calling off due to the headache but did not want to short the facility a nurse on night shift. RN #311 stated a resident had a medication that helped her and she had a prescription for the same medication so she took one of her pills. RN #311 left her office and clocked out for the day and she notified the Administrator immediately. Review of the typed unsigned statement dated 05/01/24 conducted by the Director of Nursing and Administrator revealed they interviewed RN #311. RN #311 stated she had a headache for the past few days and was unsuccessful in getting it to subside. She stated she came to work on 04/30/24 with a headache and as the night went, she stated it got worse, She stated she tried multiple ways to relieve it. The Administrator asked RN #311 if headaches were common for her and RN #311 stated they used to be but not currently. She stated she could usually get them to go away with Excedrin. The Administrator asked RN #311 if she had a prescription for migraine medication and RN #311 stated she had a prescription for sumatriptan but she did not have any at the moment. RN #311 went on to say she had been overwhelmed and could not get any relief and it was suggested to her that there was Imitrex (sumatriptan) in Unit 2. She stated she did not want to do it but she could not function. RN #311 stated she went over to Unit 2 and asked the nurse working if there was Imitrex she could take and she gave her one and she took it. RN #311 stated it did not occur to her it would be misappropriation because it was not a narcotic. RN #311 clarified the staff member who suggested there was Imitrex on Unit 2 did not state it was a resident's medication and did not state a resident's name. She also clarified the staff member was the nurse she would have relieved on 04/30/24 Licensed Practical Nurse (LPN) #312. She stated she was telling LPN #312 how she had a migraine and was feeling really bad and nothing was working. She verified at this time she knew it was a resident's medication she was taking. She stated the nurse on Unit 2 did not have to look the medication up she just got it out of the medication cart and gave it to her. She stated she thought the nurse was aware she gave her and resident's medication. RN #311 expressed deep remorse for her actions. RN #311 was informed she was suspended pending investigation. Review of the typed unsigned statement dated 05/01/24 conducted by the Director of Nursing and Administrator revealed they interviewed RN #313. RN #313 was informed it was reported RN #311 had come over to Unit 2 the night before and asked for a medication from her medic cart and if she had any recollection of it. RN #313 stated RN #311 had asked her for Imitrex. RN #313 stated she assumed it was for a resident because you needed a prescription for it. She stated RN #311 never really stated who it was for but she never seen her ingest it either. She believed it was for another resident. Review of a letter from the pharmacy dated 05/03/24 revealed the pharmacy replaced the dose of sumatriptan 100 milligrams at no cost to the resident. Review of the Ohio Board of Nursing (OBN) complaint form dated 05/08/24 revealed the facility filed a complaint concerning the incident with the OBN against RN #311. On 08/07/24 at 11:18 A.M. an interview with the Administrator verified RN #311 took medication from Resident #66 and she was terminated for misappropriation. She stated reports were filed with the OBN and police. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Misappropriation of Resident Property, and Exploitation, dated 11/01/16 revealed the facility would not tolerate mistreatment, abuse, neglect. Misappropriation of resident property, or exploitation of its residents. Misappropriation of resident property was the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. This deficiency represents noncompliance as an incidental finding during the investigation of Master Complaint Number OH00156251.

Based on closed record review, review of a fall investigation, review of hospital records, facility policy review and interview, the facility failed to ensure timely identification of changes in resident condition status post fall. Actual Harm occurred on 01/25/24 at 12:15 A.M. when Resident #288, who had confusion/ dementia and was admitted status-post left hip replacement sustained an unwitnessed fall in her bathroom/shower room with complaints of pain and signs of injury to the right hip that were not timely addressed. Following the fall, facility staff failed to complete a timely and appropriate assessment of the resident and failed to implement effective interventions. The resident was transported to the emergency room (per family request) on 01/24/25 at 2:58 P.M. due to leg pain and deformity. The resident was subsequently diagnosed with a right hip fracture requiring intravenous Morphine for severe pain and surgical intervention. This affected one resident (#288) of three residents reviewed for falls. The facility census was 84. Findings include: Review of the discharge hospital documentation dated 01/23/24 revealed Resident #288 presented with early signs of dementia with multiple assessments of pain. A verbal assessment (of pain) was not an accurate assessment due to the resident's level of confusion at the time of the examination. Review of the closed medical record for Resident #288, revealed an admitted [DATE] with diagnoses including displaced mid cervical fracture of the left femur, subsequent encounter for closed fracture with routine healing, fall on same level from slipping, tripping, and stumbling without subsequent striking against the object, subsequent encounter, after care following joint replacement surgery (left hip), unsteady on feet, muscle weakness and unspecified dementia, unspecified severity, with anxiety. Resident #288 was transferred to the emergency roiagnom on [DATE] and did not return to the facility. Review of a fall without injury event note dated 01/25/24 revealed Resident #288 had fallen on 01/25/24 at 12:15 A.M. The note indicated the resident was found in her bathroom/showroom and had ambulated to the restroom (all unwitnessed). The resident was found to be alert and wakeful. There were no nonverbal symptoms of pain assessment completed. The circumstances of the incident revealed the resident was found by a State tested Nursing Assistant (STNA) #132 on the floor in the bathroom and the STNA alerted the nurse on duty, Licensed Practical Nurse (LPN) #888 of the resident's fall. Two staff transferred the resident to a wheelchair. The note revealed the resident had no complaints of pain noted. Further review of the medical record revealed there was no objective assessment of the resident's pain completed after the fall. Further review of the medical record revealed the resident had a physician's order for Tylenol (acetaminophen) 650 milligrams (mg) every eight hours as needed for pain (on a) 1-10 (pain scale) (1 represents the least pain and 10 being the worst pain), offer nonpharmacological interventions (interventions that were non-medication such as food, fluid, a back rub etc.) prior to administration. Review of the Medication Administration Record (MAR) revealed Tylenol was administered on 01/25/24 at 6:09 A.M. for pain rated a five (out of 10) that was generalized, with distraction being ineffective and the follow up result being somewhat effective. Further review of the physician orders revealed an order for the anti-anxiety medication, Ativan 0.5 mg twice a day as needed for restlessness. Review of the January 2024 MAR revealed on 01/25/24, the Ativan was administered at 6:18 A.M. for restlessness. Follow-up indicated the medication was somewhat effective. Further review of the medical record revealed there was no documentation of the resident's restlessness to support the use of the Atvian. Further review of the physician orders revealed an order for Oxycodone (narcotic pain medication) 5 mg every four hours as needed for pain 1-10; offer non-pharmacological interventions prior to administration. The medication was administered on 01/25/24 at 7:55 A.M. with no assessment of the resident's pain (subjective or objective) and no evaluation of the medication's effectiveness after administration. Review of physician orders for Resident #288 revealed an x-ray was ordered on 01/25/24 at 10:13 A.M. The order was for post-fall and complaints of pain. The order did not indicate it was to be completed stat. Further review of the medical record revealed a progress note dated 01/25/24 at 10:14 A.M. stating the resident complained of right hip pain with repositioning and rest was ineffective. Pain medication given. The nurse called the Nurse Practitioner (NP), and the NP ordered an x-ray of the resident's right hip. A progress note dated 01/25/24 at 10:40 A.M., authored by the DON revealed the orthopedics office called to move up the resident's appointment due to concern for the resident's left leg turning in. A progress note dated 01/25/24 at 12:25 P.M. revealed the resident was complaining of right hip pain and an x-ray was ordered- pending arrival (from the mobile x-ray company). The facility was concerned about the resident's right hip pain. The family and orthopedics office were worried about the left leg turn. Review of a Physical Therapy note dated 01/25/23 at 1:12 P.M. revealed Resident #288 arrived at therapy at this time in a wheelchair with a wet gown. Therapy assisted the resident into a night gown from home and stated when asked patient to lean forward to allow gown to be pulled down (the patient) was grimacing some. Physical therapy assistant (PTA) asked if the resident was hurting, and she said yes and pointed onto right femur. The resident was assisted back to bed with posterior hip precautions to left hip and notified the staff of the resident's complaint of right hip pain. The nurse indicated, an x-ray was ordered already today. Further review of the medical record revealed a nurse progress note dated 01/25/24 at 2:22 P.M. and authored by the DON revealed the DON was notified by the charge nurse that the resident's daughter was updated that mobile x-ray had not arrived and the resident is resting comfortably at bedside with husband and grandson. A progress note dated 01/25/24 at 2:45 P.M. and authored by the DON revealed the charge nurse notified the DON that the daughter called and reported she (the daughter) had called transportation to take the resident to the emergency department (ED). A progress note dated 01/25/24 at 3:28 P.M. revealed the resident left the facility at 2:58 P.M. An interview on 01/30/24 at 3:49 P.M. with the DON revealed Resident #288 did have a dementia diagnosis but felt at the time of the facility admission, the resident was alert and oriented. The DON stated she believed cognition in residents with dementia could vary. The DON verified the facility staff did not complete a non-verbal (objective) pain assessment when the resident fell or after the fall according to the post fall documentation in the progress notes. The DON verified the resident's discharge documentation from the hospital indicated a non-verbal pain approach would need to be conducted due to the resident's cognitive impairment. The DON also verified the resident's family was not notified of the fall until the early morning due to the facility's notification policy. Further interview revealed the x-ray was not ordered stat (immediately) and the DON stated it was a fall without injury, so it was not needed as stat. The DON verified the MAR did not reflect administration of pain medication as indicated in the progress note on 01/25/24 at 10:14 A.M. The DON also verified there was no pain medication administered after therapy reported the resident's complaints of pain as indicated in the therapy documentation. Interview on 01/31/23 at 10:45 A.M. with Family Member #244 revealed the facility notified her of Resident #288's fall that occurred on 01/25/24 at 12:15 A.M. around 6:30 A.M. The DON informed her that per facility policy, the notification of the fall does not need to occur until the morning as there were no injuries noted. Family Member #244 stated she notified the Orthopedics Department of (named hospital) around 11:00 A.M. (on her lunch break) that the resident had fallen and there were concerns from the facility about the resident's left leg turning in. A return call to her from the orthopedics office stated that they had told the facility the resident needed to get to the emergency room for evaluation of the right hip and pain. When she called the facility, she was informed by a nurse (unable to remember name), that the facility was to keep the resident until the x-ray was completed and results known. She stated she asked to speak to the Administrator and the DON and was told both were busy at the time and could not speak with her. The DON did call her back and informed her that the Orthopedic office told her to use her nursing judgment on if the resident needed sent out and that they were waiting on a stat x-ray for the resident, and it was easier to keep her at the facility than moving her to the emergency room in case there was nothing wrong with her right hip. Her son (the grandson in the progress notes) and the resident's husband arrived at the facility shortly before the resident was transferred out and she spoke to them on the phone while they were there. Family Member #244 reported they told her the resident was in active pain with her non-verbal (cues) and verbally telling them. She stated she then called the facility back after she called for transportation to the emergency room for the resident with the DON explaining that she could not help that the (company name) who completes the x-rays was not there yet and that they run on their own time as well as mentioning the politics between their facility and the (hospital name) system. When she spoke to the hospital staff in the emergency room at the hospital the resident was given Morphine due to her severe pain in the right hip and had been actively shouting out with the amount of pain she was in. The family member went on to explain the resident did have dementia with some moments of confusion and the Ativan was rarely taken, only when the resident was restless. The family member reported the resident had only taken maybe a dose or two of the medication in the past six months. Review of a progress note dated 01/25/24 at 2:53 A.M. (identified as an incorrect time entry) and authored by the Director of Nursing (DON) revealed Resident's daughter calls this nurse to report that due to x ray examination is still pending at this time, that she contacted a transport to (named) emergency department (ED) for evaluation, daughter reports that Ortho stated they told us to send her the ED, but when we had spoke with them and reported that we would like to see if we could get her appointment moved up per daughters request . but if we felt she needed seen prior to that we could send her to (named) ED and informed we had already ordered an x-ray and (named mobile X-ray company) arrival is pending. Review of the emergency room documentation dated 01/25/24 revealed Resident #288 arrived at the emergency room with right hip pain with cognitive impairment. On assessment, the resident had pain in the right hip and pain with range of motion. The right leg was foreshortened compared to the contralateral hip. On x-ray it was found the resident had a femoral neck fracture to the right leg and was administered intravenous Morphine for pain. Multiple attempts to reach LPN #888 for interview were unsuccessful. Interview on 01/31/24 at 1:11 P.M. with an orthopedics office front desk staff member revealed Resident #288 was a patient of theirs and sent the nursing staff a message regarding events that occurred with the resident on 01/25/24. On 01/31/24 at 1:11 P.M. interview with the orthopedic office staff verified Resident #288 was under their care and verified they sent an email regarding the timeline of events as the information received in their office on 01/25/24. Review of the timeline for 01/25/24 with Orthopedics from Resident #288's chart (in their office) revealed the following: 10:43 A.M. the facility called the Ortho office to report family/therapy concern regarding leg turning in and hip being rotated (no mention of laterality), wanted appt moved up. 11:08 A.M. daughter called the Ortho office to report concerns of right hip pain and reports the fall. Also issues with left foot and leg turning in. 11:41 A.M. ortho communicates to the facility (after learning about the fall) to transport patient to the ER. Interview on 02/01/24 at 2:21 P.M. with STNA #132 revealed Resident #288 was found on the floor in the bathroom. Rounds were just completed, and Resident #288 told LPN #888 she had no pain but stated the resident was really shaken up and upset she had fallen, it was late too so she seemed stunned. Interview on 02/05/24 at 4:02 P.M. with the DON revealed the orthopedics office never told her to send out Resident #288 and the facility is at the ancillary services timeframe for orders such as x-ray and the daughter was unrealistic about how orders take time and the x-ray was ordered, it was just not fast enough. The DON confirmed the resident's daughter had called for transportation for the resident to be sent to the emergency room and the facility did not initiate the transfer. The DON also verified the entry for the progress note was 2:53 A.M. and was an inaccurate time. She stated she knew it was early morning, but she did not speak with the family at 2:53 A.M. as they were not notified of the fall until after 6:00 A.M. Review of the facility undated policy titled Pain Assessment and Management Protocol revealed when assessing a resident for pain, the nurse would evaluate resident's verbal expression of a pain/score level as well as non-verbal signs and symptoms that could reflect pain. This deficiency represents non-compliance investigated under Complaint Number OH00150514.

Based on closed medical record review, facility policy review, hospital record review, and interview, the facility failed to provide comprehensive wound assessment and wound care. Actual Harm occurred on 05/16/23 when the facility failed to provide adequate care/interventions and notify the physician of Resident #93's newly identified open areas to both heels and again on 05/29/23 when a skin alteration was identified to the resident's right buttock. In addition, the facility failed to ensure appropriate pressure ulcer treatments were provided, failed to implement additional pressure relieving interventions to promote healing, failed to obtain weekly wound measurements and complete comprehensive assessments to ensure the resident received optimal care. Resident #93 was discharged home on 06/04/23. Within 24 hours of his discharge, the resident was admitted to the hospital intensive care unit for treatment of sepsis (a life-threatening complication of an infection that occurs when chemicals released into the bloodstream to fight an infection trigger inflammation throughout the body. This can cause a cascade of changes that damage multiple organ systems, leading them to fail, sometimes even resulting in death) related to pressures ulcers that had developed in the facility. This affected one (Resident #93) of four residents reviewed for pressure ulcers. Findings include: Review of Resident #93' hospital history and physical (prior to the resident's admission to the facility), dated 05/12/23 revealed Resident #93 had one Stage II (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) pressure ulcer located on the right, dorsal foot (top of the foot). The resident was discharged from the hospital with orders dermagran (hydrophilic wound dressing for open wounds) to the right dorsal foot (top of foot) every day. Review of Resident #93's closed medical record revealed an admitted [DATE] with diagnoses that included coronavirus (COVID-19) infection, lactic acidosis, hypertension, and diabetes mellitus. The resident was discharged to his home on 06/04/23. Review of the admission orders dated 05/15/23 revealed the use of dermagran to the right dorsal foot (top of foot) every day. Review of the admission nursing assessment, dated 05/15/23, revealed the resident did not have any pressure ulcers. This assessment was noted to be inaccurate as the resident was admitted with and had orders for treatment of a pressure ulcer to the right dorsal foot. Review of an Illustration of Documentation and Measurements of Skin Areas, dated 05/15/23, revealed there were no open skin issues identified for Resident #93. This document was also inaccurate as the resident had an ulcer to the right dorsal foot on admission. Review of the Braden Skin Risk assessment dated [DATE] revealed a score of 19, which indicated the resident was at a low risk for the development of pressure ulcers despite the presence of a pressure ulcer on admission to the facility, the resident having bowel and bladder incontinence, requiring staff assistance with bed mobility and co-morbidities including diabetes. Review of the resident is at risk for skin breakdown related to impaired mobility, diabetes, lymphedema, and urinary and bowel incontinence plan of care, dated 05/16/23 revealed interventions including to assist the resident as needed with turning and repositioning, encourage resident to float heels, provide nutritional support as ordered, and utilize a pressure redistribution mattress. Review of the registered dietician progress note, dated 05/16/23, revealed the resident had no skin concerns noted and no recommendations were given. However, the dietician failed to acknowledge the ulcer to the resident's right dorsal foot to implement nutritional interventions to promote wound healing. Review of a Weekly Nursing Skin Tool dated 05/16/23 revealed Resident #93 had dressings on bilateral heels to open areas. Discoloration was noted on lower legs and feet. In addition, the skin tool noted the resident's buttocks were red with skin intact. Record review revealed no additional assessment, staging or interventions to address these identified skin areas. Review of a nurse practitioner (NP) progress note, dated 05/17/23, revealed the resident had an open wound located on the right foot with an order to continue walking boot when out of bed and to continue wound care. The progress note revealed no additional wounds were present. The note did not include any type of wound assessment such as measurements or staging of the ulcer to the right foot at that time. Review of the physician's orders, dated 05/17/23, revealed to complete a weekly skin check, document any new findings, and notify the physician of any concerns. Review of the Minimum Data Set (MDS) 3.0 admission assessment, dated 05/22/23, revealed the resident had intact cognition. The assessment indicated the resident required extensive, two-person physical assistance for bed mobility, transfers, dressing, personal hygiene, and toileting. Further review indicated the resident had two, Stage I pressure ulcers and one, Stage II pressure ulcer upon admission to the facility. The assessment revealed the resident was always incontinent of bowel and bladder. Review of Resident #93's history and physical completed by the physician on 05/23/23 indicated the resident had a Stage II wound to the right foot. No further information regarding the wound was provided. Review of Resident #93's physician's orders revealed a new wound care order, dated 05/29/23 to cleanse the right buttock and apply a dry, clean dressing daily. There was no additional documentation in the medical record regarding the right buttock including an assessment (staging, location, appearance of the buttock area) and/or information as to how or why the pressure ulcer developed. Review of a nursing progress note, dated 05/31/23 at 3:44 A.M., revealed new skin abnormality located on the left heel, wound nurse and physician notified (method of notification not provided). The progress note did not include any type of additional assessment or staging of this new area to the left heel as this time. In addition, no assessment, description, or staging had been completed for the area to the resident's right foot as of this time. Review of physician order, dated 05/31/23, revealed an order to cleanse the left heel with normal saline (NS) and apply skin prep and dry dressing once a day and as needed (PRN). Further review of the resident's medical record found no evidence of any comprehensive wound assessments for Resident #93 during his admission to the facility which included pressure ulcers to the right dorsal foot, left heel and right buttock. In addition, there were no updates to the resident's plan of care or new skin prevention interventions to address the development and presence of pressure ulcers. Review of the medical record revealed no recapitulation of the resident's stay was provided (at the time of the resident's discharge on 06/04/23) to the home health agency scheduled to provide home care to the resident following his discharge. The only information provided to the agency from the facility related to the resident's skin was the copy of the resident's physician's orders during his stay at the facility. No wound assessments could be provided due to the absence of wound/skin assessments while a resident in the facility. Review of the resident's discharge documentation revealed the resident was discharged home on 06/04/23. The facility documented the resident's skin was intact (no wounds). However, the resident was discharged with a printed copy of the facility physician's orders which included wound care orders for the resident's right dorsal foot, left heel and right buttock. There was no evidence the resident or family education was given regarding how to provide the wound care, no evidence wound care supplies were provided and no evidence the resident or resident's family were made aware of the status of the resident's ulcers at the time of discharge. Review of a hospital history and physical, dated 06/05/23 at 3:47 P.M. (the day after the resident was discharged from the facility with orders for a treatment to the right buttock but no assessment or description of the wound location other than right buttock), revealed the resident had a Stage II decubitus ulcer located on the sacrum with surrounding erythema (redness) and purulent drainage (thick drainage usually indicative of infection and is generally white, yellow or brown and made of white blood cells trying to fight infection) noted. Infection with wound culture ordered and broad-spectrum antibiotics initiated. The resident was admitted to the intensive care unit initially with concerns for septic shock related to decubitus ulcers. The resident's systolic blood pressure was in the 70's upon arrival at the emergency room and the resident received intravenous fluids to correct the blood pressure. On 06/12/23 at 2:28 P.M. telephone interview with Resident #93's son revealed the resident remains in the hospital as of this time and would transfer to a rehabilitation facility once he was strong enough to discharge from the hospital. The son stated the resident had numerous open areas which included his left thigh and calf, his buttock, and bilateral heels and the family was unaware of these wounds during his stay at the facility and were not made aware upon the resident's discharge to his home on 06/04/23. Further interview revealed the hospital diagnosed Resident #93 with sepsis and felt it was from a wound. The son was unable to recall exactly which wound it was and stated it may have been the right foot wound, but he wasn't sure. The resident's son indicated his father was admitted to the hospital with severe dehydration, renal failure, sepsis due to bedsores, deep vein thrombosis (DVT/blood clots) and a pulmonary embolus (blood clot in the lung). The son also added the resident was sent to the emergency room the day after his discharge from the facility because the resident's wife had issues with the resident not transferring well and just not acting himself. The resident was taken to the emergency roiagnom on [DATE] and remained in the hospital at the time of the interview. Further review of the surgery consult documentation dated 06/13/23 revealed the resident was initially admitted to the intensive care unit with concerns of septic shock related to decubitus ulcers. The resident had a wound culture completed during admission and it grew Methicillin-Sensitive Staphylococcus Aureus (MSSA) (a skin infection that was not resistant to certain antibiotics and can cause serious skin infections). Infectious disease was consulted, and the resident received antibiotics Vancomycin and Cefepime. The resident recently had a pelvic MRI which showed osteomyelitis (infection of the bone), however no mention of underlying abscess. The surgery team was consulted for co-management of the sacral wound. On 06/15/23 at 1:07 P.M. interview with the Director of Nursing (DON) confirmed there were no comprehensive wound assessments completed for Resident #93's noted to the right dorsal foot, left heel, right heel, or right buttock at any time during the resident's admission. The DON further confirmed the nursing admission assessment, dated 05/15/23, incorrectly revealed there were no pressure ulcers, and that the resident's skin was intact. The DON confirmed Resident #93 did not receive any type of nutritional interventions/supplementation to promote wound healing during his stay as the dietician was unaware of any skin alterations due to the lack of documentation in the medical record. A follow-up interview with the DON at 4:05 P.M. revealed the wound nurse was still training for his position and she had been off work and an interim DON was covering her position during her leave. The DON verified there was a lack of follow-up and communication regarding the resident's wounds and wound care. The DON also stated the resident's family signed the discharge instructions which would indicate they were aware of the treatments to the resident's wounds; however, there was no evidence education or supplies were provided to the family upon discharge. The DON stated the facility does not routinely provide wound care supplies when the resident was going home and would receive home health services even when the facility does not know when home health would begin visits and home health was unaware of skin alterations because they did not receive a recapitulation of the resident's stay describing the resident's wounds. The DON stated she believed the resident was non-compliant with care (bathing, showering turning and repositioning); however, the facility was unable to provide evidence through documentation and education of the resident's non-compliant behaviors. On 06/15/23 at 4:05 P.M. interview with Corporate Registered Nurse (CRN) #102 confirmed there were no comprehensive wound assessments completed for Resident #93's wounds to the right dorsal foot, left heel, right heel, or right buttock and confirmed the order to apply skin prep to the left heel would not be an appropriate treatment order for an open wound to the heel. Further interview revealed new pressure relieving interventions should be added to the resident's plan of care and the dietician should also be notified regarding wounds to ensure the resident is receiving adequate nutrition to promote wound healing. CRN #102 also verified the facility wound nurse would be notified of new wounds to complete the appropriate wound assessments and to ensure the appropriate treatment plan was in place by making rounds with the visiting wound team/physician. CRN #102 also verified the facility did not have any evidence to support the status of the resident's wounds upon his discharge home and verified there was no evidence wound care education provided to the family or resident upon discharge especially with the resident's skin being documented as intact upon his discharge. CRN #102 also verified the wounds should have had a weekly assessment. On 06/15/23 at 4:55 P.M. interview with Assistant Director of Nursing (ADON)/Wound Nurse #99 revealed he recalled examining Resident #93 the day after the resident's admission, after being informed of a problem with the right heel. Wound Nurse #99 stated he found some bogginess and felt the resident had a deep tissue injury (DTI) (purple or maroon localized skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) of the right heel. Wound Nurse #99 confirmed he did not obtain measurements of the wound nor complete a comprehensive assessment of the right heel. Wound Nurse #99 further confirmed there were no wound measurements or comprehensive assessments of the right heel, left heel, right buttock, or Stage II decubitus ulcer of the right dorsal foot during Resident #93's stay in facility and the resident was not referred to the facility's wound care physician. ADON #99 verified the resident did have a skin alteration present on admission to the facility and he should have initiated wound assessments at that time. The ADON verified the facility received several admissions on the date the resident was admitted and, despite it not being an excuse, the staff were very busy that day. The ADON denied knowledge of additional skin alterations/pressure wounds that developed during the resident's stay and stated had he been made aware, he and the wound physician would have followed the resident weekly to ensure appropriate wound care and a comprehensive approach would have been provided. On 06/15/23 at 5:35 P.M. interview with Nurse Practitioner (NP) #103 revealed she was not notified of any open wounds or newly identified skin alterations following Resident #93's admission to the facility. NP #103 had knowledge of only one wound, the Stage II decubitus ulcer located on the resident's dorsal right foot, which was present upon admission. NP #103 stated it was her expectation that any open wound or potential pressure wound should be comprehensively assessed. The NP also verified wound assessments are necessary to determine if a wound is healing or deteriorating. NP #103 verified the dorsal part of the foot is the top of the foot. Review of the facility undated policy titled, Pressure Injuries: Assessment, Prevention, and Treatment, revealed it was the facility 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 OH00143507.

Based on medical record review, observation, resident interview, and staff interview the facility failed to accurtely and timely assess residents' nutritional status with significant weight loss, failed to ensure nutrition recommendations were implemented and failed to ensure weights were completed as ordered. This affected three of four residents reviewed for nutrition (Residents #63, #114 and #132). The facility identified five residents with unplanned significant weight loss/gain. Actual harm occurred to Resident #132 when nutrition recommendations were not implemented until fifteen days later resulting in the resident losing 23 pounds with an avoidable 23.7 percent significant weight loss during that time period. Findings include: 1. Medical record review revealed Resident #132 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's cognition was severely impaired, required supervision with set up assistance with meals, most recent weight was 107 pounds (#), had significant weight loss that was not prescribed and the resident was not on a therapeutic or mechanically altered diet. Review of the nutrition plan of care (POC) revealed the resident had a low body mass index (BMI), intakes were less than 50 percent (%) at times, prescribed a nutrition supplement and had a [DIAGNOSES REDACTED]. Interventions included to provide supplements as ordered on [DATE]; weigh and monitor results daily for three days on admit, then weekly for four weeks, then weigh monthly and as needed. Review of the resident's nutrition assessment dated [DATE] revealed the resident had poor intakes that may lead to weight loss and the resident was under his ideal body weight. The resident's ideal body weight was 136#, estimated energy needs were 1830 to 2135 calories, 61 to 76 grams protein and 1350 to 1890 milliliters (ml) of fluids. The resident's meal intakes were ,[DATE]% at each meal and noted some gradual weight gain may benefit the resident. The nutrition recommendation was to add a high calorie nutritional supplement named Readycare 2.0, 60 ml, three times a day to provide a total of 360 calories and 14 grams of protein. Review of resident's physician orders [REDACTED]. Review of the resident's weight and vital summary form revealed the resident's admission weight was 120# on [DATE]. The following weights were obtained since then: [DATE] at 106.9#, [DATE] at 97.3# and [DATE] at 97.0#. This indicated the resident lost 13.1#, 10.9% significant weight loss on [DATE]. There was no documented evidence the weight loss on [DATE] was addressed by the dietetic technician or registered dietitian and no evidence new interventions were implemented at this time. Review of the resident's nutritional progress notes revealed on [DATE] the resident's current body weight was 97.3# and it was a 22.7# pound weight loss since admit and represented a 18.9% significant weight loss. The resident was noted to have a body mass index of 16.2, indicating the resident was underweight. Dietetic Technician (DTR) #6 inaccurately stated in the progress note dated [DATE] the resident was already on the nutritional supplement Readycare 2.0 120 ml. three times per day and there were no new nutrition recommendations. DTR #6 stated to continue weekly weights, to monitor regularly and to provide nutrition interventions as needed. Review of the resident's meal intakes from [DATE] to [DATE] revealed the resident ate 50% or less at meals 38 out of 73 meals that were recorded, which was equivalent to 52% during this time period. Review of the MAR indicated [REDACTED]. three times daily was implemented on [DATE] at dinner time. On [DATE], the facility notified the resident's wife of the resident's significant weight loss and obtained food preferences for the resident from his wife. The wife was also informed the nutritional supplement was implemented and speech therapy would be evaluating the resident. On [DATE], it was noted there was a new order for lightweight utensils and cups. Observation of the resident on [DATE] at 8:51 A.M. revealed the resident was eating in his room with a staff member present in the room. The resident was feeding himself with the staff member cueing him. Interview with Regional Nurse (RN) #8 on [DATE] at 9:08 A.M. confirmed the daily weights upon admit were not completed as stated in the nutrition plan of care. RN #8 stated it was the facility's standard protocol to complete daily weights for the first three days upon admission. Interview with Registered Dietitian (RD) #3 on [DATE] at 10:37 A.M. revealed DTR #6 worked under her license. RD #3 explained that she was required to assess the DTR's competency and supervise her on a monthly basis. DTR #6 was to email her the list of residents that were at high nutrition risk. The RD stated she reviewed the DTR's assessments and progress notes but did not confirm the accuracy of what the DTR was putting into her assessments and progress notes. The RD stated she educated the DTR to start nutritional supplements when the resident was not eating and/or losing weight and she began to do that. RD #3 confirmed the nutrition recommendations on [DATE] were not implemented until [DATE], the significant weight loss on [DATE] was never addressed by the DTR or RD, and confirmed the DTR's progress note on [DATE] inaccurately stated the resident was already on a nutritional supplement. RD #3 confirmed DTR #6 should have implemented a new nutrition intervention on [DATE] due to the significant weight loss. Further interview with RD #3 on [DATE] at 2:30 P.M. revealed DTR #6 was suspended pending investigation to rule out inaccurate and timely assessments and due to communication with the Registered Dietitian. 2. Closed medical record review revealed Resident #63 was admitted to the facility on [DATE] and expired in the facility on [DATE]. The resident had medical [DIAGNOSES REDACTED]. Review of the resident's nutrition assessment dated [DATE] revealed the resident had poor intakes and increased nutritional needs due [MEDICAL CONDITION]. The resident's current body weight was noted to be at 95 pounds (#). It was noted due to poor meal intakes, the nutrition recommendation was to add a high calorie nutritional supplement, Readycare 2.0, at 60 milliliters (ml.) three times a day to promote calorie intakes. Review of the nutritional progress note dated [DATE] revealed the resident's current body weight was 87.5#. This indicated a 9.7# weight loss that represented a 10.0 percent (%) loss within thirty days. The note stated the resident was on 60 ml. three times daily of Readycare 2.0 and recommendation was to increase it to120 ml three times per day. Review of the resident's MAR indicated [REDACTED]. This indicated the nutritional recommendations on [DATE] was already in place and not a new recommendation. Interview with DTR #6 on [DATE] at 3:40 P.M. confirmed Resident #63 was already on Readycare 2.0 120 ml. three times daily on [DATE] and there was no new nutrition recommendation on [DATE] following the documented weight loss. 3. Record review revealed Resident #114 was admitted on [DATE] with [DIAGNOSES REDACTED]. A care plan was in place for nutritional risk. Upon Resident #114's admission on [DATE], he weighed 131 pounds. On [DATE] at 3:55 P.M. a nutritional progress note by DTR #6, revealed a weight warning for Resident #114. The nutritional progress note revealed the weekly weights showed Resident #114 weighed 121 pounds with a significant weight loss of 12.7 pounds since [DATE]. A frozen nutritional treat was added at lunch time. The nutritional progress note also indicated Resident #114 would be monitored regularly. On [DATE] at 1:27 P.M. a nutritional progress note by DTR #6, revealed a weight warning for Resident #114. Per the nutritional progress note the weekly weights revealed Resident #114 weighed 120 pounds with a significant weight loss of 14 pounds in 30 days. The nutritional progress note also indicated there was no change in Resident #114's nutritional plan at that time and Resident #114 would be monitored regularly. A quarterly nutritional review dated [DATE] by DTR #6 revealed Resident #114 was eating 100% of the frozen nutritional treat. The nutritional review also revealed DTR #6 would continue to monitor weekly weeks and supplement acceptance. On [DATE] Resident #114 weighed 119 pounds. On [DATE] at 2:01 P.M. an interview with Resident #114 revealed his appetite was not good and he had lost a lot of weight since he was admitted to the facility. On [DATE] at 2:08 P.M. an interview with DTR #6 revealed no changes had been made in Resident #114's nutritional plan since [DATE]. DTR #6 also stated she was waiting to see if Resident #114 liked the frozen nutritional treat because some residents do not like it. DTR #6 stated Resident #114 had weekly weights and she monitored those. At this time, review of weights with DTR #6 revealed Resident #114 was weighed on [DATE], [DATE] and [DATE]. DTR #6 confirmed Resident #114 was not weighed the weeks of [DATE], [DATE], and [DATE]. On [DATE] at 10:48 A.M. an interview with RD #3 revealed DTR #6 should have monitored weights to make sure they were done weekly. RD #3 stated Resident #114 did not require tube feeding, have wounds, or poor intake so DTR #6 was deemed competent to monitor Resident #114. RD #3 stated an additional weight loss intervention should have been put in place since the last nutritional plan intervention had been [DATE] and Resident #114 had continued to lose weight. RD #3 stated DTR #6 should have been aware Resident #114 was not being weighed weekly.