Every finding on record at Arbors at Carroll

Based on observation, record review, interview, and review of facility policy, the facility failed to wear appropriate personal protective equipment during a mechanical lift transfer of a resident who was on enhanced barrier precautions. This affected one (Resident #17) of three residents reviewed for mechanical lift transfers. The facility census was 93 residents.Findings include:Review of Resident #17's medical record revealed an initial admission date of 03/17/26 with a readmission date of 04/09/26. Resident #17 had diagnoses that included heart failure, chronic respiratory failure, type 2 diabetes mellitus with hyperglycemia, chronic kidney disease stage 3, polyneuropathy, peripheral vascular disease, dysphagia, and lymphedema.Review of Resident #17's care plan revealed the resident had an activities of daily living (ADL) self-care performance deficit with an intervention to transfer the resident with two person assist and use of mechanical lift initiated on 03/17/26. Resident #17 also required enhanced barrier precautions related to the presence of a feeding tube and wounds with an intervention to use enhanced barrier precautions when providing high contact resident care activities (dressing, bathing, transferring, personal hygiene, changing linens, changing briefs/assisting with toileting, and device care).Review of Resident #17's Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intactObservation on 05/18/26 at 2:30 P.M. of Resident #17's door revealed a sign indicating Enhanced Barrier Precautions with guidance on when to wear personal protective equipment, including while transferring the resident.Observation on 05/18/26 at 3:19 P.M. of a mechanical lift transfer of Resident #17 by Certified Nursing Assistants (CNAs) #147 and #165. CNAs #147 and #165 performed hand hygiene, donned gloves, entered the room and closed the door for privacy. CNA #147 then exited the room to obtain gowns. CNAs #147 and #165 donned gowns. CNAs #147 and #165 placed mechanical lift pad under Resident #17. CNAs #147 and #165 removed gown and gloves, performed hand hygiene, and exited the room. CNA #147 returned to the room with clean linens. CNA #165 returned to the room with the mechanical lift without applying new gown or gloves, CNA #147 attached the mechanical lift pad to the lift on the left side of Resident #17. CNA #165 attached the mechanical lift pad to the lift on the right side of Resident #17. CNA #165 raised Resident #17 using the lift and backed the resident out of the room and into a specialized wheelchair sitting in the hallway.Interview on 05/18/26 at 3:35 P.M. with CNAs #147 and #165 confirmed personal protective equipment was not worn during the transfer of Resident #17 from the bed to the specialized wheelchair.Interview on 05/19/26 at 7:45 A.M. with Infection Preventionist Registered Nurse #130 confirmed personal protective equipment should have been worn during Resident #17's transfer in the room. Staff have been instructed not to wear personal protective equipment in the hallways so any personal protective equipment should have been removed once the CNAs reached the threshold of the door.Review of the policy 'Enhanced Barrier Precautions (EBP)' implemented 05/10/23 and reviewed/revised on 03/26/24 revealed personal protective equipment for enhanced barrier precautions is only necessary when performing high-contact care activities. High-contact resident care activities to consider include dressing, bathing, transferring, providing personal hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. In general, gown and gloves would not be recommended when performing transfers in common areas, such as dining or activity rooms, where contact is anticipated to be shorter in duration. Outside the resident's room, EBP should be followed when performing transfers or assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility.This deficiency represents non-compliance investigated under Complaint Number 2992359.

Based on observation, medical record review, interview, and facility policy review, the facility failed to provide off-loading (a critical technique used to reduce pressure on specific areas of the body, particularly in wound care) for a stage III pressure ulcer (full thickness tissue loss where subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include tunneling or undermining). This affected one resident (#21) of one resident reviewed for pressure ulcers. The facility census was 91.Findings Include:Review of the medical record for Resident #21 revealed an initial admission date of 09/19/22 with the latest readmission date of 02/04/26 with diagnoses including but not limited to chronic obstructive pulmonary disease, acute and chronic respiratory failure, congestive heart failure, malignant neoplasm of bladder, peripheral vascular disease, morbid obesity, neuropathy, pain, anxiety disorder, gastro-esophageal reflux disease, benign prostatic hyperplasia with lower urinary tract symptoms, edema, psoriasis, major depressive disorder, obstructive sleep apnea, anemia and hyperlipidemia.Review of the plan of care dated 05/27/25 revealed the resident had impaired skin integrity as evidenced by generalized/scattered bruising, stage III pressure to the left heel related to needing assistance with Activities of Daily Living (ADLs), neuropathy, peripheral vascular disease diagnosis. Interventions included administer treatments per orders, assist resident with turning and repositioning as needed, complete skin inspections weekly and as needed, complete wound evaluation to observe the progress of the resident's skin condition, consult dietitian as needed, dietary supplement as ordered, encourage good nutrition and hydration, assist as needed, encourage resident to reposition self if able, encourage/assist as needed to elevate heels off the mattress as tolerated, notify nurse of any new areas of skin impairment noted during bathing or daily care, notify physician of noted worsening skin conditions or any new areas of skin impairment, notify physician of signs/symptoms of infection, periodically complete Braden Scale, pressure redistribution device in chair, pressure redistribution mattress to bed, provide incontinence care, and therapy screen, evaluation, treatment as needed.Review of the resident's Braden scale dated 01/23/26 revealed a score of 20 indicating the resident was at low risk for skin breakdown.Review of the resident's significant change MDS assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident was at risk for skin breakdown and had one unhealed stage III pressure ulcer present on admission. The facility implemented the interventions of pressure reducing device to bed/chair, nutrition or hydration interventions to manage skin problems, pressure ulcer/injury care and applications of ointments/medications other than to feet.Review of the initial weekly skin issue assessment dated [DATE] revealed the resident was readmitted to the facility with a stage III pressure ulcer to the left lateral heel measuring 2.56 centimeters (cm) by 2.12 cm by zero depth and described as having epithelial and granulation tissue as well as slough and eschar with no odor, however the wound was documented as having odor after cleansing the wound. Further review of the assessment revealed no documentation determining how much of the wound was slough and how much was eschar. Review of the Wound Nurse Practitioner (WNP) progress note dated 02/10/26 revealed the stage III pressure ulcer measured 0.5 cm by 0.5 cm by 0.1 cm with 100% pink wound base with a scant amount of serosanguinous exudate. The peri-wound was described as being dry with flaking skin. The WNP documented the previously healed stage III pressure ulcer had reopened this past week as the resident returned to the facility from hospitalization. The wound was described as being a healing stage III pressure ulcer. The WNP initiated the treatment to cleanse with normal saline, apply betadine soaked gauze, cover with an abdominal (ABD) pad and wrap with kerlex three times a week and as needed. The staff was educated on the importance of offloading to promote wound healing. Review of the WNP progress note dated 02/17/26 revealed the stage III pressure ulcer measured 0.5 cm by 0.6 cm by 0.1 cm with 100% pink wound base with a scant amount of serosanguinous exudate. The peri-wound was described as being dry with flaking skin. The WNP determined the wound was unchanged and determined the wound was similar in size and appearance as on 02/10/26 and continued the current treatment.Review of the WNP progress note dated 02/24/26 revealed the stage III pressure ulcer measured 0.6 cm by 0.3 cm by 0.1 cm with 100% pink wound base with a scant amount of serosanguinous exudate. The peri-wound was described as being dry with flaking skin. The WNP determined the wound was unchanged and determined the wound was similar in size and appearance as on 02/17/26 and implemented the treatment to cleanse with normal saline, apply collagen, cover with ABD pad, and wrap with Kerlex daily and as needed. Review of the WNP progress note dated 03/03/26 revealed the stage III pressure ulcer measured 0.6 cm by 0.5 cm by 0.1 cm with 100% pink wound base with a moderate amount of serosanguinous exudate. The peri-wound was described as being dry with flaking skin, macerated and moist. The WNP determined the wound was unchanged and determined the wound was similar in size and appearance as on 02/24/26, however, increased exudate was noted on examination, with moisture and maceration present in the peri-wound area. The facility implemented the treatment cleanse with normal saline, apply collagen to wound bed, cover collagen with calcium alginate, cover with ABD pad, and wrap with Kerlex daily and as needed. On 03/02/26 at 12:13 P.M. an observation and interview with Resident #21 revealed he had stage III pressure ulcer to his left heel. Observation of the resident revealed there was no off-loading while sitting up in his wheelchair. Further observation revealed the resident's left heel was resting on the floor with no off-loading to the wound.On 03/03/26 at 2:30 P.M., an observation of Resident #21 revealed he was sitting up in his wheelchair in his room watching television with his left heel resting on the floor providing no off-loading to the stage III pressure ulcer.On 03/04/26 at 10:15 A.M., an observation of Resident #21 revealed the resident's left heel was resting on the floor providing no off-loading to the stage III pressure ulcer. On 03/04/26 at 11:49 A.M., an interview with the Director of Nursing (DON) verified the resident had no off-loading to the stage III pressure ulcer to the left heel while sitting up in his wheelchair. On 03/04/26 at 12:31 P.M., an observation of Resident #21's stage III pressure ulcer to left heel with Registered Nurse (RN) #124 and Certified Medication Technician (CMT) #159 revealed the residents wound was the size of a quarter with pink tissue. The surrounding tissue was white and moist in color. Review of the facility policy titled, Wound Treatment Management, last revised on 10/26/23 revealed it was the policy of the facility to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician ordered.

Based on observation, interview, medical record review, and review of the facility policy, the facility failed to ensure Resident #3 was treated with dignity when his indwelling urinary catheter collection bag was not covered and was visible from the hallway. This affected one (Resident #3) of one resident reviewed for catheters. The facility census was 91. Findings include: Review of Resident #3's medical record revealed the resident was initially admitted to the facility on [DATE] and re-admitted to the facility 12/23/25. Resident #3 had diagnoses that included morbid (severe) obesity with alveolar hypoventilation, obstructive and reflux uropathy, major depressive disorder, retention of urine unspecified, hydronephrosis with ureteral stricture, and overactive bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact and had an indwelling catheter. Review of the care plan dated 08/25/25 revealed Resident #3 had an indwelling catheter related to obstructive uropathy with interventions that included privacy cover to catheter drainage bag. Observation of Resident #3 on 03/02/26 at 11:40 A.M. revealed the indwelling urinary catheter bag was hanging on the left side of the resident's bed. A privacy cover was not in place, and urine was visible in the collection bag from the hallway. Observation of Resident #3 on 03/03/26 at 7:41 A.M. revealed the indwelling urinary catheter bag was hanging on the left side of the resident's bed. A privacy cover was not in place, and urine was visible in the collection bag from the hallway. Observation of Resident #3 on 03/03/26 at 5:28 P.M. revealed the indwelling urinary catheter bag was hanging on the left side of the resident's bed. A privacy cover was not in place, and urine was visible in the collection bag from the hallway. Interview with Nursing Certified Nursing Assistant (CNA) #147 on 03/03/26 at 5:28 P.M. confirmed Resident #3's indwelling urinary catheter bag did not have a privacy cover and urine was visible in the collection bag from the hallway. Review of the policy titled Catheter Care Procedure - Urinary, implemented 10/30/20 and reviewed/revised on 12/28/23, revealed privacy bags are used to cover catheter drainage bags while in use.

Based on observation, medical record review, interview, and facility policy review, the facility failed to provide privacy while incontinence care was provided. This affected one resident (#22) of one resident reviewed for bowel and bladder. The facility census was 91. Findings Include:Review of the medical record for Resident #22 revealed an initial admission date of 01/06/23 with diagnoses including cerebrovascular accident with left sided hemiplegia, dementia, convulsions, diabetes mellitus, chronic kidney disease, dysphagia, seizures, peripheral vascular disease, celiac artery compression syndrome, hypertension, insomnia and anxiety disorder.Review of the plan of care dated 10/11/23 revealed the resident had bowel and bladder incontinence related to impaired mobility and physical limitations. Interventions included assist the resident with toileting needs, check at regular intervals and change as needed, and provide perineal (peri) care after each incontinent episode and apply house barrier cream after incontinence care.Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit and was dependent upon staff for toileting. The assessment indicated the resident was always incontinent of bladder and frequently incontinent of bowel. Review of the resident's monthly physician orders for March 2026 identified orders dated 12/17/25 to offer bed pan every two hours, check and change every two hours and on 03/03/26 the resident was ordered zinc cream to buttocks/peri-area as needed for itching every one hour as needed.An observation on 03/03/26 at 3:46 P.M. revealed Licensed Practical Nurse (LPN) #155 provided incontinence care for Resident #22. The LPN provided incontinence care with the window blind open, facing another wing of the facility within view of other resident's windows with open blinds. An interview on 03/03/26 at 4:08 P.M. with LPN #155 verified the resident's window blind was not closed for privacy during the incontinence care allowing the adjacent hallway resident rooms to potentially view into Resident #22's room.Review of the facility policy titled, Resident Rights Implementation, last revised on 01/01/22 revealed for any procedure that involves direct care, follow these steps, including to close the room entrance door and provide for the resident's privacy.

Based on observation, record review, interview, and review of facility policy, the facility failed to provide timely podiatry care for Residents #30 and #51. This affected 2 residents (#30 and #51) of 9 residents reviewed for activities of daily living. The facility census was 91.Findings Include:1. Record review for Resident #30 revealed the resident was admitted to the facility on [DATE] with diagnoses including: spinal stenosis, diabetes mellitus, hypertension, hyperlipidemia, osteoarthritis, muscle weakness, cognitive communication deficit, major depressive disorder.Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 was dependent on staff for personal hygiene.Further review of the medical record revealed Resident #30 was last seen by podiatry services in the facility on 10/21/25. Observation and interview on 03/02/26 at 3:42 P.M. with Resident #30 revealed she had long toenails that were hanging over the skin. The resident confirmed she would like her toenails cut. She affirmed she previously notified an unknown staff member about the need for her toenails to be cut. 2. Record review for Resident #51 revealed the resident was admitted to the facility on [DATE] with diagnoses including: acute respiratory failure with hypoxia, Crohn's disease, end stage renal disease, muscle weakness, generalized anxiety, osteoarthritis, and congestive heart failure. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 was dependent on staff for personal hygiene.Observation and interview on 03/02/26 at 3:42 P.M. with Resident #51 revealed she had an ingrown toenail and her toenails were so long they were hanging over the skin. Resident #51 stated her toenails were so long that they were causing her pain when wearing shoes.During an interview with Social Services Director (SSD) #120 on 03/04/26 at 9:51 A.M. confirmed podiatry had not visited the facility since 10/21/25, so Resident #51 had not been seen by podiatry in the facility yet. The next visit was scheduled for 03/17/26. SSD #120 confirmed both Resident #30 and #51 were to have their toenails clipped by podiatry services. During an interview on 03/04/26 at 10:51 A.M. with the Director of Nursing (DON) confirmed that podiatry would typically trim toenails for the residents. She agreed it had been an extended period since the last toenail trims had occurred.Review of the facility's policy Nail Care revised 08/20/24 revealed routine nail care will be provided for residents on a regularly and as needed basis.

Based observation, staff and resident interviews, medical record review, and review of facility policy on dental services, the facility failed to ensure residents received timely dental services related to dentures. This affected one (#3) of three residents reviewed for dental. The facility census was 91.Findings include:Review of the medical record for Resident #3 revealed the resident was admitted to the facility on [DATE] and re-admitted to the facility 12/23/25. Resident #3 had diagnoses that included chronic respiratory failure unspecified whether with hypoxia or hypercapnia, chronic obstructive pulmonary disease unspecified, type 2 diabetes mellitus without complications, chronic diastolic (congestive) heart failure, chronic kidney disease stage 3, morbid (severe) obesity with alveolar hypoventilation, obstructive and reflux uropathy, major depressive disorder, dysphagia, retention of urine unspecified, dependence on supplemental oxygen, atherosclerotic heart disease of native coronary artery without angina pectoris, obstructive sleep apnea, venous insufficiency, hypothyroidism, restless leg syndrome, hydronephrosis with ureteral stricture, and overactive bladder.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact and did not exhibit any physical, verbal, other behavioral symptoms, or rejection of care. Resident #3 had mouth or facial pain, and discomfort or difficulty with chewing.Review of the care plan dated 08/18/25 revealed Resident #3 was at risk for dental problems related to no natural teeth with interventions that included refer to dental services as needed.Review of dental progress notes dated 12/14/23 revealed impressions were obtained for dentures.Review of dental progress note dated 02/12/24 revealed upper and lower dentures were seated and fit well. Review of dental progress notes dated 07/01/25 revealed prior authorization for full dentures was submitted.Review of progress notes revealed no further documentation or follow up on the full dentures prior authorization. Observation of Resident #3 on 03/02/26 at 11:40 A.M. revealed Resident #3 was not wearing upper or lower dentures.Interview with Resident #3 on 03/02/26 at 11:40 A.M. revealed Resident #3 could not find the lower dentures. Resident #3 was unable to report when the lower dentures were lost and reported difficulty chewing at times.Interview with Social Services Director #120 on 03/03/26 at 2:10 P.M. revealed Resident #3 was last seen by the dentist on 07/01/25. Social Services Director #120 revealed Resident #3 consented to dentures at that visit and should be fit for dentures at the next dental appointment scheduled July 2026. She confirmed the residents bottom dentures were lost and also confirmed that a year between the prior authorization in July of 2025 and the fitting scheduled for July of 2026 was not considered timely. Review of the facility policy titled Dental Services implemented 10/18/20 and reviewed/revised 10/30/23 revealed social services will assist the resident or representative in making dental appointments and applying for dental reimbursement. Further review of the policy revealed the facility will promptly refer residents with lost or damaged dentures for dental services and service staff/dietary manager or designee will document what was done to ensure the resident could eat and drink adequately while awaiting dental services and will describe the extenuating circumstance around the delay. Additionally, the facility shall not charge a resident for the loss or damage of dentures when it is determined to the facility's responsibility.

Based on record reviews, observations and interviews, the facility failed to ensure safe storage and labeling of medications. This affected eight residents (#49, #56, #57, #58, #62, #63, #68 and #70) of 29 who received medications for the medication cart on South Long Hall. The facility census was 95.Findings include: 1. Review of Resident # 49's medical record revealed she was admitted on [DATE] with diagnoses including lumbar spinal stenosis, diabetes type two, low back pain, idiopathic neuropathy, and hypertension. Review of the care plan dated 02/06/25 revealed Resident #49 had an impaired musculoskeletal status related to spinal stenosis and osteoarthritis with interventions including administering medications as ordered. In addition, Resident #49 was at risk for pain related to limited mobility, comorbidities with interventions including administering medications per orders and observing for side effects and effectiveness.Review of Resident #49's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. The resident was dependent on staff for toileting and required set-up assistance for eating.Review of Resident #49's physicians orders dated 09/25/25 revealed orders for Aspirin Low Dose Oral Tablet Chewable 81 milligrams (mg) (blood thinner); give one tablet by mouth in the morning, Cyanocobalamin (Vitamin B) Tablet 500 micrograms (mcg); give one tablet by mouth in the morning, Lisinopril (medication for high blood pressure) Oral Tablet 40 mg; give one tablet by mouth in the morning, Meloxicam (medication for pain and inflammation) Oral Tablet 7.5 mg; give one by mouth in the morning, Metformin HCL (hydrochloride) (medication to control high blood sugars) Oral Tablet 500 mg; give one tablet by mouth every morning and at bedtime, Metoprolol Tartrate (medication for high blood pressure) Oral Tablet 50 mg; give one tablet by mouth every morning and at bedtime and Oxycodone HCL (Opioid analgesic used to treat moderate to severe pain) Oral Tablet 5 mg; give 5 mg by mouth every morning and at bedtime.Review of Resident # 49's Medication Administration Record (MAR) dated 09/25/25 revealed, Registered Nurse (RN) #521 signed the following medications were administered as ordered; Aspirin 81mg, Cyanocobalamin 500 mcg, Lisinopril 40 mg, Meloxicam 7.5 mg, Metformin 500 mg, Metoprolol Tartrate 50 mg and Oxycodone HCL 5 mg.2. Review of Resident #56's medical record revealed she was admitted on [DATE] with diagnoses including hypertension, anxiety, chronic pain, bipolar disorder, depression, and rheumatoid arthritisReview of the care plan dated 03/11/25 revealed the following care plans: Resident #56 was at risk for impaired cognitive function related to bipolar disorder with an intervention to administer medications as ordered. Resident #56 had an impaired metabolic status related to diabetes with an intervention to administer medications and treatments as ordered. Resident #56 had anxiety/restless, delusions with an intervention to administer medications as ordered, and Resident #56 had an impaired musculoskeletal status related to rheumatoid arthritis with an intervention to administer medications as ordered.Review of Resident #56's MDS 3.0 assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. The resident was assessed to require assistance with showers and bathing and set up assistance for eating.Review of Resident #56's physicians orders dated 09/25/25 revealed orders for Alprazolam (medication for anxiety) Tablet 0.25 mg; give one tablet by mouth three times a day for anxiety, Amlodipine (medication for high blood pressure) Oral Tablet 5 mg; give 5 mg by mouth in the morning, Baclofen (medication for muscle relaxant) Oral Tablet 5 mg; give 5 mg by mouth three times a day, Buspirone HCL (used for anxiety) Oral Tablet 30 mg; give one tablet by mouth every morning and at bedtime, Cholecalciferol ( Vitamin D) Oral Capsule; give 125 mcg by mouth in the morning, Lamictal (medication for seizures and mood stabilizer) Oral Tablet 100 mg; give one tablet by mouth every morning and at bedtime, Metoprolol Succinate ER (used for high blood pressure) Oral Tablet 25 mg; give two tablets by mouth in the morning, Plaquenil ( medication for rheumatoid arthritis) 200 mg; give two tablets by mouth in the morning, Senna Plus ( medication for constipation) Oral Tablet 8.6/50 mg; give one tablet by mouth in the morning and Venlafaxine HCL ER (medication for depression) Oral Tablet 150 mg; give one tablet by mouth one time a day.Review of Resident #56's MAR dated 09/25/25 revealed RN #521 signed the following medications were administered as ordered; Alprazolam 0.25 mg, Amlodipine 5 mg, Baclofen 5 mg, Buspirone HCL 30 mg, Cholecalciferol 125 mcg, Lamictal 100mg, Metoprolol Succinate 25 mg, Plaquenil 200 mg, Senna Plus 8.6/50 mg and Venlafaxine HCL ER 150 mg.3. Review of Resident #57's medical record revealed she was admitted on [DATE] with diagnoses including hypertension, dementia, anxiety, and muscle weakness.Review of the care plan dated 07/10/25 revealed the following care plans: Resident #57 had behaviors related to dementia with an intervention to administer medications as ordered, and Resident #57 had impaired cognitive function with an intervention to administer medications as ordered.Review of Resident #57's MDS 3.0 assessment dated [DATE] revealed a BIMS of 3 of 15, indicating severe cognitive impairment. The resident was assessed to require dependent assistance with toileting, dressing and personal hygiene and set up assistance for eating.Review of Resident #57's physicians orders dated 09/25/25 revealed orders for Amlodipine Besylate (medication for high blood pressure) Oral Tablet 5 mg; give one tablet by mouth in the morning, Cimetidine ( medication to reduce stomach acid) Oral Tablet 200 mg; give 200 mg by mouth in the morning, Lisinopril ( medication for high blood pressure) Oral Tablet 20 mg; give one tablet by mouth in the morning and Tizanidine HCL (muscle relaxant) Oral Tablet 2 mg; give 2 mg by mouth every morning.Review of Resident # 57's MAR dated 09/25/25 revealed RN #521 signed the following medications were administered as ordered; Amlodipine 5mg, Cimetidine 200 mg, Lisinopril 20 mg and Tizanidine HCL 2 mg.4. Review of Resident #58's medical record revealed she was admitted on [DATE] with diagnoses including congestive heart failure, anxiety, depression, bladder disorder, hypertension, epilepsy and gastro-esophageal reflux disease.Review of Resident #58's MDS 3.0 assessment dated [DATE] revealed the resident was assessed to require assistance with toileting and personal hygiene. She was identified as cognitively impaired by staff.Review of the care plan 09/25/25 revealed the following care plans: Resident #58 had an impaired neurological status related to epilepsy, with an intervention to administer medications as ordered, and Resident #58 had impaired cognitive function related to fluctuations in cognition at times, with an intervention to administer medications per order, and observe for side effects and effectiveness.Review of Resident #58's physicians orders dated 09/25/25 revealed orders for Aspirin Oral Tablet Chewable 81mg; give one tablet by mouth in the morning, Buspirone HCL (medication for anxiety) Oral Tablet 10 mg; give one tablet by mouth three times a day, Cholecalciferol (Vitamin D) Tablet 1000 mg; give one tablet by mouth in the morning, Famotidine (medication for stomach acid) Oral Tablet 20 mg; give two tablets by mouth in the morning, Ferrous Sulfate (Iron Supplement) Oral Tablet 325 mg; give one tablet by mouth three times a day, Furosemide (medication used for fluid retention and high blood pressure) Oral Tablet 20 mg; give one tablet by mouth in the morning, Guaifenesin ( medication for congestion) ER 600 mg tablet; give one tablet by mouth every morning, Lactobacillus ( Probiotic) Oral Tablet; give one capsule by mouth in the morning, Metoprolol Tartrate (medication for high blood pressure) Oral Tablet 25 mg give one tablet by mouth in the morning and at bedtime, Oxybutynin ( medication for overactive bladder) Chloride Oral Tablet 5 mg; give one tablet by mouth in the morning, Potassium Chloride Crys ER Oral Tablet 10 MEQ ( milliequivalents); give 10 MEQ by mouth in the morning and Sertraline ( medication for depression) HCl Oral 100 mg; give one tablet by mouth in the morning.Review of Resident #58's MAR dated 09/25/25 revealed RN #521 signed the following medications were administered as ordered; Aspirin 81mg, Buspirone HCL 10 mg, Cholecalciferol 1000 mg, Famotidine 20 mg, Ferrous Sulfate 325 mg, Furosemide 20 mg, Guaifenesin ER 600 mg, Lactobacillus, Metoprolol Tartrate, Oxybutynin Chloride, Potassium Chloride ER 10 MEQ and Sertraline 100 mg.5. Review of Resident #62's medical record revealed she was admitted on [DATE] with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, depression and hypertension.Review of the care plan dated 06/25/25 revealed the following care plans: Resident #62 had an impaired metabolic status with an intervention to administer medications and treatments as ordered, and Resident #62 was at risk for fluid volume deficit with an intervention to administer medications as ordered.Review of Resident #62's MDS 3.0 assessment dated [DATE] revealed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. The resident was assessed to require assistance with bathing and dressing and set up assistance for eating.Review of Resident #62's physicians orders dated 09/25/25 revealed orders for Cyanocobalamin (Vitamin B12) Tablet 500 mcg; give one tablet by mouth in the morning, Famotidine (medication for stomach acid) Oral Tablet 20 mg; give one tablet in the morning, Folic Acid Oral Tablet 1 mg; give one tablet by mouth in the morning, Furosemide (medication used for fluid retention and high blood pressure) Oral Tablet 40 mg; give one tablet by mouth in the morning and Vitamin D3 Oral Tablet 25 mcg; give one tablet by mouth in the morning.Review of Resident #62's MAR dated 09/25/25 revealed RN #521 signed the following medications were administered as ordered; Cyanocobalamin 500 mcg, Furosemide 40 mg, Famotidine 20 mg, Folic Acid 1 mg and Vitamin D3 25 mcg.6. Review of Resident #63's medical record revealed she was admitted on [DATE] with diagnoses including diabetes mellitus, malignant neoplasm of left breast, anxiety, osteoarthritis, dementia, Alzheimer's disease, depression, hypertension and cerebral infarction with left hemiplegia.Review of the care plan dated 03/31/25 revealed the following care plans: Resident #63 had an impaired neurological status with an intervention to administer medications and treatments as indicated by orders, and Resident #63 had an impaired mood/psychiatric status with an intervention to administer medications and treatments as ordered.Review of Resident #63's MDS 3.0 assessment dated [DATE] revealed a BIMS score of 08 out of 15, indicating moderate cognitive impairment. The resident was assessed to require dependent assistance with toileting, dressing and personal hygiene and set up assistance for eating.Review of Resident #63's physicians orders dated 09/25/25 revealed orders for Aspirin Tablet Chewable 81 mg; give one tablet by mouth in the morning, Actos (medication to control blood sugars) Tablet 45 mg; give one tablet by mouth in the morning, Anastrozole (medication for breast cancer) Tablet 1 mg; give one tablet by mouth in the morning, Buspirone HCL (medication for anxiety)Tablet 15 mg; give one tablet by mouth three times a day, Calcium Carbonate Tablet Chewable 500 mg; give one tablet by mouth three times a day, Dailyvite Vitamin D 125 mcg Capsule. Give one capsule by mouth in the morning, Famotidine (medication used for stomach acid) Oral Tablet 20 mg; give one tablet by mouth in the morning every Monday, Tuesday, Wednesday, Thursday, Friday and Saturday, Galantamine Hydrobromide (medication used for Alzheimer's disease) Oral Tablet 4 mg; give one tablet by mouth two times a day, Januvia ( medication used for high blood sugars) Tablet 100 mg; give one tablet by mouth in the morning, Lactobacillus Rhamnosus (Probiotic) Tablet Chewable; give one unit by mouth every morning and at bedtime, Lamictal (medication used for seizures and mood stabilizer) Oral Tablet 100 mg; give 100 mg by mouth in the morning, Lorazepam (medication used for anxiety) Tablet 1 mg; give one tablet by mouth three times a day, Meloxicam (medication used for inflammation) Tablet 7.5 mg; give one tablet by mouth in the morning, Metformin (medication used for high blood sugars) HCL Tablet 1000 mg; give one tablet by mouth two times a day, Multiple Vitamin Tablet; give one tablet by mouth in the morning, Norvasc (medication used for high blood pressure) Tablet 5 mg; give one tablet by mouth in the morning, Oxycodone- Acetaminophen (medication used for moderate to severe pain) Tablet 5-325 mg; give one tablet by mouth three times a day and Venlafaxine (medication used for depression) HCL Oral Tablet 75 mg; give 75 mg by mouth every morning and at bedtime.Review of Resident # 63's MAR dated 09/25/25 revealed RN #521 signed the following medications were administered as ordered; Actos 45mg, Anastrozole 1 mg, Aspirin 81 mg, Buspirone 15 mg, Calcium Carbonate 500 mg, Dailyvite 5000 mcg, Famotidine 20 mg, Galantamine Hydrobromide 4 mg, Januvia 100 mg, Lactobacillus Rhamnosus, Lamictal 100 mg, Lorazepam 1 mg, Meloxicam 7.5 mg, Metformin 1000 mg, Multiple Vitamin, Norvasc 5 mg, Oxycodone- Acetaminophen 5-325 mg and Venlafaxine 75 mg.7. Review of Resident #68's medical record revealed she was admitted on [DATE] with diagnoses including Parkinsonism, hyperlipidemia, gastro-esophageal reflux disease and asthma.Review of the care plan dated 05/19/25 revealed the following care plans: Resident #68 had an impaired metabolic status with an intervention to administer medications and treatments as ordered, and Resident #68 had an impaired neurological status with an intervention to administer medications and treatments as indicated by orders.Review of Resident #68's MDS 3.0 assessment dated [DATE] revealed a BIMS of 13 out of 15, indicating the resident was cognitively intact. The resident was assessed to require assistance with dressing and personal hygiene and set up assistance for eating.Review of Resident #68's physicians orders dated 09/25/25 revealed orders for Carbidopa- Levodopa (medication used for Parkinson's symptoms) Oral Tablet 25-100 mg; give three tablets by mouth in the morning, Docusate Sodium (stool softener) Oral Tablet 100 mg; give one tablet by mouth in the morning, Multivitamin Oral Tablet; give one tablet by mouth in the morning; Omeprazole (medication used for stomach acid) Oral Tablet Delayed Release 20 mg; give one tablet by mouth every morning and at bedtime, Potassium Chloride Crys ER Oral Tablet 10 MEQ; give one tablet by mouth in the morning, Rosuvastatin (medication used for high cholesterol) Calcium Oral Tablet 20 mg; give one tablet by mouth in the morning and Zyrtec Allergy Oral Tablet; give 10 mg by mouth in the morning.Review of Resident #68's MAR dated 09/25/25 revealed RN #521 signed the following medications were administered as ordered; Carbidopa- Levodopa 25-100mg, Calcium 20 mg, Zyrtec 10 mg, Potassium Chloride 10 MEQ, Docusate Sodium 100 mg, Multivitamin, Omeprazole 20 mg and Rosuvastin 20 mg.8. Review of Resident #70's medical record revealed she was admitted on [DATE] with diagnoses including anemia, epilepsy, chronic kidney disease and depression.Review of the care plan dated 08/15/25 revealed the following care plans: Resident #70 had behaviors with an intervention to administer medications as ordered, and Resident #70 was at risk for pain with an intervention to administer medications per orders and observe for side effects and effectiveness.Review of Resident #70's MDS 3.0 assessment dated [DATE] revealed a BIMS score of 08 out of 15, indicating moderate cognitive impairment. The resident was assessed to require dependent assistance with toileting, dressing and bathing. Review of Resident #70's physicians orders dated 09/25/25 revealed orders for Cholecalciferol (Vitamin D) Tablet 1000 units; give two tables by mouth in the morning, Ferrous Sulfate Oral Tablet 325 mg; give one tablet by mouth one time a day, Folic Acid Oral Tablet 400 mcg; give one tablet by mouth in the morning, Gabapentin (medication used to treat seizures and nerve pain) Oral Capsule 300 mg; give one capsule by mouth three times a day, Levetiracetam (medication used to treat seizures) Oral Tablet 750 mg; give one tablet by mouth every morning and at bedtime, Magnesium Oxide Oral Tablet 400 mg; give one tablet by mouth in the morning, Pristiq (medication used to treat depression) Oral Tablet Extended Release 50 mg; give one tablet by mouth in the morning and Tylenol Extra Strength (ES) Oral Tablet 500 mg; give 1000 mg by mouth every morning and at bedtime.Review of Resident #70's MAR dated 09/25/25 revealed RN #521 signed the following medication were administered as ordered; Pristiq 50 mg, Tylenol ES 500 mg, Cholecalciferol 1000 units, Ferrous Sulfate 325 mg, Folic Acid 400 mcg, Gabapentin 300 mg, Levetiracetam 750 mg and Magnesium Oxide 400 mg.Observation on 09/25/25 at 8:18 A.M of South Long Hall nursing medication cart with RN #521 revealed eight medicine cups in the top drawer with initials on them. RN #521 revealed the filled medicine cups belonged to Residents #49, #56, #57, #58, #62, #63, #68 and # 70. Interview on 09/25/25 at 8:20 A.M. with RN #521 revealed she had pre-pulled the morning medications for the eight residents and placed the medicine cups in the top drawer to dispense later. Further interview with RN #521 revealed she was not allowed to have pre-pulled medicine. RN stated, I know I'm not allowed to pre pull meds like that, I'm really not supposed to do that. RN #521 also verified all the medications in each medicine cup for each of the eight residents.Interview on 09/29/25 at 11:30 A.M. with the Director of Nursing (DON) revealed nurses should pull medications at the time they are administering them to the resident, they are not allowed to pre pull medications.This deficiency represents non-compliance investigated under Complaint Number 2614688.

Based on medical record review, staff interview, facility fall investigation reports, and facility policy review, the facility failed to develop and implement timely interventions after a resident fall. This affected one (Resident #1) of three residents reviewed for falls. The facility census was 96. Findings Include: Resident #1 was admitted to the facility on [DATE]. Her diagnoses were conversion disorder, intellectual disabilities, aneurysm of heart, hypertension, hyperparathyroidism, chronic obstructive pulmonary disease, lack of coordination, dysphagia, dementia, major depressive disorder, spondylosis, muscle weakness, cognitive communication deficit, difficulty walking, osteoarthritis, hypothyroidism, osteoporosis, and hypertensive heart disease. Review of Resident #1's Minimum Data Set (MDS) assessment, dated 11/18/24, revealed she had a mild cognitive impairment. Review of Resident #1 fall investigation, dated 09/30/24, revealed she attempted to go to the bathroom independently, and fell between the toilet and the wall. Review of the fall investigation report and summary revealed the interventions put in place were replacing the non-skid strips in the bathroom and continued reminders and education on unassisted transfers and toileting. Review of Resident #1 fall investigation, dated 11/08/24, revealed she attempted to go to the bathroom and fell in between the wall and the toilet. Review of the fall investigation report and summary revealed the intervention put in place was education to Resident #1 to use the call light both before and after using the toilet. Review of Resident #1 fall and incident investigation records and care plans, dated 09/30/24 to 11/15/24, revealed there were no other interventions put in place to reduce the likelihood of Resident #1 going to the bathroom independently or performing tasks in the bathroom without staff assistance. The only intervention to assist with preventing Resident #1 going to the bathroom independently, was educating her about asking for assistance prior to going. Interview with the Director of Nursing (DON) on 12/12/24 at 8:06 A.M. confirmed they have tried to educate Resident #1 about asking for help and educating staff to watch for signs Resident #1 exhibits when she is going to the bathroom. One sign that Resident #1 needs to go to the bathroom is when she wheels her chair into her room; staff should be aware of this. The DON stated Resident #1 spent most of her time in the hall and common areas. Interview with Certified Nursing Aide (CNA) #70 on 12/12/24 at 12:22 P.M. confirmed they are to check on Resident #1 every two hours to see if she needs to go to the bathroom. She confirmed she is aware that Resident #1 will go to the bathroom on her own; they try to catch her before she gets up or remind her to use her call light, but those are the interventions they have in place. Review of the policy Fall Prevention Program, dated 10/26/23, revealed each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness and the plan of care will be revised as needed.

Based on interview, medical record review and review of facility policy, the facility failed to complete laboratory testing as ordered by the physician for Resident #81. This affected one resident (#81) of two residents reviewed for hydration. The facility census was 96. Findings include: Review of Resident #81's medical record revealed an admitted [DATE] with diagnoses including type two diabetes mellitus, neuromuscular dysfunction of the bladder, anxiety disorder, osteomyelitis, cognitive communication deficit, depression, colostomy status, and resistance to vancomycin. Review of Resident #81's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #81's laboratory results dated [DATE] revealed her potassium was high at 5.6 milliequivalents (mEq) per liter (L). Review of Resident #81's progress note dated 12/4/24 revealed her potassium was 5.6 mEq/L on her laboratory results. The Certified Nurse Practitioner (CNP) gave an order for Kayexalate (a medication used to lower the amount of potassium in the blood) and to repeat lab orders on 12/05/24. Review of Resident #81's medical record revealed her next labs were drawn on 12/10/24. Interview on 12/11/24 at 8:18 A.M. with the Director of Nursing (DON) verified Resident #81's labs were not redrawn on 12/05/24 as ordered by the CNP.

Based on interview and medical record review the facility failed to ensure medication parameters were in place and followed for Resident #34, #69, and #79, who received blood pressure medication. This affected three residents (#34, #69, and #79) of six residents who were reviewed for medication administration. The facility census was 96. Findings include: 1. Review of the medical record for Resident #69 revealed an admitted [DATE] with diagnoses including cerebral infarction, type two diabetes mellitus, acute respiratory failure, osteomyelitis, cognitive communication deficit, anxiety disorder, osteoarthritis, and hypertension. Review of Resident #69's quarterly Minimum Data Set (MDS) 3.0 dated 11/22/24 revealed he had intact cognition. Review of Resident #69's plan of care dated 07/17/24 revealed the resident had impaired cardiovascular status related to hyperlipidemia and hypertension. Interventions included observing and reporting to the physician any signs of hypertension, administering medications as ordered, and observing vital signs as needed. Review of Resident #69's physician order dated 11/16/24 revealed an order for Metoprolol Tartrate (an antihypertensive) 25 milligrams (mg) one tablet by mouth every morning and at bedtime related to hypertension. There were no parameters for holding the medication Review of Resident #69's Medication Administration Record (MAR) from 12/01/24 to 12/08/24 revealed the resident's Metoprolol medication was held on 12/01/24 for a blood pressure of 94/54 mmHg, twice on 12/02/24 for a blood pressure of 102/59 mmHg and 98/61 mmHg, on 12/05/24 for a blood pressure of 110/57 mmHg and 106/61 mmHg, on 12/06/24 for a blood pressure of 96/54 mmHg, and on 12/08/24 for a blood pressure of 110/48 mmHg. His medication was not held on 12/03/24 for a blood pressure of 106/68 mmHg and on 12/09/24 for a blood pressure of 107/58 mmHg. His blood pressure was not recorded as assessed on 12/03/24, 12/04/24, 12/07/24, and 12/08/24. Review of Resident #69's progress notes dated 12/01/24 to 12/08/24 revealed no indication the physician was notified the medication was held. Interview on 12/12/24 at 9:09 A.M. and 9:12 A.M. with the Director of Nursing (DON) verified nursing was holding Resident #69's blood pressure medications without parameters and without notifying the physician. She reported blood pressure parameters should be in place. The DON indicated the medication should be held for a systolic blood pressure reading below 110 mmHg and/or a diastolic blood pressure reading below 60 mmHg. 2. Review of Resident #34's medical record revealed an admitted [DATE] with diagnoses including end stage renal disease with dependence on renal dialysis, type two diabetes mellitus, chronic obstructive pulmonary disease, psychosis, and cognitive communication deficit. Review of Resident #34's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #34's physician order dated 11/26/24 revealed an order for carvedilol (an antihypertensive) one tablet twice a day for high blood pressure. The medication was to be held prior to dialysis on Monday, Wednesday, and Friday. Review of Resident #34's MAR for 12/02/24 to 12/11/24 revealed carvedilol was not held prior to dialysis on 12/02/24, 12/04/24, 12/06/24, and 12/11/24. Interview on 12/12/24 at 9:09 A.M. with the Director of Nursing (DON) verified Resident #34's carvedilol was not held as ordered. 49039 3. Review of the medical record for Resident #79 revealed an re-admitted [DATE] with diagnoses of chronic kidney disease, type two diabetes mellitus, atrial fibrillation, essential hypertension, pain and venous insufficiency. Review of Resident #79's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he was cognitively intact and had hypertension. Review of Resident #79's care plan dated 10/31/24 revealed he had impaired cardiovascular status related to angina/chest pain, coronary artery disease, hyperlipidemia/hypercholesteremia, hypertension, obesity, and pacemaker placement. Listed interventions include labs/diagnostic testing as ordered, administering medications as ordered, observing for side effects and reporting to the physician, and observing vital signs as needed. Review of Resident #79's physician orders dated 09/06/24 revealed the resident received isosorbide mononitrate (a nitrate used to prevent chest pain and lower blood pressure) extended release 30 mg by mouth in the morning related to hypertension, nifedipine (an antihypertensive) extended release oral tablet 30 mg every morning related to hypertension, and carvedilol 3.125 mg every morning and bedtime related to hypertension. Review of Resident #79's MAR for 12/01/24 to 12/10/24 revealed no hold parameters were in place for the resident's ordered isosorbide mononitrate, nifedipine, and carvedilol. Resident #79 was listed as having received his ordered dose of carvedilol on the evening of 12/02/24 with a blood pressure result of 105/66 mmHg, on the morning of 12/03/24 with a blood pressure result of 108/62 mmHg, on the evening of 12/03/24 with a blood pressure result of 93/53 mmHg, on the morning of 12/04/24 with a blood pressure result of 108/92 mmHg, on the evening of 12/06/24 with a blood pressure result of 96/90 mmHg, on the evening of 12/09/24 with a blood pressure result of 102/72 mmHg, and on the evening of 12/10/24 with a blood pressure result of 107/64 mmHg. Review of Resident #79's progress notes dated 12/02/24 and 12/08/24 revealed carvedilol was held due to low blood pressure, but neither note indicated the physician had been notified. Review of Resident #79's updated physician orders dated 12/12/24 revealed the resident's orders for carvedilol and nifedipine received parameters to hold if the systolic blood pressure reading below 110 mmHg and/or a diastolic blood pressure reading below 60 mmHg. Interview on 12/12/24 at 08:49 AM with Licensed Practical Nurse (LPN) #45 revealed nursing has parameters to hold the medication. The parameter is located in the medical record next to hypertension, stating (I10), which meant to hold the blood pressure medications if the blood pressure is under 110. LPN #45 was asked to clarify what the first digit next to hypertension was, and LPN #45 confirmed it was an I and not a 1 and stated the I must have been an error. LPN #45 confirmed some of the administrations on Resident #79's MAR were not held when the blood pressures were under 110. LPN #45 confirmed the residents' medication orders did not include specific parameters written in or in any additional areas. LPN #45 stated if Resident #79's systolic blood pressure is lower than 110, she is required to hold the medication and notify the physician, which should be documented in the resident's medical record. Interview on 12/12/24 at 09:08 AM with the DON confirmed all residents who receive blood pressure medications should have parameters to hold the medication if the systolic blood pressure is less than 110 mmHg and/or the diastolic blood pressure is less than 60 mmHg. The DON verified the nursing staff is also required to notify the physician of low blood pressure readings and medications which have been held.

Based on interview, record review, and policy review, the facility failed to ensure as-needed controlled medications were recorded on the Medication Administration Record (MAR) when administered. This affected one resident (Resident #81) of two residents reviewed for pain management. The facility census was 96. Findings include: Review of Resident #81's medical record revealed an admitted [DATE] with diagnoses including type two diabetes mellitus, neuromuscular dysfunction of the bladder, anxiety disorder, osteomyelitis, cognitive communication deficit, depression, colostomy status, and resistance to vancomycin. Review of Resident #81's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #81's plan of care dated 02/23/24 revealed Resident #81 was at risk for pain related to comorbidities. Interventions included but were not limited to administering medications as ordered, offering non-pharmacological interventions to relieve pain, and observing for effectiveness. Review of Resident #81's physician orders from 11/11/24 to 12/08/24 revealed an order for Oxycodone (a controlled, narcotic analgesic) 5 milligrams (mg), give two tablets by mouth every four hours as needed for pain. The order specified nonpharmacological interventions were to be attempted prior to medication administration. Reconciliation of Resident #81's MAR and Controlled Drug Receipt Record (CDRR) for November 2024 revealed the following discrepancies related to oxycodone: - 11/02/24 - four doses were signed out on the CDRR, and two doses recorded on the MAR - 11/05/24 - four doses were signed out on the CDRR, and two doses were recorded on the MAR - 11/06/24 - three doses were signed out on the CDRR, and two doses were recorded on the MAR - 11/09/24 - six doses were signed out on the CDRR, and three doses were recorded on the MAR - 11/13/24 - five doses were signed out on the CDRR, and three doses were recorded on the MAR - 11/23/24 - four doses were signed out on the CDRR, and two doses were recorded on the MAR - 11/24/24 - four doses were signed out on the CDRR, and three doses were recorded on the MAR - 11/25/24 - four doses were signed out on the CDRR, and two doses were recorded on the MAR - 11/27/24 - four doses were signed out on the CDRR, and three doses were recorded on the MAR Reconciliation of Resident #81's MAR and CDRR from 12/01/24 to 12/08/24 revealed the following discrepancies related to oxycodone: - 12/04/24 - three doses were signed out on the CDRR, and two doses were recorded on the MAR - 12/07/24 - four doses were signed out on the CDRR, and two doses were recorded on the MAR - 12/08/24 - five doses were signed out of the CDRR, and four doses were recorded on the MAR. Interview on 12/11/24 at 3:42 P.M. with the Director of Nursing (DON) verified nursing staff had not documented in the MAR all administrations of Resident #81's Oxycodone.

Based on interview, record review, and facility policy review, the facility failed to ensure residents received trauma-informed care that accounted for the resident's experiences and preferences in order to minimize or eliminate triggers that may cause re-traumatization of the residents. This affected two residents (#73 and #43) of two residents reviewed for trauma informed care. The facility census was 96. Findings include: 1. Review of Resident #73's medical record revealed an admitted [DATE]. Medical diagnoses included fracture of the left radius, chronic obstructive pulmonary disease, systemic lupus, major depressive disorder, muscle weakness, dysphasia, cognitive communication deficit, and post traumatic stress disorder (PTSD). Interview on 12/09/24 at 10:55 A.M. with Resident #73 confirmed that she had witnessed a family suicide, and was triggered by gun shots and loud noises. Resident #73 stated she had not been involved in care planning related to her PTSD diagnosis, but she used coloring and crafting as non-pharmacological coping methods to manage her mood. Interviews on 12/10/24 at 1:26 P.M. and 1:45 P.M. with Social Services Director (SSD) #48 confirmed upon admission, an initial social service assessment was completed for all residents. If a resident had identified triggers, the care plan was built around those triggers. SSD #48 was unaware of the nature and source of Resident #73's PTSD, and stated that no triggers had been reported or identified. Review of Resident #73's Initial Social Service History assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 15 (indicating intact cognition). Resident #73 was documented as having experienced a frightening, horrible, or traumatic event, such as, a loved dying through homicide or suicide. Resident #73 was documented as trying hard not to think about the event, was constantly on guard, and was easily startled. Review of Resident #73's Behavior Management Monthly Note dated 10/01/24, 10/30/24, and 11/27/24 revealed the resident had behavior-related diagnoses of bipolar disorder, major depressive disorder, anxiety, PTSD, and schizoaffective disorder. Resident #73 was documented as having no known triggers on all three documents. Review of Resident #73's PTSD care plan, revised 09/18/24, revealed the resident had impaired mood/psychiatric status related to depression, anxiety, bipolar disorder, PTSD, and schizoaffective disorder. The listed goal was for Resident #73 to remain free of signs and symptoms of depression, anxiety, or sad mood. Care planned interventions included to administer medications and treatments as ordered, assist Resident #73 to cope by discussing possible solutions to conflict, behavioral health consultations as needed, and encourage on-going involvement with family and friends. 49039 2. Review of the medical record for Resident #43 revealed an admitted [DATE]. Medical diagnoses included schizophrenia, chronic pain syndrome, bipolar disorder, anxiety, PTSD, and impulsiveness. Review of Resident #43's Minimum Data Set (MDS) 3.0 quarterly assessment completed 11/05/24 revealed Resident #43 was moderately cognitively impaired, exhibited verbal behavioral symptoms towards others, and rejection of care four to six days of the week. Review of diagnoses coded on the assessment revealed psychiatric/mood disorders of anxiety, depression, bipolar disorder, schizophrenia, and PTSD. Review of Resident #43's care plan dated 09/06/23 revealed the resident had impaired mood/psychiatric status related to schizophrenia, depression, anxiety, bipolar disorder, PTSD, and insomnia. Interventions included administering medications and treatments, assisting the resident to cope by discussing possible solutions to conflict, behavioral health consults, observing for and reporting any signs and/or symptoms of changes in mood or acute psychosis from the resident's baseline, and observing mood to determine if problems appear to be related to external causes. Review of Resident #43's progress notes revealed a note dated 08/11/24 which stated the resident was noted to be agitated and yelling at beginning of shift and was medication-seeking. Review of Resident #43's two-week psychiatry follow-up note dated 08/15/24 revealed the provider re-evaluated the patient for a history of schizoaffective disorder, anxiety, PTSD, and dementia. Resident #43 reported situational irritability and was noted to have tolerated medication changes since the last session. Resident #43 remained at baseline for mood and behaviors. Anxiety remained at baseline, with no new or worsening symptoms reported. The note indicated there was no reports of depression, PTSD, aggression, irritability, or agitation. Review of Resident #43's progress notes revealed a note dated 08/28/24 which stated the resident was observed to be yelling at staff that morning. Review of Resident #43's Social Service Progress Review dated 05/08/24 revealed the resident was oriented, had no memory issues, and was independent with daily decision-making. She had a diagnosis of PTSD, with PTSD symptoms noted as being managed effectively, with no mention of any known triggers. Interview on 12/10/24 at 1:50 P.M. with Social Services Director (SSD) #48 confirmed Resident #43 has a current diagnosis of PTSD with no mention of triggers in the care plan or attempts to identify the triggers. SSD #48 confirmed the care plan does not include information pertinent to the treatment of PTSD, and therefore, she is unable to confirm symptoms are being managed effectively if the triggers are not identified. Review of a policy Trauma Informed Care dated 10/24/22 revealed the facility would ensure residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice. The facility will account for residents' experiences, preferences, and cultural differences to eliminate or mitigate triggers that may cause re-traumatization of the resident. The facility care plans will be initiated and updated to address those residents identified. Individualized approaches will be identified, and interventions will be put into place.

Based on record review, interview, and facility policy review, the facility failed to ensure dietician recommendations were implemented timely and orders were followed. This affected 2 (Residents #12 and #74) of six residents reviewed for nutrition. The facility census was 96. Findings Include: 1. Review of the medical record for Resident #12 revealed an admitted [DATE]. Medical diagnoses included chronic kidney disease, dysphasia, muscle weakness, major depressive disorder, cognitive communication deficit, anemia, gastro-esophageal reflux disease (GERD) and unspecified psychosis. Review of Resident #12's care plan dated 10/31/23 revealed the resident was at risk for altered nutritional status related to therapeutic diet, and medical diagnosis that include hypertension, peripheral vascular disease, depression, cognitive communication deficit, anemia, and GERD. A listed goal included for Resident #12 to receive and tolerate his diet, and to maintain weight with no further significant changes. Care planned interventions included to periodically obtain the resident's weight, evaluate, and report to dietician, provider, and responsible party any significant weight changes. Review of Resident #12's Minimum Data Set (MDS) 3.0 quarterly assessment completed 09/19/24 revealed the resident was moderately cognitively impaired, was independent with activities of daily living including eating, was on a mechanically altered and therapeutic diet. Review of Resident #12's physician orders revealed an order dated 10/27/24 for weekly weight to be obtained in the morning every Sunday for weight monitoring. Resident #12 also had an order dated 09/11/24 for a diet of NAS (No Added Salt) diet, Level 3 texture, Regular fluid, thin consistency and fortified pudding with lunch and dinner. Review of Resident #12's weight summary revealed weekly weights were completed on 10/28/24, 11/03/24, 11/30/24, and 12/01/24. There was no recorded weekly weights for 11/10/24, 11/17/24, or 11/24/24, or 12/08/24. Interview on 12/11/24 at 4:03 P.M. with the Director of Nursing (DON) confirmed nursing staff did not obtain Resident #12's weights as ordered. 2. Review of the medical record for Resident #74 revealed an admitted [DATE]. Medical diagnoses included schizophrenia, major depressive disorder, anxiety, GERD, dysphasia and chronic kidney disease. Review of Resident #74's MDS 3.0 quarterly assessment completed 10/14/24 revealed the resident was cognitively intact, required setup/clean-up assistance with meal service and was on a therapeutic diet. Review of Standards of Care Meeting dated 11/05/24 revealed the interdisciplinary team met to review Resident #74 weight loss and noted the resident had lost 6.9% of her body weight in one month. Resident #74 received 90 milliliters (ml) Med Pass (liquid nutritional supplement) three times per day, and the note indicated the Med Pass supplement was to be increased to 120 ml three times a day and Resident #74 would be placed on weekly weight monitoring. Review of Resident #74's progress notes dated 11/06/24 revealed the interdisciplinary team met regarding Resident #74's weight loss. The note indicated a new order was received to increase Med Pass supplement to 120 ml three times a day and to obtain weekly weights for four weeks. Review of Resident #74's physician orders revealed an order dated 07/04/24 for Med Pass 90 ml three times a day for nutritional supplement. Resident #74 had an order dated 11/10/24 for weekly weights for four weeks, to be completed on day shift every Sunday. An order dated 12/09/24 indicated Resident #74 required a regular diet with level 3 texture, and thin/regular liquid consistency. Review of Resident #74's weight summary revealed weights were taken on 11/03/24, 11/18/24, 11/24/24, 12/02/24 and 12/08/24 with weight gain. There was no recorded weekly weight for 11/10/24 which created a 15 day gap in weight tracking. Interview on 12/11/24 at 4:03 P.M. with the DON confirmed nursing staff did not obtain Resident #74's weights as ordered on 11/10/24. The DON additionally confirmed staff did not modify the residents order for Med Pass supplement to increase the amount to 120 ml three times a day. Review of the policy Weight Monitoring, dated 10/26/23, revealed a weight monitoring schedule will be created upon admission for all residents, with those experiencing weight loss being monitored on a weekly basis. Interventions will be identified, implemented, and regularly assessed and adjusted based on the resident's assessed needs, preferences, goals, and current professional standards to ensure the maintenance of an acceptable nutritional status.

Based on observation, interview, medical record review, and policy review, the facility failed to ensure residents who were dependent on staff for assistance received turning and repositioning and transferring to a char as ordered by the physician. This affected one (Resident #59) of two residents reviewed for positioning. The facility census was 96. Findings include: Review of the medical record for Resident #59 revealed an admitted [DATE]. Medical diagnoses included cerebral palsy, hydrocephalus, speech disturbances, contractures of muscle, dysphasia, cognitive communication deficit, and congenital deformities of skull, face and jaw. Review of the care plan dated 10/30/23 revealed Resident #59 had activities of daily living self-care performance deficit related to cerebral palsy, cognitive impairment, and an impaired ability to communicate. Listed interventions included placing the resident in a chair from 10 A.M. to 2 P.M. daily and encouraging participation in activities. The care plan also indicated Resident #59 was at risk for impaired skin integrity due to being confined to a chair most of the time, impaired cognition, bladder and bowel incontinence, need for assistance with daily living activities, and preventive tube feed site dressing. Interventions included turning and repositioning as needed, as well as encouraging the resident to reposition himself if able. Review of Resident #59's physician orders revealed an order dated 01/12/24 which stated Resident #59 was to remain in a chair from 10 A.M. to 2 P.M. daily and engage in activities. A follow-up order dated 10/31/24 instructed staff to turn and reposition Resident #59 every two hours. Review of the Minimum Data Set (MDS) 3.0 assessment completed 09/02/24 revealed Resident #59 was severely cognitively impaired, fully dependent on staff for all daily activities, and at high risk for developing pressure ulcers/injuries. Review of the Braden Scale for predicting pressure sore risk, dated 11/19/24, revealed Resident #59 had very limited sensory perception, was occasionally moist, chairfast, completely immobile, with adequate nutritional intake and potential for friction and shear. These factors indicated a moderate risk for skin impairments. Review of the task labeled turn and reposition every two hours and as needed (PRN) revealed on 12/11/24, Resident #59 was documented as being turned at 12:56 A.M., 1:59 P.M., and 8:33 P.M. Observations on 12/11/24 at 11:43 A.M. of Resident #59 revealed the resident was awake and lying in bed. He was positioned with his knees pointed toward the wall, and his legs were bent, with the right leg on top of the left. He was wearing socks on both feet, but his heels were not elevated off the bed. The resident was not covered with a blanket. A specialized chair was present in the resident's room. The specialized chair had a lap tray positioned directly over the top of the seat. The lap tray contained a small amount of clutter on the top of the tray. Observation on 12/11/24 at 1:42 P.M. and 3:01 P.M. revealed Resident #59 remained in the same position in the bed as observed at 11:43 A.M. The specialized chair and lap tray remained in the same location in the resident's room. The clutter on the top of the tray remained unchanged. Observation on 12/11/24 at 4:12 P.M. of Resident #59 revealed both of his socks had been removed, he had been covered up with a blanket, and his legs were propped up on a pillow. His body position remained unchanged from the prior observations at 11:43 A.M, 1:42 P.M., and 3:01 P.M. Interview on 12/11/24 at 4:15 P.M. with Certified Nursing Assistant (CNA) #75 confirmed Resident #59 required assistance with turning and needed to be repositioned every two hours. She explained CNAs were not allowed to perform this task because the resident has a tube feed. CNA #75 clarified the nurse assigned to the resident was responsible for turning him. CNA #75 confirmed she had not transferred Resident #59 to his specialized chair nor had she turned him every two hours during her shift. Interview on 12/11/24 at 4:17 P.M. with Licensed Practical Nurse (LPN) #65 confirmed Resident #59 required assistance with turning, and both CNAs and nursing staff were responsible for repositioning Resident #59 every two hours. LPN #65 stated she had recently entered Resident #59's room to remove the resident's socks and apply lotion but was unable to recall when he was last turned before adjusting his legs. LPN #65 confirmed physician orders specified the resident should be placed in the chair from 10 A.M. to 2 P.M. daily and repositioned every two hours. She noted CNAs do not have direct access to physician orders but can read the care plan. Observation on 12/11/24 at 5:33 P.M. of Resident #59 showed he had been repositioned since the prior observation. Resident #59 was positioned on his left side, with his knees bent and left leg positioned above his right leg. Subsequent review of Resident #59's medical record revealed the task labeled turn and reposition every two hours and PRN on 12/11/24 at 5:35 P.M. revealed the resident's recent repositioning had not been documented in his medical record. Interview on 12/12/24 at 12:36 P.M. with the Administrator and Director of Nursing (DON) confirmed Resident #59's medical record lacked evidence to indicate the resident was regularly repositioned every two hours or placed in his chair between 10 A.M. and 2 P.M.as ordered. Review of the turning and repositioning policy, dated 01/01/22, revealed all residents at risk of pressure injuries should be turned and repositioned every two to four hours. This task is primarily the responsibility of nursing assistants, though all nursing staff are expected to assist. The routine turning schedule involves alternating between side-lying and back positions, rotating between the right side, back, and left side.

Based on interview, record review, and review of facility policy the facility failed to ensure a referral to an ophthalmologist for cataract surgery was made for Resident #17. This affected one resident (#17) of two residents reviewed for communication and sensory. The facility census was 96. Findings include: Review of Resident #17's medical record revealed an admitted [DATE] with diagnoses including type two diabetes mellitus, depression, anxiety, myasthenia gravis, dysphagia, personality disorder, and chronic respiratory failure. Review of Resident #17's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #17's plan of care dated 10/31/23 revealed the resident was at risk for visual impairment related to age, diabetes, and myasthenia gravis. Interventions included administering medications and treatments as ordered, arranging a consultation with the eye care provider as needed, encouraging the resident to wear glasses, and assist with applying glasses as needed. Review of Resident #17's note dated 07/23/24 from the eye care group revealed the eye doctor's plan for the resident included a recommendation for cataract survey through a ophthalmology consult. Review of Resident #17's medical record from 07/23/24 to 12/09/24 revealed no evidence a referral was made to ophthalmology. Interview on 12/09/24 at 12:38 P.M. with Resident #17 revealed she had seen the eye doctor that morning and he had told her the facility was supposed to have followed up to help her get cataract surgery. Interview on 12/11/24 at 3:00 P.M. with the Director of Nursing (DON) verified there had been a recommendation for a referral that was not completed. Review of the policy 'Hearing and Vision Services' dated 10/30/23 revealed once vision or hearing services have been identified the resident was to be assisted in making appointments and arranging for transportation if needed.

Based on observation, staff interview, and facility policy review, the facility failed to ensure dietary spreadsheets were followed and all food items on the spreadsheets were offered to the residents according to their needs on a level three dysphagia diet. This affected 14 residents, (Residents #6, #10, #14, #17, #31, #33, #48, #59, #61, #64, #66, #72, #85, and #89) the facility identified as having physician orders for a level three dysphagia diet, out of 87 residents receiving meals from the kitchen. Resident #68 was identified by the facility as receiving nothing by mouth. The facility census was 88. Findings Include: Review of the lunch menu dated 02/07/24 revealed ham steak, rice pilaf, broccoli and cheese sauce, assorted cookies, and a beverage was the scheduled meal. Review of the dietary spreadsheets dated 02/07/24 revealed residents with an a level three dysphagia diet should receive ground ham steak with gravy, soft rice pilaf with gravy, chopped soft broccoli and cheese sauce, and pudding. Observation of tray line for the lunch meal on 02/07/24 at 11:55 A.M. with Cook #712 revealed the chopped broccoli for the residents on an ordered level three dysphagia diet was plain in water and did not have a cheese sauce. Continuous observation on 02/07/24 from 11:55 A.M. to 12:25 P.M. of lunch tray line service revealed the plain chopped broccoli was served to all residents without a cheese sauce. Interview on 02/07/24 at 12:25 P.M. with Dietary Manager (DM) #710 confirmed the chopped broccoli did not have a cheese sauce. DM #710 confirmed according to the dietary spreadsheet, the chopped broccoli should have had a cheese sauce. Review of the facility policy, Therapeutic Diets, dated 09/01/21, revealed the policy stated, diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care.

Based on record review, staff interviews, review of laboratory test results, review of McGreer's criteria for infections, and facility policy review, the facility failed to follow antibiotic stewardship policies and procedures prior to starting antibiotic treatment for two residents (Residents #43, and #84). The facility also failed to ensure laboratory test results were received prior to starting antibiotic treatment for one resident (Resident #11). The deficient practices affected three residents (Residents #11, #43, and #84) of seven residents reviewed for infections and antibiotic use. The facility census was 88. Findings Include: Review of the medical record for Resident #11 revealed an initial admitted on 06/08/21 and a readmitted on 10/23/23. Medical diagnoses included schizoaffective disorder, chronic obstructive pulmonary disorder (COPD), other irritable bowel syndrome, other disorders of urea cycle metabolism, delusional disorders, overactive bladder, urinary tract infection, and severe chronic kidney disease stage four. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had mildly impaired cognition and scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #11 required variable assistance from staff to complete Activities of Daily Living ranging from set up help to maximal assistance. Review of progress notes for Resident #11 revealed she was sent to a local hospital on 04/24/23 to be evaluated for chest pain and have her medications reviewed. She was discharged back to the facility on [DATE] with a diagnosis of UTI and exacerbation of COPD. On 04/25/23 at 4:03 P.M. the progress notes indicated the hospital sent her back to the facility with an order for Cefdiner. There was no indication a urinalysis with culture and sensitivity (UA C&S) had been done for Resident #11 prior to beginning the course of antibiotic treatment with the Cefdiner which did not meet McGreer's criteria. On 04/29/23 at 11:01 A.M., Resident #11 was sent to another emergency room per her request. A complete UA C&S was completed and found the organism was not susceptible to Cefdinir. Review of the Medication Administration Record (MAR) dated April 2023 revealed Resident #11 had an order for Cefidinir (an antibiotic) 300 milligrams (mg) orally every 12 hours for a urinary tract infection (UTI) for 14 days with a start date on 04/25/23 at 9:00 A.M. and an end date on 05/01/23 at 1:20 P.M. Resident #11 was administered eight doses of the antibiotic from 04/25/23 to 04/28/23 then she went on a leave to the hospital beginning on 04/29/24. Review of the MAR dated May 2023 revealed Resident #11 returned to the facility on [DATE] and had an order for Cefidinir 300 mg orally two times a day related to UTI for seven days with a start date on 05/01/23 at 9:00 P.M. and an end date on 05/04/23 at 4:05 P.M. Resident #11 received six doses of the antibiotic from 05/01/23 to 05/04/23. Beginning on 05/04/23 at 9:00 P.M. a new order for Ciprofloxacin Hydrochloride (HCl) 500 mg orally two times a day for UTI for ten days began to be administered to Resident #11 with an end date of 05/14/23. Resident #11 received 20 doses of the Ciprofloxacin HCL from 05/04/23 to 05/14/23. Further review of the medical record revealed there was no evidence a UA C&S had been completed and resulted prior to Resident #11 being started Cefdinir antibiotic. Review of the laboratory test results for a urinalysis with culture and sensitivity (UA C&S) completed while Resident #11 was at the emergency room dated 05/04/23 revealed Resident #11 had a positive result for a urinary tract infection (UTI) and identified pseudomonas aeruginosa as the organism with a greater than 100,000 CFU/mL growth. Interview on 02/07/24 at 4:25 P.M. with the Director of Nursing (DON) #533 confirmed Resident #11 received doses of the Cefdinir antibiotic prior to obtaining any UA C&S lab results or verifying the resident had exhibited signs or symptoms of infection. DON #533 confirmed once UA C&S lab results were received, Resident #11 required antibiotic treatment with a different antibiotic that the organism was susceptible to. Review of the facility policy, Antibiotic Stewardship Program, revised 12/13/23, revealed the policy stated, antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness. 2. Review of the medical record for Resident #43 revealed an admitted on 10/27/23. Medical diagnoses included Alzheimer's Disease, Type II Diabetes Mellitus with diabetic chronic kidney disease, chronic kidney disease stage 3, and unspecified psychosis. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 had impaired cognition and scored a seven out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #43 required varied assistance from staff to complete Activities of Daily Living (ADLs) which ranged from set up help only to substantial/maximal assistance. Resident #43 was frequently incontinent of bowel and bladder. Review of progress notes for Resident #43 revealed on 01/23/24 at 8:49 P.M., the resident continued with increased behaviors. The Nurse Practitioner visited and ordered a urinalysis with culture and sensitivity (UA C&S). On 01/24/24 at 12:54 A.M., an order for a UA C&S one time only for increased confusion and behaviors was administered. Review of the urinalysis with culture and sensitivity (UA C&S) laboratory test results reported to the facility on [DATE] revealed Resident #43 was positive for a urinary tract infection (UTI). The organism identified was Escherichia coli (e-coli) bacteria with a greater than 100,000 CFU/mL. Review of the Medication Administration Record (MAR) dated February 2024 revealed Resident #43 had an order for Cephalexin 500 milligrams (mg) orally three times a day for infection for five days with a start date on 02/01/24 at 6:00 A.M. Resident #43 received 14 doses of the antibiotic. Review of McGreer's Criteria for a UTI without a catheter revealed Resident #43's symptom of increased confusion was not a valid symptom to use in determining a UTI. Interview on 02/07/24 at 4:32 P.M. with the Director of Nursing (DON) #533 confirmed Resident #43 did not meet the McGreer's criteria for an infection and was treated with antibiotics. DON #533 stated the facility had not been using the McGreer's criteria to determine if a resident met the appropriate criteria for an infection and use of antibiotics and had been treating residents with antibiotics only based on a positive UA C&S result. Interview on 02/08/24 at 3:47 P.M. with Physician #703 revealed some of those UTI's (for Resident #43) probably are not really true UTI's. She has had positive urine cultures. Review of the facility policy, Antibiotic Stewardship Program, revised 12/13/23, revealed the policy stated, antibiotic use protocols: the facility uses the McGreer criteria to define infections. 07316 3. Review of the medical record for Resident #84 revealed an admitted [DATE] and diagnoses of diabetes, chronic kidney disease, and urinary retention. Review of nursing progress notes revealed on 09/12/23 at 1:14 A.M. it was documented that a urine specimen was collected for urinalysis and culture and sensitivity. There was nothing documented to indicate why the urine specimen was collected and no symptoms of a urinary tract infection documented. Review of a laboratory report revealed a urine specimen was collected on 09/12/23 and results on 09/15/23 showed >100,000 Proteus Mirabilis and Escherichia Coli. The nurse practitioner was notified on 09/15/23 at 6:09 P.M. and an order was received for an antibiotic (Bactrim DS 800-160 milligrams) twice daily for seven days for a urinary tract infection. Review of the medication administration record revealed the Bactrim was administered from 09/16/23 to 09/22/23 for a total of 13 doses. Review of the facility infection record (McGeer criteria) revealed a resident must meet criteria 1 and 2 for it to be considered a urinary tract infection. (Criteria 1 includes symptoms and Criteria 2 is a urine culture with >100,000 bacteria). The infection record indicated an onset date of 09/11/23 but did not include any symptoms of a urinary tract infection under Criteria 1. Interview with the Director of Nursing on 02/07/24 at 2:45 P.M. confirmed there were no symptoms of a urinary tract infection documented for Resident #84 on 09/12/23 when a urine specimen was collected. She confirmed the resident was treated with an antibiotic without meeting the facility guidelines/McGeer criteria for a urinary tract infection. Review of nursing progress notes on 10/31/23 at 1:27 P.M. revealed Resident #84 had a suspected urinary tract infection as the resident was complaining of frequency with episodes of confusion. The note stated a urine sample was to be collected and sent out in the morning and an antibiotic (Cipro 500 milligrams) was ordered twice daily for seven days. The note stated once the final results were received, will have to ensure appropriate antibiotic in place. Review of the medication administration record revealed the resident received Cipro 500 milligrams twice daily from 11/01/23 to 11/05/23 (10 doses). Review of urine culture results reported on 11/05/23 revealed >100,000 Escherichia Coli that was not sensitive to Cipro. Review of nursing progress notes on 11/06/23 at 6:28 A.M. revealed final urine culture sent to physician. New order to discontinue Cipro and start a different antibiotic (Nitrofurantoin) 100 milligrams twice daily for seven days. Review of the medication administration record revealed Nitrofurantoin was administered from 11/06/23 to 11/12/23 for a total of 14 doses. Review of the facility infection record (McGeers criteria) revealed an onset date of 10/30/23 and did not document that any criteria had been met to indicate a urinary tract infection. Interview with the Director of Nursing on 02/07/24 at 2:45 P.M. confirmed an antibiotic was started prior to a urinary tract infection being confirmed. She confirmed that the antibiotic the resident received (Cipro) 10 doses of was not an antibiotic that the bacteria was sensitive to so the antibiotic had to be changed. She further confirmed the McGeers form did not indicate criteria was met for a urinary tract infection. Review of nursing progress notes on 11/13/23 at 11:10 A.M. revealed the resident received the last dose of antibiotic and states she feels a little better but not all the way. Continues at times to be slightly confused. Updated nurse practitioner who said ok to get another urine culture if needed in morning. On 11/14/23 at 11:37 P.M. a urine specimen was collected. Review of urine culture results reported on 11/18/23 revealed >100,000 Proteus Mirabilis. The bacteria was not sensitive to any oral antibiotics (only intravenous or intramuscular medications). The resident was started on an antibiotic (Amoxicillin-potassium clavulanate 875-125 milligrams) twice daily for seven days on 11/20/23. This antibiotic was not listed on the urine culture for the bacteria being sensitive to it. Review of the medication administration record revealed the resident received the Amoxicillin-potassium clavulanate from 11/20/23 to 11/27/23 for a total of 14 doses. There was nothing documented to indicate why the antibiotic was not started for two days after the urine culture results were reported. Interview with the Director of Nursing on 02/07/24 at 2:45 P.M. confirmed the resident was still confused so another urine culture was obtained on 11/14/23. She confirmed the bacteria was not listed as sensitive to the antibiotic that was used. She stated she did not know why the antibiotic was not started after the results were reported on 11/18/23. She confirmed the antibiotic did not start until 11/20/23 and could have started 11/19/23 in the morning. Review of a text message from the physician on 02/07/24 at 3:21 P.M. revealed regarding antibiotic selection (on 11/20/23) he chose it as the best oral alternative being the most like the IV ampicillin. This was a clinical decision made to try to avoid having to subject the resident to the greater risk of IV and infusion when this oral alternative is likely to be effective. Review of urine culture results on 01/18/24 revealed >100,000 Proteus Mirabilis. Review of nursing progress notes did not indicate why the urine specimen was collected. There were no symptoms of a urinary tract infection documented. The physician was notified on 01/18/24 at 4:22 P.M. and an antibiotic (Augmentin 875 milligrams) was ordered twice daily for seven days. Review of the medication administration record revealed the antibiotic was given from 01/19/24 to 01/25/24 for a total of 14 doses. Review of physician progress notes from September 2023 to January 2024 revealed they were silent to any treatment of urinary tract infections. Interview with the Director of Nursing on 02/07/24 at 2:45 P.M. revealed the antibiotic was ordered 01/18/24 due to increased confusion/hallucinations. She confirmed Resident #84 did not meet the McGeer criteria for any of the urinary infections she was treated for. Review of the facility policy titled Antibiotic Stewardship Program dated 10/24/22 and revised 12/13/23 revealed the purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Licensed nurses were to follow protocols as established by the program. Antibiotic use protocols include the use of the McGeer criteria to define infections.

Based on observation, staff interview, and facility policy review, the facility failed to follow proper hand hygiene protocols during pureed food preparation. This had the potential to affect all nine residents, (Residents #2, #22, #27, #29, #41, #49, #50, #76, and #297) the facility identified as having physician orders for pureed diets, out of 87 residents receiving meals from the kitchen. Resident #68 was identified by the facility as receiving nothing by mouth. The facility census was 88. Findings Include: Review of the lunch menu dated 02/07/24 revealed ham steak, rice pilaf, broccoli and cheese sauce, assorted cookies, and a beverage was the scheduled meal. Review of the dietary spreadsheets dated 02/07/24 revealed residents with an ordered pureed textured diet should receive pureed ham steak, pureed rice pilaf, pureed broccoli with cheese sauce, pureed cookies, and a beverage. Review of the recipe, Pureed Ham Steak, revealed for preparation, combine chicken base and water to make chicken broth. Place prepared meat in a washed and sanitized food processor. Gradually add broth and blend until smooth. If product needs thinning, gradually add an appropriate amount of liquid (not water) to achieve a smooth, pudding or soft mashed potato consistency. If the product needs thickening, gradually add a commercial or natural food thickener (potato flakes or baby rice cereal) to achieve a smooth, pudding or soft mashed potato consistency. Observation of the pureed ham steak preparation on 02/07/24 at 10:30 A.M. with Cook #712 revealed the cook washed her hands at the sink and put on clean gloves. Cook #712 turned around to the steamer and grabbed two oven mitts from the top of the steamer and proceeded to put both of them on over her clean gloves. With the oven mitts on, Cook #712 retrieved a large covered pan from the steamer and placed it on the preparation counter. Cook #712 removed the oven mitts and placed them back on the top of the steamer. Without changing gloves or completing hand hygiene, Cook #712 used tongs to remove several ham steaks from the pan and placed them in the food processor. Cook #712 added a small amount of chicken broth and turned on the processor. Cook #712's glove on her left hand had a hole in the tip of the middle finger which exposed her finger outside of the glove. At 10:40 A.M., Cook #712 was observed touching the inside of the food processor lid and bowl with contaminated gloves on. After checking the ham three or four times, at 10:45 A.M., Corporate Food Manager (CFM) #715 instructed Cook #712 to remove some of the pureed ham steaks from the food processor in order to obtain the desired consistency quicker. Cook #712 grabbed a small metal container already lined with a plastic wrap with the contaminated gloves on. Cook #712 used her right gloved hand to press the inside of the plastic wrap down inside the container and then proceeded to transfer some of the ham from the processor into the container on top of the plastic wrap. Cook #712 continued processing the remaining ham in the processor. At 10:49 A.M., Dietary Manager (DM) #710 was observed handing Cook #712 a clean glove. Cook #712 removed her left glove (that had a hole in the middle finger) and donned the clean glove without washing her hands. At 10:50 A.M., Cook #712 was observed placing her contaminated gloved fingers inside the food processor and inside the plastic lining of the metal container which held some of the pureed ham mixture. At 10:53 A.M., CFM #715 stated, looks good to Cook #712. At that time, Cook #712 stopped the processor and proceeded to transfer all of the pureed ham into the metal container. The pureed ham appeared lumpy during the transfer. At 10:55 A.M., Cook #712 confirmed she was prepared to place the pureed ham on the steam table to be served to residents. Cook #712 removed both gloves and discarded them in a covered trashcan then washed her hands at the sink with soap and water. Interview on 02/07/24 at 10:57 A.M. with Cook #712 confirmed she did not change gloves or wash her hands after placing oven mitts over clean gloves and had touched the inside of the food processor lid, bowl, and the plasic wrap on the inside of the metal container with contaminated gloves on. Cook #712 also confirmed she did not complete hand hygiene after removing the compromised glove from her left hand and donning a clean glove. Review of the facility policy, Hand Washing, dated 09/01/21, revealed the policy stated, wash your hands as often as possible. It is important to wash your hands: before putting on gloves, after handling soiled utensils or equipment, as often as needed during food preparation and when changing tasks. Gloves, wet-wipes, or hand antiseptics are not substitutes for hand washing.

Based on observation, staff interview, review of the pureed ham recipe and facility policy, the facility failed to ensure pureed foods were prepared to the appropriate pureed consistency. This affected nine residents, (Residents #2, #22, #27, #29, #41, #49, #50, #76, and #297) the facility identified as having physician orders for pureed diets, out of 87 residents receiving meals from the kitchen. Resident #68 was identified by the facility as receiving nothing by mouth. The facility census was 88. Findings Include: Review of the lunch menu dated 02/07/24 revealed ham steak, rice pilaf, broccoli and cheese sauce, assorted cookies, and a beverage was the scheduled meal. Review of the dietary spreadsheets dated 02/07/24 revealed residents with an ordered pureed textured diet should receive pureed ham steak, pureed rice pilaf, pureed broccoli with cheese sauce, pureed cookies, and a beverage. Review of the recipe, Pureed Ham Steak, revealed for preparation, combine chicken base and water to make chicken broth. Place prepared meat in a washed and sanitized food processor. Gradually add broth and blend until smooth. If the product needed thinning, gradually add an appropriate amount of liquid (not water) to achieve a smooth, pudding or soft mashed potato consistency. If the product needed thickening, gradually add a commercial or natural food thickener (potato flakes or baby rice cereal) to achieve a smooth, pudding or soft mashed potato consistency. Observation of the pureed ham steak preparation on 02/07/24 at 10:30 A.M. with Cook #712 revealed the cook used tongs to place several ham steaks into the food processor, added a small amount of chicken broth and proceeded to process the ham. At 10:40 A.M. Cook #712 checked the contents of the food processor multiple times. At 10:45 A.M. Corporate Food Manager (CFM) #715 instructed Cook #712 to remove some of the pureed ham steaks from the food processor in order to obtain the desired consistency quicker. Cook #712 transferred some of the ham from the processor into a container and then continued to process the remaining ham still in the food processor. At 10:53 A.M. CFM #715 stated looks good to Cook #712 who then stopped the food processor and proceeded to transfer all of the pureed ham from the food processor into a metal container. The pureed ham appeared lumpy. At 10:55 A.M. Cook #712 confirmed she was ready to place the pureed ham on the steam table to be served to residents and had not sampled the texture of the pureed ham. The surveyor intervened due to seeing lumps in the ham and requested to taste the pureed ham. Upon looking into the container, several intact pieces of the ham skin were present in the pureed ham. The surveyor tasted a spoonful of the pureed ham and felt two intact pieces of the skin or rind on the tongue which required chewing to safely swallow it. Cook #712 verified the pureed ham was not a smooth, pudding or mashed potato like consistency. At 10:57 A.M. during the observation, interviews conducted with Cook #712 and Dietary Manager #710 confirmed the pureed ham was not a safe consistency for residents in need of a pureed diet. Review of the facility policy, Therapeutic Diets, dated 09/01/21, revealed the policy stated, diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care.

Based on observations, medical record review, resident interview, and staff interview, the facility failed to comprehensively assess Resident #84's dental status. This affected one resident (#84) of 27 sampled residents. The facility census was 88. Findings Include: Review of the medical record for Resident #84 revealed an admitted [DATE] with diagnoses including diabetes, chronic kidney disease, and hemiplegia. Review of a nursing admission assessment dated [DATE] revealed it stated Resident #84 does not use dentures or partials and edentulous was not marked. Review of an initial nutrition assessment dated [DATE] revealed it stated Resident #84 had her own teeth. Review of an admission Minimum Data Set (MDS) assessment completed 08/11/23 revealed Resident #84 was not edentulous and did not have broken or loose dentures. Review of a quarterly MDS assessment completed 11/20/23 revealed Resident #84 had a Brief Interview for Mental Status score of 15, indicating intact cognition. It stated the resident did not have broken or loose dentures. Review of a nutritional assessment dated [DATE] revealed it stated Resident #84 had her own teeth. Interview with Resident #84 on 02/06/24 at 8:42 A.M. revealed she had broken her upper denture when she fell at home prior to admission. She stated she needed a new upper denture and had asked to be put on the list to see the dentist. Observations on 02/07/24 at 9:30 A.M. revealed Resident #84 to have her own bottom teeth but no teeth or denture on top. Interview with Nursing Assistant #506 (providing care on the hall where Resident #84 resided) on 02/07/24 at 9:32 A.M. revealed she did not know the resident's dental status as the resident does her own oral care. Interview with Licensed Practical Nurse (LPN) #429 (nurse for Resident #84) on 02/07/24 at 9:42 A.M. revealed she thought Resident #84 had her own teeth and did not require dentures. Interview with MDS LPN #414 on 02/07/24 at 9:56 A.M. confirmed the nutrition assessments, nursing assessment, and MDS assessments were not accurate since Resident #84 did not have all of her own teeth and had dentures on top, which the resident said were broken. She confirmed a comprehensive assessment of Resident #84's dental status was not completed.

Based on observation, record review and interview the facility failed to prevent the development of a pressure ulcer to Resident #14's left ischium, failed to ensure the ulcer was not unstageable at the time it was found and failed to ensure timely and necessary care and treatment was implemented to promote healing and effective pressure relief. Actual harm occurred when Resident #14, who was assessed to be at risk for skin breakdown developed an unstageable (full thickness tissue loss) pressure ulcer to the left ischium from pressure caused by the resident's wheelchair and positioning. This affected one resident (Resident #14) of three residents reviewed for pressure ulcers. Findings include: Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident utilized a wheelchair for mobility. Record review revealed a plan of care was developed, dated 08/11/17 which indicated the resident was at risk for pressure ulcer development related to impaired mobility and history of pressure ulcers with a goal to have intact skin free of redness, blisters or discoloration through 01/20/19. Interventions included to educate resident/family/caregivers as to causes of skin breakdown including transfer/positioning requirements, importance of taking care during mobility, good nutrition, frequent repositioning and to float heels when in bed as tolerated. Record review revealed the plan of care did not include any evidence of pressure reducing devices to be used when the resident was out of bed and in a wheelchair or determining proper positioning in the wheelchair. The care plan also failed to address the frequency for which the resident's skin should be assessed. Review of the Norton Plus Pressure Ulcer Assessment scale, dated 10/10/18 revealed the resident was at moderate risk for developing a pressure ulcer. Review of the bath sheet documentation completed by state tested nursing assistant (STNA) staff, dated 11/05/18, 11/08/18 and 11/12/18 revealed Resident #14 had no skin breakdown. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was alert and oriented with a Brief Interview for Mental Status (BIMS) score of 15. The assessment revealed the resident required total assistance from staff for transfers and bed mobility and was dependent on one staff member for personal hygiene. There was no indication the resident refused or was resistive to care. Record review revealed on 11/15/18 during a shower/bath, Resident #14 was found to have an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer to the left ischium. The pressure ulcer was assessed to be three (3) centimeters (cm) in length by three (3) cm width with depth that could not be determined (UTD). Record review revealed the Norton Plus Pressure Ulcer Assessment scale was not repeated after the resident developed the unstageable pressure ulcer as per facility policy. Review of a nursing progress note, dated 11/15/18 and completed by Registered Nurse (RN) #13 revealed Resident #14 had a wound to the left hip/ischium and included the following description: non-stageable pressure ulcer to left hip wound measuring 3.0 cm length by 3.0 cm width with UTD (depth) due to eschar. The surrounding tissue was light pink, measuring 0.5 cm with no pain to the area. The note indicated the Director of Nursing (DON) was notified and wanted to view how the resident sits in the wheelchair as perhaps the area may be being compromised with sitting in the wheelchair. A new intervention was initiated at that time to remind/assist resident with repositioning frequently while up in wheelchair. A treatment was ordered on [DATE] to cleanse the pressure ulcer with normal saline, pat dry, apply [MEDICATION NAME] gel and cover with a dry dressing. The order was changed the next day, on 11/16/18 to use Santyl (a [MEDICATION NAME] agent) ointment, apply to wound every day shift for wound care. Following the identification of the unstageable pressure ulcer, Resident #14's plan of care was updated to include the use of a low air loss mattress to the bed, reminding the resident to reposition in wheelchair frequently, encourage and assist to turn and reposition frequently when in bed, identify/document potential causative factors and eliminate/resolve where possible. The care plan did not include any pressure reducing device when up in wheelchair or determining proper positioning in chair. The care plan also failed to address assessing the resident's skin weekly by the nurse or assessing the resident for pain. A nursing progress note, dated 11/20/18 revealed no change to the left ischium unstageable pressure ulcer. Record review revealed at the time of the development of the pressure ulcer, the resident was being seen by physical therapy. A therapy note, dated 11/20/18 indicated the resident was being seen for wheelchair management for modification of wheelchair components to enhance the resident's function/posture and analysis of resident's body alignment and functional skills in new or existing wheelchair. Staff were educated on positioning to allow for better posture and comfort at that time. There was no specific mention of positioning related to the unstageable pressure ulcer in the therapy note dated 11/20/18. A nursing progress note, dated 11/27/18 reflected the unstageable pressure injury to left buttocks with 100% firmly adherent white slough tissue. The note dated 12/04/18 revealed some improvement to left ischium ulcer, however, the wound bed was still covered with white, firmly adherent slough. Record review revealed Resident #14 was seen by the physician on 12/04/18. Review of the physician progress notes [REDACTED]. Review of nursing progress notes dated 12/11/18, 12/18/18 and 12/24/18 revealed the resident continued to have an unstageable pressure ulcer to the left ischium with 100% firmly adherent white slough tissue. On 12/17/18 a new physician order [REDACTED]. Change daily and as needed. On 12/26/18 at 10:30 A.M. interview with Resident #14 revealed he had used a cushion when out of bed at home prior to coming to the facility and he didn't know why the facility didn't have this same type of cushion for him to use for pressure relief. During the interview, the resident did not provide any additional information as to how or why he thought the pressure ulcer had developed but acknowledged he required staff assistance for moving in bed and transferring to/from bed to a wheelchair. Following the resident interview on 12/26/18 at 10:30 A.M. Licensed Practical Nurse (LPN) #12 was observed completing wound care for Resident #14. The LPN removed the resident's soiled dressing, cleansed the wound and applied a new dressing utilizing proper infection control techniques and according to physician order. The resident was observed to have an unstageable pressure ulcer with 100% tan-yellow colored slough tissue. At the time of the treatment observation, the wheelchair in Resident #14's room was observed. The resident was observed to have a high back wheelchair with a gel cushion in the seat of it. Upon touching the chair cushion the cushion was found to be hard in the center seat area with a small soft rim that remained cushioned. When removing the cover to inspect the cushion, the gel center was flat and hard and the foam on top was broke down with little to no cushion left. LPN #12 verified the condition of the cushion and indicated she would need to take it to therapy to see if they had another one that would provide pressure relief. On 12/26/18 at 10:53 A.M. interview with the DON verified Resident #14, who was at risk for pressure ulcer development was found to have an unstageable pressure ulcer to the left ischium on 11/15/18 and continued to have the unstageable ulcer as of this date. The DON indicated the most probable cause of the ulcer development was from the resident's positioning in the wheelchair and after the wound developed he was provided a high back wheelchair so staff could tilt it back for positioning. During the interview, the DON indicated the expectation was for weekly skin assessments to be completed for all residents, however the most current assessment for Resident #14 was during the week of 10/31/18. On 12/26/18 at 3:30 P.M. interview with Director of Rehabilitation #15 revealed the therapist who had worked with Resident #14 was not available to interview but from reviewing the notes, it appeared as though therapy was working with the resident for better positioning after the resident got new leg splints. He stated there was no evidence the therapist had looked at him in relation to his wound or related to the development of the pressure ulcer. Review of the facility undated Pressure ulcers/Pressure injury prevention and treatment - clinical protocol revealed based on the comprehensive assessment of a resident, a resident received care consistent with professional standards of practice to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing. Under the protocol for assessment and management the policy reflected weekly skin evaluation/assessments by the licensed nurse on residents who have no current pressure ulcers. The certified nurse aide completes a skin worksheet/point of care documentation with bath or shower. Following a change of condition, complete a new Norton's Plus Scale. The facility clinical protocol revealed the pressure ulcer treatment program should focus on the following strategies: Assessing the resident and the pressure ulcer, managing tissue load and if the pressure ulcer fails to show any evidence of progress toward healing within 2-4 weeks, the area and the residents overall clinical condition should be reassessed. Re-evaluation of the treatment plan included determining whether to continue or modify the current interventions. If deciding to continue the same treatment regimen in the absence of progression, the clinician should document rationale in the medical record. This deficiency substantiates Complaint Number OH 780.

Based on medical record review and staff interview, the facility failed to ensure adequate supervision was provided to prevent a fall. This affected one of four sampled residents of five residents identified with falls and fractures (Resident #81). The census was 93. Harm occurred when the facility failed to ensure adequate supervision was provided for Resident #81 and the resident fell out of her wheelchair and sustained a nasal fracture. Findings include: Review of Resident #81's medical record revealed she had [DIAGNOSES REDACTED]. Review of the Fall/Injury assessment dated [DATE] revealed Resident #81 was assessed as at high risk for falls. Resident #81 was routinely admitted to the facility for respite stays on Thursdays and was discharged to home on Mondays. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #81's cognitive skills were severely impaired and she never or rarely made decisions. Resident #81 required extensive assistance of two plus staff for physical assistance for transfers, dressing, and hygiene. Resident #81 did not ambulate. There was no history of falls identified. Review of the Plan of Care (POC) dated 09/08/11 revealed Resident #81 leaned, was unsteady, and had poor weight-bearing ability. Resident #81 was to have two staff with transfer. However, the POC did not identify the amount of supervision the resident required. The POC also revealed the resident was to have a high/low bed and a low bed with two grab bars. The bed had surrounding modifications of a mat to the floor, lock the bed wheels, and the bed was to be next to the wall. No safety interventions for fall prevention were identified in the POC while she was seated in the wheelchair. Review of the facility's Accident/Incident Report dated 09/16/11 at 5:30 P.M. revealed Resident #81 was found lying on the floor on her right side in her room with her nose bleeding. The facility had obtained the resident's vital signs, started neurological assessments, applied ice packs and gave the resident Tylenol. Review of a written statement from State-tested Nurse Aide (STNA) #5 (which was part of the facility's investigation but not part of the medical record) revealed she and STNA #6 transferred Resident #81 from the bed to her wheelchair. STNA #5 stated before she left the resident in her room, the resident's posture was erect, her face was dry, and her lips were moist. When taking another resident to the shower room, they (STNAs #5 and #6) observed Resident #81 still sitting in her wheelchair with erect posture in an upright position. After assisting STNA #6, STNA #5 went back down the hall, and that was when she had found the resident on the floor with "blood around her face." The statement also revealed there were no alarms to the resident's wheelchair. After STNA #5 observed the resident lying on the floor, she yelled for the nurse. The nurse helped STNA #5 get Resident #81 off the floor and back into bed. According to STNA #5's written statement, the nurse immediately assessed the resident; however, there was nothing documented in the nurses' notes that reflected the nursing assessment was completed. An ice pack was placed on Resident #81's nose, and her head was elevated. STNA #5 placed a towel across the resident's chest in case any bleeding occurred. STNA#5 also revealed in her written statement when the daughter visited, she wanted the resident evaluated at the emergency room . Review of the nurses' notes dated 09/16/11 did not address any information in regard to Resident #81's fall and any injuries that had occurred during the fall. Documentation at 7:30 P.M. by Licensed Practical Nurse (LPN) #7 revealed the resident's daughter was at the facility, was very upset, and insisted the resident be sent to the emergency room . LPN #7 also documented she had applied pressure to the face (i.e., cheeks and mouth) with no grimacing and moaning. There was no documentation in regard to assessment of the resident's nose. LPN #7 also revealed she had sat down beside Resident #81 and asked if she was having any pain. The resident was unable to answer. At 8:00 P.M., the resident was sent to the emergency room per the daughter's request. Review of the nurses' notes dated 09/17/11 at 12:40 A.M. revealed documentation by LPN #8 that Resident #81 returned to the facility with a [DIAGNOSES REDACTED]. There was no documentation that evidenced the facility had implemented interventions after assessing the resident as high risk for falls to prevent the resident from falling while being seated in her wheelchair. On 10/04/11 at 1:00 P.M., the above information was verified during interview with the Director of Nursing. This certification deficiency substantiated allegations contained in Complaint Number OH 453.

Based on record review, review of the medication error report, and staff interview, the facility failed to ensure one of 18 sampled residents was free of a significant medication error. Harm occurred when Resident #36 ingested a narcotic medication from a medication patch that should have been removed by nursing staff prior to the application of an additional narcotic patch resulting in hospitalization and treatment. Findings include: Clinical record review of Resident #36 revealed the resident was admitted to the facility 06/08/10 and readmitted following a stay in the local hospital on [DATE]. The record indicated the resident had medical [DIAGNOSES REDACTED]. The record indicated the resident was alert and oriented and able to make his needs known. The record also indicated the physician had written an order for [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. on 06/30/10. There was no documentation on the July 2010 MAR indicated [REDACTED]. On the controlled medication sign out sheet the staff documented, by signing out the narcotic pain patch on 07/02/10 at 10:00 P.M., they were administering the medication to the resident. There was no evidence in the clinical record the previous patch had been removed from the resident. Further review of the record indicated a nursing note dated 07/03/10 at 4:00 P.M. which stated the resident was found to be non-responsive. The documentation stated the resident's face was slightly purple, his eyes rolled back in his head and his respirations were labored and had gurgles. The resident was also noted to have white liquid in the back of his throat. The resident was noted with a [MEDICATION NAME] with a single layer of paper tape wrapped around it. The nurse documented she removed the patch from the inside cheek area and proceeded with treatment for [REDACTED]. Oxygen was applied and the oxygen saturation level was 74%. The oxygen was increased and the oxygen level raised to 84%. The notes revealed the resident was taken to the emergency room via ambulance. Review of the hospital documentation revealed the resident stated to the physician at the emergency room , after being given [MEDICATION NAME] (a medication to counteract opiate overdose) that he had put the patch in his mouth himself to "get high." Review of the medication error report form completed by staff revealed the resident had two patches of [MEDICATION NAME]. The explanation for the reason for the error was written as the resident was found with a patch in his mouth and one on his back. Results of the error were documented as the resident had decreased responsiveness, low oxygen levels, and was sent to the emergency room . There was no signature by the Director of Nursing (DON), administrator, or the Medical Director on the medication error report form. The review of the supplied medication error report revealed the facility had not followed their policy and procedure for investigating medication errors. Review of the manufacturer's directions for the [MEDICATION NAME] revealed it was a very strong opioid narcotic pain medication that could cause serious and life threatening breathing problems. It also stated not to wear more than one patch at a time unless directed by the physician to do so. The instructions for applying the patch revealed a person was not to wear more than one patch at a time unless the physician instructed you to do so. It also stated before putting on a new patch the old patch should be removed and disposed of properly. On 10/20/10 at 9:45 A.M., interview with the current Director of Nursing verified the above findings.