Every finding on record at Arbors at Springfield

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, hospital documentation review, staff interviews, policy review, and review of facility initiated corrective action, the facility failed to ensure appropriate treatment and care was provided to prevent a pressure wound from worsening. This resulted in actual harm when Former Resident (FR #35) sustained an unstageable pressure wound from a fracture boot that required debridement and developed an infection. This affected one (FR #35) of four residents reviewed for wounds. The facility census was 34. Findings include: Review of the medical record for FR #35 revealed an admission date of 08/22/22 and discharge date of 07/25/25 with diagnoses including but not limited to fracture of right lower leg, immunodeficiency, chronic kidney disease, type two diabetes with diabetic polyneuropathy, wedge compression fracture of first lumbar vertebra, spinal stenosis lumbar region with neurogenic claudication, major depressive disorder, and need for assistance with personal care. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. FR #35 had an unstageable pressure injury that was not present on admission. Review of the care plan dated 07/26/23 revealed the resident had impaired skin integrity related to chronic end stage renal disease, incontinence of bowel and bladder, and on medications that increase the risk for skin integrity impairment as evidenced by pressure wound to top of right foot from medical device and pressure of right outer foot from medical device initiated on 06/20/25. Interventions included follow up with orthopedic physician as needed for splint initiated on 07/02/25, resident may wear lace up ankle brace if having pain with only ace wrap to right ankle/foot initiated on 06/23/25, administer treatments as ordered initiated on 06/23/25, complete skin inspections weekly and as needed initiated on 06/20/25, and complete wound evaluation to observe the progress of the resident's skin condition.Review of the progress notes from 06/06/25 through 06/20/25 revealed no mention of boot/splint being placed at the orthopedic office. Review of physician orders revealed no orders for boot/splint to be monitored or that the resident had a boot from 06/06/25 through 06/23/25. Review of the after-visit summary dated 06/06/25 from the orthopedic office revealed no mention of the boot or care. Review of the weekly skin assessments revealed no assessments completed from 05/27/25 through 06/10/25 and 06/10/25 through 06/23/25. Review of the Treatment Administration Record (TAR) for June 2025 revealed wound treatment was ordered to be started on 06/21/25. Treatments were completed as ordered as of 06/21/25. Weekly skin assessments signed off on 06/03/25, 06/20/25, and 06/17/25 although only the 06/10/25 skin assessment could be located. Review of the orthopedic visit on 06/20/25 revealed history of present illness for FR #35 presented for routine follow up of right bimalleolar ankle fracture that is being managed nonoperatively due to medical comorbidities. FR #35 stated that he had been keeping the boot in place and ace wrap had not been taken down in the last two weeks. Per the facility, they were not instructed to do any kind of wound care, so they did not remove the dressings or examine the foot. The facility did not reach out to the office regarding the drainage at any point. Significant desquamation and fracture blisters are noted with slough of superficial skin on the dorsum of the foot. Full-thickness dermis loss on the dorsum of the foot without significant ulceration or purulent drainage. The physician had a discussion with the patient on the need for daily dressing changes as soon as possible as there was concern about the state of the skin and the potential for this progressing to an infection that could possibly progress to an amputation. Orders included: referral to wound care, wound change dressings daily, Bactrim DS twice daily, no weight bearing on right foot, and remove boot for wound care and personal hygiene. Review of the orthopedic office visit for 06/27/25 revealed black eschar noted on the dorsum of right foot. Erythema/edema from prior examination significantly improved. No drainage. The physician had a discussion with FR #35 that they were pleased with the progress that the wound team has made on the edema and drainage of the foot. Discussed doing dressing changes twice daily with Silvadene over the eschar and continue Bactrim DS twice daily for another week and return in two weeks. Continue to wear boot, may be removed for dressing changes and showers, remain non weight bearing, continue wound care, continue antibiotic, and apply Silvadene ointment to eschar area. Review of the orthopedic office visit for 07/18/25 revealed FR #35 presented for routine follow up of bimalleolar ankle fracture being managed nonoperatively with open dorsal foot wound that has been managed with wound care. FR #35 reported that his wound dressing changes were not done twice a day as had been ordered. FR #35 reported the last dressing change on his foot was two days ago when he received a bath. On physical examination he has a dorsal necrotic unstageable ulcer of the right foot with malodorous bloody/purulent drainage. He does have surrounding erythema and pitting edema of the foot and ankle. Vascular skin changes noted to the mid-calf without extension of erythema beyond the foot wound margin. The physician had an extensive discussion with FR #35 that given the progression of his dorsal foot wound and vascular calcification seen on x-ray that there is concern about the blood flow to the foot to appropriately heal the wound that he has. The physician would like the resident to go to the emergency room given the purulent drainage and concern for wet gangrene of the foot to have a formal evaluation for possible amputation versus more aggressive wound care than he has been getting at the facility he has resided in. Interview on 10/16/25 at 2:08 P.M. with the Director of Nursing (DON) revealed FR #35 did not have a splint/boot until an orthopedic visit on 06/06/25. The DON verified that the boot nor the ace wrap were removed from 06/06/25 through 06/20/25. The DON verified no documentation was available regarding whether the nursing staff contacted the orthopedic office to obtain orders regarding the boot or ace wrap. The DON verified there should have been an order to monitor the boot and skin integrity under the boot. The DON further verified no skin assessments could be located from 06/06/25 through 06/20/25 with the exception of 06/10/25. Interview on 10/20/25 at 1:43 P.M. with Physical Therapy Assistant (PTA) #226 verified the resident came back from the orthopedic office with a boot. Review of the policy titled, Pressure Ulcer/Skin Breakdown-Clinical Protocol, dated 03/20/24 revealed weekly skin evaluation/assessment by the licensed nurse on residents who have no current pressure ulcers (PU) or pressure injury (PI). The plan of care for prevention and/or treatment of PU/PI's will be developed based on the assessments above to include but not limited to support surfaces, turning schedule/off-loading, moisture management, incontinence management, nutritional management, pain management, disease effects on perfusion and/or healing, and medications that affect perfusion and/or healing. The deficient practice was corrected on 06/23/25 when the facility implemented the following corrective actions: On 06/20/25, the wound Nurse Practitioner was notified of the wound by the Unit Manager. On 06/20/25, Licensed Practical Nurse (LPN) #35 notified FR #35 and his wife of new orders by the orthopedic physician. On 06/23/25, the DON/designee audited all residents with splints for orders and skin assessed with no negative findings. On 06/23/25, the MDS nurse completed an audit of care plans for all residents with splints. On 06/23/25, the DON updated the Braden Scale (used to predict pressure injury risk) with a score of 14 indicating moderate risk. On 06/23/25, the DON/designee completed an audit of recent physician visits in the past two weeks for new orders with no negative findings. On 06/23/25, the DON placed an order for a soft air splint for FR #35. On 06/23/25, the DON/designee educated all nurses regarding after-visit summary for appointments and to clarify if devices are on the resident upon return from the appointment. The DON/designee will audit all new residents with splints for orders, skin condition, and care plan updates weekly times four weeks. The DON/designee will audit after visit summary for all residents with outside appointments for new orders and visual check of residents for new devices weekly for four weeks. An AD HOC Quality Assurance and Performance Improvement (QAPI) committee meeting was completed on 06/23/25. Results of the audits will be reviewed in the QAPI Committee meeting for one month with revisions to the plan/change in monitoring as deemed by the QAPI committee. This deficiency represents noncompliance investigated under Complaint number 2642319.

Based on record review, observation, interview, and policy review, the facility failed to ensure fall interventions were in place. This affected one (#33) of four residents reviewed for falls. The facility census was 34.Findings include:Review of the medical record for Resident #33 revealed an admission date of 07/02/25 with diagnoses including but not limited to anoxic brain damage, respiratory failure, cardiac arrest, and anxiety.Review of the minimum data set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Resident #33 was dependent on staff for activities of daily living.Review of the care plan dated 10/07/25 revealed the resident was at risk for falls related to anoxic brain damage and muscle weakness. Interventions included perimeter overlay to air mattress and low bed.Observation on 10/20/25 at 1:27 P.M. of Resident #33 revealed the resident was lying in bed with an air mattress and the bed was in high position approximately chest high to surveyor with no one in the room.Interview on 10/20/25 at 1:32 P.M. with Certified Nursing Assistant (CNA #118) verified the bed was in high position with no one in the room. CNA #118 stated the resident's husband was in the room prior and would raise the bed when he visited. CNA #118 verified the husband was no longer at the facility and the bed was not lowered per care plan.Review of policy titled, Fall Prevention Program, dated 10/26/23 revealed the nurse will indicate the resident's fall risk and initiate interventions on the resident's baseline care plan. Interventions will be monitored for effectiveness.

Based on record review, observation, interview, and policy review, the facility failed to ensure proper hand hygiene was completed during a dressing change. This affected one (#7) resident of one resident observed for wound care. The facility census was 34.Findings include:Review of the medical record for Resident #7 revealed an admission date of 07/09/25 with diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), chronic kidney disease stage four, dependence on respirator (ventilator) status, anxiety, and need for assistance with personal care.Review of the minimum data set (MDS) dated [DATE] revealed the resident was cognitively intact. The resident was dependent on staff for activities of daily living.Review of the physician order revealed right lower abdomen cleanse with normal saline, pat dry, apply moistened collagen and cover with foam dressing three times weekly and as needed.Observation on 10/20/25 at 2:16 P.M. of wound care with Licensed Practical Nurse (LPN #205) for Resident #7 revealed LPN #205 gathered supplies which included calcium alginate, scissors, normal saline vial, soft silicone foam dressing, and four by four dressings. LPN #205 cleaned scissors with an alcohol pad and placed them on clean trash bag laid out on treatment cart along with the dressing supplies. LPN #205 knocked on door, entered room and explained to the resident what she was going to do. Resident agreeable to dressing change. LPN #205 then washed hands, donned a gown and placed a clean barrier to cover the bed table and arranged the supplies. LPN #205 donned gloves and removed the old dressing from the residents right lower abdomen. Wound appeared beefy red and peri wound was intact. No odor was noted. LPN #205 then removed her gloves and donned a new pair of gloves. LPN #205 then opened four by four gauze packages and cleansed the wound with normal saline. LPN #205 removed gloves and donned new gloves. LPN #205 placed calcium alginate in the wound and opened the silicone foam dressing. LPN #205 stated that she would date the dressing prior to applying it to the resident. LPN #205 removed her gloves and dated the dressing. LPN #205 donned new gloves and placed the foam dressing over the wound. LPN #205 was not observed to wash or sanitize hands after removing soiled gloves and donning clean gloves on four occasions. Interview on 10/20/25 at 2:42 P.M. with LPN #205 revealed the nurse verified she did not wash or sanitize hands between glove changes. LPN #205 verified she was supposed to wash hands or sanitize hands prior to donning new gloves. Review of policy titled, Clean Dressing Change, dated 12/28/23 revealed policy explanation and compliance guidelines: explain the procedure to the resident and screen for privacy, multi-use wound care supplies should be dated and initialed when opened, set up clean field with needed supplies for wound cleansing and dressing application, establish area for soiled products to be placed, wash hands and put on clean gloves, place a barrier cloth or pad next to the resident under the wound to protect the bed linen and other body sited, loosen the tape and remove the existing dressing, remove gloves, wash hands and put on clean gloves, cleanse the wound as ordered, measure wound, wash hands and put on clean gloves, apply topical ointments or creams and dress the wound as ordered, secure dressing mark with date and initials, discard disposable items and gloves into appropriate receptacle and wash hands.

Based on record review, staff interviews, and policy review, the facility failed to ensure proper positioning technique for safe bed mobility was implemented which resulted in a major fall with injury. The facility also failed to ensure a fall investigation was completed that included root cause analysis. This resulted in Actual Harm when Resident #30, who was severely cognitively impaired, at risk for falls and dependent on staff for turning and repositioning sustained a fall when two staff members were providing incontinent care and the resident fell to the floor face first due to improper positioning technique. This affected one (Resident #30) of three residents reviewed for falls. The census was 33. Findings include: Record review revealed Resident #30 was admitted of [DATE]. Medical diagnoses included anoxic brain injury, anemia, hypertension, renal failure, pneumonia, diabetes, acute respiratory failure with hypoxia, cardiac arrest, morbid obesity, encephalopathy, and need for assistance for personal care. She weighed 369 pounds. Review of care plan dated [DATE] revealed Resident #30 was at risk for activities of daily living self-care deficit related to anoxic brain injury damage and morbid obesity. Interventions were a two-person assistance for bed mobility, toileting, transfers with the use of the Hoyer lift. Resident #30 had acquired absence of the left leg below the knee, and she was ventilator dependent. She was at risk for falls with injury due to an anoxic brain injury. The intervention was to ensure the resident's room was free from accident hazards, providing adequate lighting ensuring there was no trip hazards. Review of fall risk assessment dated [DATE] revealed Resident #30 was a high fall risk. Review of quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #30 was rarely or never understood. She was impaired to the lower left extremity. She didn't exhibit any signs or behaviors. Her functional status was dependent on toileting, bathing, and bed mobility. Eating and transfers were not attempted due to medical condition or safety concerns. She was always incontinent of bowel and bladder. She used a mechanical ventilator, had a tracheostomy, feeding tube, and oxygen. Review of the progress notes dated [DATE] at 5:00 P.M. revealed Resident #30 rolled from a wet mattress to the floor. Care was provided by State tested Nursing Assistants (STNA) #80 and #102. An assessment was completed, and the physician was notified. Neurological (neuro) testing was initiated, and the results were at baseline. There was swelling to the left eye. Her temperature was 97.3 degrees Fahrenheit (F), pulse 64, respirations 18, blood pressure ,d+[DATE], and oxygen saturation was 94 percent. The resident was transferred back to bed by a Hoyer lift and the family was notified. The neuro testing continued. On [DATE] at 2:48 P.M., swelling to the left eye continued. On [DATE] at 5:30 A.M., Resident #30 was transferred to the hospital. A review of a witness statement from STNA #80 dated [DATE] revealed he and STNA #102 were cleaning Resident #30 up and when rolling her onto her side she jerked and slid off the bed. STNA #102 tried to slow her down and she was too much weight to hold. The STNAs moved the bed out of the way and alerted the nurse. A review of a witness statement from STNA #120 dated [DATE] revealed he and STNA #80 went into the room to clean Resident #30. They went to roll the resident to her side to remove the linens and put new down and the resident coughed, and the vent popped off. STNA #120 grabbed the vent, and the resident slid off the bed and STNA #120 tried to catch her, and she fell to the floor. Review of the witness statement from Licensed Practical Nurse (LPN) 56, dated [DATE] at 5:00 P.M., revealed STNA's #120 and #80 called her to Resident #30's room. Resident #30 was lying on the floor on her back. The resident had swelling to the left side of her head and face and her eye was swollen shut. Resident #30 was at baseline for cognition, pupils reactive, range of motion (ROM) was negative for pain and dislocation. After the assessment was completed, the resident was placed in a Hoyer lift and put back to bed and neuro checks continued. Review of progress note dated [DATE] at 11:57 P.M. revealed the admitting hospital diagnoses for Resident #30 were subdural hematoma and subgaleal hematoma. Review of the investigation report for Resident #30, dated [DATE], revealed STNAs #120 and #80 were providing incontinent care to the resident when they rolled the resident to the right side. The vent tubing disconnected, and the aide grabbed tubing when the resident continued to roll out of the bed onto floor, hitting the left side of her face. Vent tubing was reconnected, the nurse was alerted immediately, and assessment was completed with the physician on the phone. The resident was opening eyes with swelling noted to left eye brow. Range of motion was performed to all extremities without deficit, no deficit in pupils and they were equal, round, and reactive to light and accommodation (PERLLA) from resident's baseline PERRLA. The resident has anoxic brain injury and only opens eyes at baseline, no signs of distress, to continue to monitor neuro checks and swelling. The family was made aware of the incident. Assisted up to bed with six staff members who assisted with the Hoyer lift. Resident monitored throughout night when swelling to face increased, the physician was in the facility on [DATE] at 5:30 A.M. to round and assessed the resident with an order to send to the hospital for evaluation. The scan was completed and revealed subdural hematoma and subgaleal hematoma. No root cause analysis for the fall was provided by the facility. Review of the discharge hospital records dated [DATE] revealed Resident #30 had fallen out of bed at the nursing facility. She hit her head, and the CT scan showed there was a small subdural hematoma and subgaleal hematoma. A repeat CT scan was done, and it showed the subdural hematoma changes were stable, and no surgery was planned. The resident was found to have lower lobe pneumonia, probable urinary tract infection and was also septic. The family met with the physicians on [DATE] at 4:02 PM. at the hospital and discussed the terminal prognosis and the family decided that living on life support was not acceptable for the resident. The resident expired on [DATE] at 6:30 P.M. During an interview on [DATE] at 7:40 A.M., the Director of Nursing (DON) stated Resident #30 didn't expire because of the fall. It was identified at the hospital that the resident had a small subdural hematoma (that was stable) pneumonia and probable urinary tract infection. She stated the family decided to remove the ventilator and initiate hospice care for her. She stated the aides followed the care plan for two-person assistance and her investigation revealed the facility wasn't at fault for anything. She did acknowledge something happened in the room but wasn't sure what it was because she wasn't in the room the time it happened. She didn't know the resident was placed on the edge of the bed at the time of the fall either and didn't get that in her investigation. She revealed the interdisciplinary team (IDT) talked about a root cause analysis, but didn't write anything down in the record. During an interview on [DATE] at 9:35 A.M., STNA #80 stated he was helping STNA #102 with incontinence care for Resident #30 on [DATE] around 4:45 P.M. He stated he was standing on the left side of the bed. He grabbed the draw sheet and moved the resident toward him and then rolled her over to the edge of the bed. He said her ventilator popped off. STNA #102 grabbed the ventilator hose to put back on the resident and the resident went onto the floor hitting the left side of her face on the feed tubing pole and then to the floor face first. He said he tried to grab her from across from the bed, but it happened so fast he couldn't reach her. He stated STNA #102 tried to break her fall but couldn't. During an interview on [DATE] at 11:01 A.M., STNA #102 revealed he was the aide who provided incontinence care with STNA #80 on [DATE] at 4:45 P.M. He stated he was on the right side of the bed and was holding onto the resident when STNA #120 rolled her to him. He stated she was on the edge of the bed and his body was placed in the middle of the bed to the lower end of the bed, because that was where the most weight was. He said when she was turned toward him and she was up against his body, her ventilator tubing came out and she was gurgling and coughing. He reached behind her left shoulder, because the tubing fell on to the bed and when he reached, she fell on to the left side of her face into the feeding tube pole and tumbled to the ground. He said it all happened so fast. He said he went and got the nurse. During an interview on [DATE] at 10:03 A.M., the Medical Director (MD) 124 stated she remembered the staff calling her on the evening of [DATE]. She asked the usual questions when someone hit their head. The questions were how they fell , was the fall witnessed, did the resident strike their head, was their skin broken, was there any blood, injuries, medications the resident was on, and if the resident had loss of consciousness. She stated it was determined to keep the resident in the facility and do the neuro checks. She said the facility would need to call her service if they weren't able to do the neuro checks and they didn't call. She said Nurse Practitioner (NP) 126 came in the morning of [DATE] at 5:30 A.M. and the resident didn't look good. She called the physician and it was decided to send her out to the hospital. Review of the policy titled Falls Protocol, dated [DATE], revealed as part of an initial and ongoing resident assessment, the staff will help identify individuals with a history of falls and risk factors for subsequent falling. This deficiency represents non-compliance investigated under Complaint Numbers OH00159043, OH00158875 and OH00158872.

Based on record review, interview and policy review, the failed to hold care conferences for residents. This affected nine (Residents #3, #8, #10, #12, #14, #17, #27, #28, and #34) of 13 residents reviewed. The census was 33. Findings include: 1. Review of Resident #8's medical record revealed an admitted d of 01/19/24. Quarterly MDS assessments were completed on 02/09/24, 05/11/24, 08/11/24, and 09/22/24. Review of Resident #8's medical record revealed a care conference was held on 02/20/24. No further care conferences were held. 2. Review of Resident #10's medical record revealed an admitted d of 09/08/22. MDS assessments were completed on 02/22/24, 04/04/24, 04/15/24, and 06/11/24, and 09/09/24. Review of Resident #10's medical record revealed a care conference was held on 01/24/24. No further care conferences were held. 3. Review of Resident #27's medical record revealed an admitted d of 08/17/23. MDS assessments were completed on 05/06/24 and 08/24/24. Review of Resident #27's medical record revealed a care conference was held on 11/01/23. No further care conferences were held. 37447 4. Review of the medical record for Resident #17 revealed she was admitted [DATE]. Resident #17 had MDS assessments competed on 02/24/24, 05/26/24 and 08/26/24. Only one care conference was held, on 01/24/24. During an interview on 10/22/24 at 3:56 P.M., Social Services Designee (SSD) #80 verified the January care conference was the only conference held this year for Resident #17. 5. Review of the medical record for Resident #28 revealed he was admitted initially 11/07/23 with re-entry 03/16/24. Resident #28 had MDS assessments completed on 03/28/24, 06/20/24 and 09/20/24. Only one care conference was held, on 02/01/24. During an interview on 10/22/24 at 3:42 P. M. the Director of Nursing (DON) confirmed care conferences should be held quarterly. During an interview on 10/22/24 at 3:56 by the Social Services Designee (SSD #80) he verified the February care conference was the only conference held this year. 45751 6. Review of medical record for Resident #3 revealed an admitted [DATE]. The most recent MDS assessment was completed on 07/10/24. Review of the Care Conference Summaries revealed the last care conference held was on 01/31/24. 7. Review of medical record for Resident #12 revealed an admitted [DATE]. The most recent MDS assessment was completed on 07/26/24. Review of Care Conference Summaries revealed the last care conference was held on 02/21/23. During an interview on 10/22/24 at 4:00 P.M., SSD #80 stated they did not hold a care conference for Resident #12 due to the resident has a court appointed guardian and the guardian did not want to be included in any care conferences. SSD #80 was not aware that a care conference with the interdisciplinary team should be held quarterly even if the guardian did not want to attend. 8. Review of medical record for Resident #14 revealed an admitted [DATE]. The most recent MDS assessment was completed on 09/23/24. Review of Care Conference Summaries revealed the last care conference was held on 01/26/24. 9. Review of medical record for Resident #34 revealed an admitted [DATE]. The most recent MDS assessment was completed on 09/17/24. Review of the Discharge Planning Evaluation dated 06/12/24 revealed the facility indicated that it was the initial care conference. No other care conference documentation was provided by the facility. During an interview on 10/22/24 at 4:00 P.M., SSD #80 verified the care conferences were not held quarterly for Residents # 3, #8, #10, #12, #14, #17, #27, #28, and #34. Review of policy titled Participation in 72 Hour Care Review- Assessment/Care Plans, dated 03/20/24, revealed the comprehensive care conference is scheduled after the completion of the comprehensive care plan and quarterly. Document the outcome of this meeting in the progress notes. This care conference should be attended by Social Services, Dietary, Activities, and Nursing.

Based on medical record review and staff interview, the facility failed to discontinue a medication as ordered. This affected one (Resident #8) of six residents reviewed for medications. The census was 33. Findings include: Record review revealed Resident #8 was admitted on [DATE]. Diagnoses included bronchopneumonia, anxiety disorder, obstructive sleep apnea, acute and chronic respiratory failure, and dependence on a ventilator. Review of the pharmacy recommendations revealed a recommendation dated 05/10/24 to discontinue Prevacid DR capsule (heartburn medication) due it should not be crushed. Resident #8's physician signed the recommendation on 05/22/24 to discontinue Prevacid DR. Review of a pharmacy recommendation dated 07/06/24 revealed a recommendation to again discontinue Prevacid DR due to it not being discontinued in May 2024. Resident #8's physician signed the recommendation on 07/25/24 to discontinue Prevacid DR. Review of medication administration records (MAR) revealed Resident #8 received Prevacid DR 30 milligrams (mg) twice day from 05/22/24 to 07/25/24. During an interview on 10/22/24 at 9:27 A.M., the Director of Nursing verified the medication was not discontinued as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00158346.

Based on record review, interview and policy review, the facility failed to ensure a narcotic medication was given to a resident on hospice care in a timely manner. This affected one (Resident #13) of one residents reviewed for Oxycodone administration. The census was 33. Findings include: Record review revealed Resident #13 was admitted on [DATE]. Medical diagnoses included unilateral primary osteoarthritis of the left knee, diabetes, and Alzheimer's disease. Resident #13 had a physician order dated 05/09/24 for Oxycodone five milligrams (mg), give one by mouth twice a day for pain. Review of care plan dated 07/26/24 revealed Resident #13 has a terminal prognoses with hospice care related to Alzheimer's. Interventions were to administer medications as ordered and observe for effectiveness. Also evaluate for verbal and non-verbal signs and symptoms related to pain. Review of annual Minimum Data Set (MDS) assessment, dated 08/09/24, revealed Resident #13 was severely cognitively impaired. Review of the progress note dated 10/09/24 at 8:41 A.M. revealed the resident was out of Oxycodone. Hospice was notified and per hospice, the prescription will be sent to the pharmacy. On 10/10/24 at 9:55 A.M. hospice was notified to send the prescription for Oxycodone to pharmacy. On 10/12/24 at 8:53 A.M. the pharmacy was called about Resident #13's Oxycodone and the pharmacy was waiting on the prescription. The nurse contacted hospice regarding the prescription and the receptionist will have nurse call the facility back. At 9:21 A.M. the hospice nurse called the facility and stated they would call in the prescription. Review of the Medication Administration Record (MAR) dated 10/09/24 through 10/23/24 revealed the resident wasn't given Oxycodone five mg two times a day on 10/09/24, 10/10/24, 10/11/24, or 10/12/24. Review of the notes revealed there were no concerns regarding Resident #14 being in pain during this time. During an interview on 10/23/24 at 2:31 P.M., the Director of Nursing stated the Oxycodone wasn't given to the resident because the facility couldn't get them, and they wouldn't be able to pull out of the emergency box because the physician has to write a new prescription. She said the resident was monitored and she wasn't in any pain or withdrawal. During an interview on 10/24/24 at 7:16 A.M., Registered Nurse (RN) #103 stated someone didn't order the medication for Resident #13 and confirmed she went four days without the Oxycodone. Review of the policy titled Pain Management, dated 10/26/23, revealed the facility will ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goal and preferences.

Based on observation, record review, interview and policy review, the facility failed to ensure a resident received podiatry services and failed to ensure baths and showers were provided to residents. This affected two (Residents #13 and #3) of three residents reviewed for activities of daily living. The census was 33. Findings include: 1. Record review revealed Resident #13 revealed an admitted [DATE]. Medical diagnoses included unilateral primary osteoarthritis of the left knee, diabetes, and Alzheimer's disease. Review of the podiatry visits revealed the last visit for Resident #13 was 04/28/22. Review of podiatry Do Not Treat list, dated 03/25/24, revealed Resident #13 was on the list labeled as other. There were no notes in Resident #13's record related to not being treated by the podiatrist. During an observation on 10/21/24 at 9:52 A.M., Resident #13 had long, thick, yellow toenails. Review of list of patients to be seen by the podiatrist on 10/25/24 did not include Resident #13. During an interview on 10/23/24 at 2:15 P.M., the Director of Nursing stated it was the responsibility of the facility to trim the nails of the residents by the staff or an outside service. She confirmed Resident #13's toenails were long and thick and hadn't been trimmed in a while. She said she couldn't trim them since they were thick, and she would add Resident #13 to the podiatry list. She said she didn't know why Resident #13 was on the Do Not Treat list. 45751 2. Record review revealed Resident #3 was admitted on [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, lymphedema, dependence on respirator (ventilator) status, depression, and tracheostomy status. Review of Care Plan dated 10/16/24 revealed the resident had an ADL self-care deficit related to vent dependency. The resident required the assistance of two staff for bathing and required a mechanical lift for transfers. Review of shower documentation for September 2024 revealed the residents shower days were Wednesday and Saturday on day shift. No documentation for for shower or bed bath was noted on 09/14/24, 09/18/24, and 09/21/24. Review of shower documentation for October 2024 revealed no documentation for shower or bed bath was noted on 10/02/24, 10/09/24, and 10/12/24. The resident refused on 10/19/24. During an interview on 10/21/24 at 9:00 A.M., Resident #3 stated she did not get washed up like she should. During an interview on 10/22/24 at 2:19 P.M., Resident #3 stated her shower days are Wednesday and Saturday and that she takes a bed bath instead of a shower. Resident #3 stated she does not always receive her bed bath on the scheduled days. Resident #3 stated she may have refused once in the last two months. During an interview on 10/22/24 at 2:28 P.M., the DON verified that the showers or bed baths were not documented as given on 09/14/24, 09/18/24, 09/21/24, 10/02/24, 10/09/24, and 10/12/24. Review of the policy entitled Nail Care dated 08/20/24 revealed the purpose of this procedure is to provide guidelines for the care of a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines: 1. Assessments of resident nails will be conducted on admission and readmission to determine the resident's nail condition, needs, and preferences for nail care, if possible. a. Report unusual or abnormal conditions of the nails to the physician and the responsible party (e.g., curling, color changes, separation from the nail bed, redness, bleeding, pain, odor, infection,etc.). b. Obtain history and preferences regarding podiatrist. 2. Identify conditions that increase risk for foot or nail problems, such as diabetes, peripheral vascular disease, heart failure, renal disease, or stroke. 3. Routine cleaning and inspection of nails will be provided during ADL care ongoing. 4. Routine nail care, to include trimming and filing, will be provided on a regular basis and as the need arises. 5. Principles of nail care: a. Nails should be kept smooth to avoid skin injury. b. Only podiatrists, physician/practitioners, or licensed nurse shall trim toenails for residents with diabetes or circulation problems. c. Each resident will have his/her own nail care equipment (e.g., clippers, emery boards, files, etc.). Equipment will not be shared between residents. Clean equipment after each use and before storing. Review of policy titled Activities of Daily Living (ADLS) dated 10/26/23 revealed a resident who is unable to carryout ADLs will receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This deficiency represents non-compliance investigated under Complaint Number OH00158346.

Based on observation, record review, and interview the facility failed to ensure the tube feeding bag and syringe was changed per the physician order. This affected two (Residents #34 and #191) of three residents reviewed for tube feeding. The facility census was 33. Findings include: 1. Record review revealed Resident #34 was admitted on [DATE]. Diagnoses included anoxic brain damage, respiratory failure with hypoxia, cardiac arrest, encephalopathy, hypertension, anxiety, and acute gastric ulcer without hemorrhage or perforation. Review of Minimum Data Set (MDS) assessment, dated 09/17/24, revealed Resident #34 was severely cognitively impaired and required enteral nutrition (tube feeding). Review of current physician orders revealed to change the feeding syringe on night shift, label with residents name and date. During an observation on 10/22/24 at 10:08 A.M., the tube feeding syringe was laying on the nightstand unwrapped with no date or name. The graduated cup was dated 10/06/24. No plastic bag was observed in the room for the tube feed syringe to be stored in. During an interview on 10/22/24 at 10:13 A.M., Med Tech #69 verified the tube feed syringe was not dated nor in plastic sleeve and that the graduated cup was dated 10/06/24. Med Tech #69 stated she was unsure when the graduated cups had to be changed but she believed it was weekly. Med Tech #69 verified the tube feed syringe was to be changed daily on night shift. 2. Record review revealed Resident #191 was admitted on [DATE]. Diagnoses included amyotrophic lateral sclerosis, acute on chronic respiratory failure, dependence on respirator, asthma, progressive bulbar palsy, gastrostomy status, and dysphagia. Review of the MDS dated [DATE] revealed the resident was severely cognitively impaired and required enteral nutrition. Review of current physician orders revealed to change feeding syringe and/or container daily on night shift, label with resident name and date, [NAME] Farms tube feeding 1.4 at 55 milliliters per hour (ml/h) continuous to equal 1320 calories, may hold for care. During an observation on 10/21/24 at 9:09 A.M., the tube feed hanging on the pole was dated 10/16/24. A visitor in the room at that time stated they were told the facility ran out of bags for the tube feed. During an interview on 10/21/24 at 9:16 A.M., Licensed Practical Nurse (LPN ) #56 verified the tube feed bag hanging on the pole was dated 10/16/24. LPN #56 told the visitor in the room that the facility had bags and she would hang a new one. During an interview on 10/22/24 at 9:54 A.M., Central Supply Staff #115 stated they did not run out of tube feed bags for Resident #191. Central Supply Staff #115 stated she has a whole box of bags in the supply room and they would not have run out of bags over the weekend. During an interview on 10/22/24 at 1:18 P.M., LPN #104 stated the bags were to be changed daily on night shift. The tube feed bags were not a closed system and the bag had to be opened to pour the tube feed into the bag.

Based on record review and interview, the facility failed to ensure pharmacy recommendations were addressed timely by the physician resulting in extended duplicate selective serotonin reuptake inhibitors (SSRI) therapy. This affected one (Resident #28) of five residents reviewed for unnecessary medications. The facility census was 33. Findings include: Record review revealed Resident #28 was initially admitted on [DATE] with re-entry 03/16/24. His diagnoses included congestive heart failure, type 1 diabetes, moderate protein-calorie malnutrition, chronic kidney disease stage 4, anxiety disorder, anemia, insomnia, hypertension, and hypothyroidism. Review of the Minimum Data Set (MDS) assessment, dated 09/20/24, revealed Resident #28 was cognitively intact. intact. Review of a pharmacy recommendation dated 08/07/24 recommended discontinuing one of his two SSRI medications to decrease the risk of serotonin syndrome. This recommendation was not reviewed, agreed to and signed until 10/08/24. Review of the Medication Administration Record (MAR) for August, September and October for Resident #28 revealed he continued to receive duplicate SSRI therapy from 08/07/24 until 10/08/24. During an interview on 10/22/24 at 3:40 P.M., the Director of Nursing confirmed the pharmacy recommendation was not addressed timely.

Based on record review and interview, the facility failed to obtain laboratory values as planned by the practitioner. This affected one (Resident #141) of six residents reviewed for unnecessary medications. The census was 33. Findings include: Review of Resident #141's closed medical record revealed an admitted [DATE]. Diagnoses included chronic respiratory failure, dependence on a ventilator, pneumonia, and cerebral infarction. Resident #141 was discharged from the facility to a local hospital on 09/21/24 and did not return. Review of nurse practitioner (NP) progress notes dated 09/19/24 at 8:31 A.M. revealed Resident #141 had been having loose stools with recent antibiotic use. Plan was stool checked for clostridium difficile (C-diff), complete blood count (CBC), and basic metabolic panel (BMP) were ordered. Review of physician orders revealed no order dated 09/19/24 and review of lab results revealed nothing for a CBC, BMP, and C-diff. During an interview on 10/23/24 at 1:30 P.M., the DON confirmed the CBC, BMP, and C-diff had not been ordered or obtained. The orders are entered directly into the lab's computer system by the practitioner. Nothing is kept in the electronic medical record. This deficiency represents non-compliance investigated under Complaint Number OH00158346.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the facility incident log, staff interview, and policy review, the facility failed to ensure an intravenous (IV) medication was administered as ordered. This affected one (#31) resident out of the three residents reviewed for medication administration. The facility census was 36. Findings include: Review of the medical record for Resident #31 revealed an admitted [DATE] with medical diagnoses of anoxic brain injury, chronic respiratory failure, dependence on respirator, and persistent vegetative state. Review of the medical record revealed Resident #31 was discharged to the hospital on 05/27/24 and returned to the facility on [DATE]. Review of the medical record for Resident #31 revealed an annual Minimum Data Set (MDS) assessment, dated 04/23/24, which indicated Resident #31 was noncommunicable due to persistent vegetative state. The MDS indicated Resident #31 was dependent upon all staff for activities of daily living (ADL). Review of the medical record for Resident #31 revealed hospital discharge orders dated 06/11/24 for Avycaz (antibiotic) 2.5 grams IV every eight hours with end of treatment on 06/14/24. Review of physician orders revealed the resident had Avycaz 2.5 grams IV every eight hours for six administrations dated 06/14/24. Review of Resident #31's Medication Administration Record (MAR) revealed documentation to support Resident #31 received Avycaz as ordered until 06/16/24. Review of the medical record for Resident #31 revealed an Interdisciplinary Team (IDT) note on 06/14/24 at 1:53 P.M. which stated Resident #31 readmitted from the hospital on 06/11/24 with a diagnosis of chronic respiratory failure, anoxic brain damage, pseudomonas, and Klebsiella pneumonia. The note stated Resident #31 was ordered Avycaz for eight doses and one dose was given at the hospital before discharge and per Nurse Practitioner (NP) the first dose of the antibiotic could be administered at 10:00 A.M. when arrived from the pharmacy to the facility on [DATE]. The note continued to stated Resident #31 was noted to have a decrease in oxygen saturation throughout the night and pulmonologist group was notified and an order was received to increase oxygen to keep pulse oxygen saturation above 89% with oxygen at eight liters per tracheostomy mask, elevate head of bed, and order to continue Avycaz for six doses with flush orders. The note stated the guardian was notified and stat complete metabolic panel and complete blood count labs were obtained. The note stated NP stated no x-rays were needed as the facility is aware Resident #31 had pneumonia and pseudomonas and felt that facility needed to complete the antibiotic as ordered. Further review of the medical record for Resident #31 revealed no documentation to support Resident #31 demonstrated any further respiratory issues. Review of the facility incident report revealed documentation of a medication error for Resident #31 on 06/14/24. Interview on 07/19/24 at 11:20 A.M. with Director of Nursing (DON) confirmed Resident #31 returned to the facility on [DATE] from the hospital with an order for Avycaz 2.5 grams IV for eight doses to be administered for three days. DON stated on 06/14/24 it was discovered that Resident #31 had six doses of Avycaz IV medication remaining in the medication storage room. DON stated an investigation was initiated and it was determined the night shift nurse had not administered the IV medication as ordered. DON stated NP was notified and new orders were received to administer the remaining six doses of Avycaz and to obtain stat complete metabolic panel and complete blood count lab work. DON stated Resident #31 was assessed and did not sustain any negative outcomes from Avycaz not being administered as ordered. DON stated all the nursing staff were educated on medication administration, all medication carts and medication storage rooms were audited for excessive medications and an ad hoc Quality Assurance and Quality Improvement (QAPI) was conducted. DON stated the night shift nurse was terminated. Review of the facility policy titled, Medication Administration, revised 01/17/23 stated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination. As a result of the incident, the facility took the following actions to correct the deficient practice by 06/17/24: 06/14/24 DON notified Physician and Guardian of medication error. 06/14/24 Resident #31 was assessed by licensed nurse with no negative findings. 06/14/24 stat lab work was obtained from lab company. 06/14/24 DON received new order for Avycaz 2.5 gram IV to be continued every eight hours for six doses. 06/14/24 Assistant Director of Nursing (ADON) audited all medication carts and IV medications in medication storage room for excessive medications or evidence of medications not administered as ordered. 06/14/24 DON provided education to all clinical staff on medication administration policy, labeling/dating of IV bags and tubing, MAR to be signed when administering medications, and call physician if medication orders need clarify. 06/14/24 DON/designee would complete IV medication administration audit five days per week for four weeks. 06/14/24 ad hoc QAPI completed. This deficiency represents non-compliance investigated under Complaint Number OH00155335.

Based on resident interview, staff interview, and review of staff schedules, the facility failed to ensure adequate staffing to meet residents needs. This had the potential to affect all 40 residents of the facility. The facility census was 40. Findings Include: Interview on 12/19/23 at 4:25 P.M. with Resident #41 revealed he did not feel the facility had enough staff. Resident #41 stated there were long call light response times and they were longer on the three days per week the facility provided dialysis services. Resident #41 stated there was usually one nurse and one State tested Nurse Aide (STNA) on each of the two halls. Interview on 12/19/23 at 4:50 P.M. with Resident #15 revealed he only received bed baths once a week and was scheduled to receive showers twice a week. Resident #15 stated there was not enough staff and it sometimes took longer than one hour for staff to respond to call lights. Interview on 12/20/23 at 9:35 A.M. with Registered Nurse (RN) #100 revealed the back hallway (200 hall) was an especially heavy hallway with residents who required a lot of assistance. RN #100 stated the STNAs did the best they could, but the facility staffed based on the census and not the acuity level of the residents. RN #100 stated all of the residents, except one, on the 200 hall (18 residents) required two person assistance. The 200 hall also had residents with tracheostomies and ventilators. Additionally, the facility provided dialysis three days per week and the STNAs were responsible for ensuring those residents were up out of bed, dressed and transported to and from dialysis in addition to their regular tasks of answering call lights, providing showers, providing personal care, and passing meal trays. RN #100 stated that is a lot for one or two aides to be responsible for. Interview on 12/20/23 at 11:35 A.M. with STNA #113 revealed she did not feel the facility had enough staff to provide resident care. STNA #113 stated it was impossible to complete the required checks on residents every two hours. STNA #113 stated she was able to check on residents three times in a 12 hour shift and she should be completing six checks on each of the residents. STNA #113 also stated she was not able to complete all resident showers as scheduled. Interview on 12/20/23 at 12:22 P.M. with Social Services (SS) #141 revealed he had been a STNA prior to his current position. SS #141 stated the back hallway (200 hall) had a very high resident acuity. SS #141 stated he used to work as an STNA on that hallway and it could take 45 minutes to complete care for one resident and, by the time the care was done, there may be eight or nine other call lights going off. SS #141 stated he was usually able to complete his tasks but would have to stay late to ensure all tasks were completed because it is a lot back there. Interview on 12/20/23 at 1:26 P.M. with STNA #104 revealed she worked mostly on the 200 hall and did not feel the facility had enough staff. STNA #104 stated she was usually able to answer call lights in a timely manner but sometimes she answered the call light, turned it off, and would tell the resident she would have to come back to provide needed assistance later. STNA #104 stated she had difficulty completing scheduled showers, especially on dialysis days, and was not able to complete two hour checks on residents as required, noting it was about every three hours she was able to check on residents. Interview on 12/20/23 at 5:10 P.M. with the Administrator confirmed she was aware of staff concerns related to staffing. The Administrator was actively hiring additional staff but was having difficulty retaining new staff because of the high acuity level of the residents. Review of the staff schedules from 11/24/23 through 11/30/23, revealed the following day shift STNA staffing levels: 11/24/23, two STNAs (one on each hall) and 11/25/23 two STNAs for the full 12 hour shift (one on each hall) and one STNA for four hours. This deficiency represents non-compliance investigated under Complaint Number OH00148646.

Based on medical record review, resident interview, staff interview, review of shower schedules and review of facility policy, the facility failed to ensure residents, who were dependent for care, received showers as scheduled. This affected two (#15 and #21) of three residents reviewed for activities of daily living (ADLs). The facility census was 40. Findings Include: 1. Review of the medical record for Resident #15 revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included acute transverse myelitis in demyelinating disease of central nervous system (inflammation of part of the spinal cord), acute and chronic respiratory failure with hypoxia, rheumatoid arthritis, muscle weakness, mild cognitive impairment of uncertain or unknown etiology, unspecified abnormalities of gait and mobility, unspecified lack of coordination, [NAME] Nile Virus infection with encephalitis (inflammation of the brain), and quadriplegia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/30/23, revealed Resident #15 had intact cognition and required extensive assistance to total dependence from one to two staff to complete ADLs. Review of Resident #15's progress notes from 10/19/23 to 12/19/23 revealed no documentation related to showers, including refusals. Review of the care plan, revised 12/19/23, revealed Resident #15 had an ADL self-care performance deficit related to quadriplegia, cognition, and weakness. Interventions included bathing with two person assistance. Review of the shower bed board revealed Resident #15 was scheduled to receive showers during day shift on Sundays and Thursdays. Review of shower documentation for the last 30 days revealed Resident #15 received showers on 11/23/23, 11/26/23, 11/30/23, 12/10/23, and 12/14/23. There was no documentation Resident #15 received showers as scheduled on 11/16/23, 11/19/23, or 12/03/23. Interview on 12/19/23 at 4:50 P.M. with Resident #15 revealed he only received bed baths but preferred an actual shower. Additionally, Resident #15 stated he only received one bed bath per week instead of twice weekly, as scheduled. Resident #15 stated he had only had his hair washed once in the last two or three weeks. Interview on 12/20/23 at 8:25 A.M. with the Administrator verified there was no evidence Resident #15 received showers on 11/16/23, 11/19/23, or 12/03/23 as scheduled. 2. Review of the medical record for Resident #21 revealed an admitted on 08/27/21. Medical diagnoses included end stage renal disease, type II Diabetes Mellitus, morbid obesity, psychotic disorder with delusions, hoarding disorder, cognitive communication deficit, and muscle wasting and atrophy. Review of the quarterly MDS assessment, dated 09/22/23, revealed Resident #21 had intact cognition and required extensive assistance from two or more staff to complete ADLS. Review of Resident #21's progress notes from 10/19/23 through 12/19/23 revealed no documentation related to showers, including refusals. Review of the care plan, dated 07/27/23, revealed Resident #21 had an ADL self-care performance deficit related to chronic kidney disease, depression, generalized weakness, impaired vision, neuropathy, obesity, and opioid use. Interventions included bathing assistance from two staff. Review of the shower bed board revealed Resident #21 was scheduled to receive showers during night shift on Mondays and Thursdays. Review of shower documentation for the last 30 days revealed there was no documented showers for Resident #21. Interview on 12/20/23 at 1:15 P.M. with the Administrator confirmed there was no evidence Resident #21 received showers or bed baths as scheduled. This deficiency represents non-compliance investigated under Complaint Number OH00148646

Based on medical record review, observation, resident interview, staff interview, review of Resident Council meeting minutes and review of facility policy, the facility failed to ensure residents had appropriately fitted wheelchairs. This affected one (#15) of three residents reviewed for accommodation of needs. Additionally, the facility failed to timely respond to call lights. This directly affected one (#22) resident, with the potential to affect all 40 residents of the facility. The facility census was 40. Findings Include: 1. Review of the medical record for Resident #15 revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included acute transverse myelitis in demyelinating disease of central nervous system (inflammation of part of the spinal cord), acute and chronic respiratory failure with hypoxia, rheumatoid arthritis, muscle weakness, mild cognitive impairment of uncertain or unknown etiology, unspecified abnormalities of gait and mobility, unspecified lack of coordination, [NAME] Nile Virus infection with encephalitis (inflammation of the brain), and quadriplegia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/30/23, revealed Resident #15 had intact cognition, required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs), had impairments on both sides of both his upper and lower extremities and used a wheelchair for mobility. Review of the physician orders dated November 2023 revealed Resident #15 had an order for Physical Therapy (PT) to treat three to five times per week for four weeks for therex, theract, neuro re-education, and wheelchair management. Resident #15 had an additional order to extend PT care three to five times per week for weeks dated 12/12/23. Review of the care plan, revised 12/19/23, revealed Resident #15 had an ADL self-care performance deficit related to quadriplegia, cognition, and weakness. Interventions included manual wheelchair for locomotion. Observations of Resident #15 on 12/19/23 at 4:50 P.M., 12/20/23 at 10:40 A.M., and 12/20/23 at 2:00 P.M. revealed Resident #15 was laying in his bed in his room. Interview with Resident #15 on 12/19/23 at 4:50 P.M. revealed he used a wheelchair for locomotion. Resident #15 stated the facility provided a manual wheelchair that did not fit him properly, noting it was too narrow and low for him to be able to sit in it comfortably for longer periods of time. Resident #15 stated he frequently slid down in it and staff had to use a Hoyer lift to pull him back up in the wheelchair. Resident #15 stated he was not able to sit in it for longer periods due to the chair causing pain in his back, shoulders, legs, and buttocks. Resident #15 stated he had been requesting another wheelchair since he was admitted in July 2023, but it had not been provided. Resident #15 stated PT had also recommended a different wheelchair for him. Interview on 12/20/23 at 9:35 A.M. with Registered Nurse (RN) #100 revealed Resident #15 did not like to get up out of bed unless he was able to sit in a dialysis chair, which was more comfortable for him to sit in. RN #100 confirmed Resident #15 was not able to tolerate sitting in the manual wheelchair provided to him for very long. Interview on 12/20/23 at 12:56 P.M. with Rehabilitation Director (RD) #155 revealed Resident #15 had started the process to be fitted for a custom wheelchair a month or two ago, but the chair was not ready yet. RD #155 stated the manual wheelchair provided for Resident #15 was not the appropriate size for the resident and had been donated to the facility from a previous resident. RD #155 stated he requested a Broda chair for Resident #15, but the facility was not able to accommodate the request due to a lack of storage space and added expense to the facility. RD #155 confirmed the manual wheelchair was snug width wise and was not the proper height for Resident #15. RD #155 stated he suggested the nursing staff stop using the manual wheelchair for Resident #15 due to an improper fit for the resident. Review of the facility policy titled Accommodations of Needs, revised 01/01/22, revealed the facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident. 2. Interview on 12/19/23 at 4:25 P.M. with Resident #41 revealed call light responses were long and, on the three days per week the facility provided dialysis, the response times were worse. Observation on 12/19/23 at 4:47 P.M. revealed the call light had been activated for room [ROOM NUMBER], Resident #22's room. Continuous observation revealed two different staff walked past room [ROOM NUMBER], without answering the call light or checking on the residents in the room. At 5:32 P.M. (45 minutes later), a State tested Nurse Aide (STNA) was observed responding to the call light. Interview on 12/19/23 at 4:50 P.M. with Resident #15 revealed call lights were not responded to promptly, stating sometimes it was over an hour before staff responded. Interview on 12/19/23 at 5:34 P.M. with Resident #22 confirmed his call light had been activated and an STNA had just entered the room to check on him. Interview on 12/19/23 at 6:15 P.M. with the Administrator confirmed a call light response time of 45 minutes was well outside the expectation for a response time. The Administrator expected staff to answer call lights within five minutes,whenever possible, noting there may be a delay if staff were assisting another resident. Even if staff were assisting another resident with care, the Administrator verified it still should not take 45 minutes to respond to a call light. Review of the Resident Council meeting minutes dated 10/17/23 revealed the residents voiced concerns related to call lights not being answered timely. This deficiency represents non-compliance investigated under Complaint Number OH00148646

Based on medical record review, resident interview, staff interview, review of a medication error investigation and review of facility policy, the facility failed to ensure medications were administered according to physician orders. This affected one (#15) of three residents reviewed for physician orders. The facility census was 40. Findings Include: Review of the medical record for Resident #15 revealed an admitted [DATE] and a readmitted [DATE]. Medical diagnoses included acute transverse myelitis in demyelinating disease of central nervous system (inflammation of part of the spinal cord), acute and chronic respiratory failure with hypoxia, rheumatoid arthritis, muscle weakness, mild cognitive impairment of uncertain or unknown etiology, unspecified abnormalities of gait and mobility, unspecified lack of coordination, [NAME] Nile Virus infection with encephalitis (inflammation of the brain), and quadriplegia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/30/23, revealed Resident #15 had intact cognition and required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). Review of Resident #15's Medication Administration Record (MAR) for November 2023 revealed the following orders: GlycoLax Powder (Polyethylene Glycol 3350), with instructions to give 17 grams (gm) by mouth one time only for colon prep, mix 0.5 Miralax bottle in 32 ounces of Gatorade for one day (in liquid) and mix whole bottle in 64 ounces sport drink then divide into two bottles. The start date and time for these orders was 11/08/23 at 5:00 P.M. Further review of the MAR confirmed the medications were administered as ordered on 11/08/23. Additional review of the MAR revealed the following order, to be completed on 11/09/23 at 2:30 A.M.: GlycoLax Powder (Polyethylene Glycol 3350), with instructions to give 17 grams (gm) by mouth one time only for colon prep, mix 0.5 Miralax bottle in 32 ounces of Gatorade for one day. Drink eight ounces every 15 minutes until completed with a start date of 11/09/23 at 2:30 A.M. The medication was marked as administered on 11/09/23 at 7:09 A.M. (nearly five hours after the medication was due to be administered). Review of a progress note dated 11/09/23 at 1:00 P.M. revealed Resident #15 returned from a scheduled colonoscopy, with a need to reschedule with the physician's office. Review of incident reports from 09/19/23 to 12/19/23 revealed on 11/09/23 at 2:30 A.M., a medication error occurred for Resident #15. Review of the facility medication error investigation, dated 11/09/23, revealed Resident #15 had a colonoscopy ordered to be completed on 11/09/23 at 7:30 A.M. at the hospital and did not receive GlycoLax Powder medication at 2:30 A.M. as ordered. Resident #15's colonoscopy was not able to be completed due to stool being present in his upper colon. Interview on 12/20/23 at 4:50 P.M. with Resident #15 revealed he had a colonoscopy scheduled to be completed in November 2023 but the nurse messed up the bowel preparation and he was only provided with one of the drinks instead of two that were needed for the prep. Resident #15 was sent to the hospital for the procedure but, after the procedure was started, was told it would have to be rescheduled due to inadequate preparation. Interview on 12/20/23 at 10:50 A.M. with the Director of Nursing (DON) verified Resident #15 was not administered one of the Miralax and Gatorade mixtures at 2:30 A.M., per the physician's orders. Resident #15 did not receive the mixture until 7:09 A.M. (nearly five hours late) and, due to the error, Resident #15 was not able to receive his scheduled colonoscopy procedure. Review of the facility policy titled, Medication Administration, revised 01/01/22, revealed the policy revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. This deficiency represents non-compliance investigated under Complaint Number OH00148646.

Based on medical record review, resident interview, family interview, and staff interview, the facility failed to ensure transportation was arranged for scheduled outside appointments, resulting in missed appointments. This affected one (#15) of three residents reviewed for transportation needs. The facility census was 40. Findings Include: Review of the medical record for Resident #15 revealed an admitted [DATE] and a readmitted [DATE]. Medical diagnoses included acute transverse myelitis in demyelinating disease of central nervous system (inflammation of part of the spinal cord), acute and chronic respiratory failure with hypoxia, rheumatoid arthritis, muscle weakness, mild cognitive impairment of uncertain or unknown etiology, unspecified abnormalities of gait and mobility, unspecified lack of coordination, [NAME] Nile Virus infection with encephalitis (inflammation of the brain), and quadriplegia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/30/23, revealed Resident #15 had intact cognition and required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). Review of Resident #15's progress notes revealed no evidence related to scheduling transportation for outside appointments on 09/19/23 or 11/30/23. Interview on 12/19/23 at 4:50 P.M. with Resident #15 revealed he had missed a couple of scheduled appointments due to the facility not being able to arrange transportation for him. Resident #15 stated his wife scheduled all of his outside appointments and provided the facility with at least three weeks notice for each appointment in order to give the facility ample time to secure transportation. Interview on 12/20/23 at 8:25 A.M. with the Administrator revealed the facility had difficulty with finding transportation for Resident #15 to attend outside appointments because of limited transportation options available to provide stretcher transportation for a resident with a tracheostomy. The Administrator stated the facility did not have a Respiratory Therapist (RT) available to go with Resident #15 to ensure safe transport if the resident went in a wheelchair to his appointments. The Administrator stated Resident #15 needed supervision to be transported by wheelchair for safety. Interview on 12/20/23 at 10:50 A.M. with the Director of Nursing (DON) revealed some of Resident #15's appointments needed to be rescheduled due to inability to secure transportation. The DON confirmed Resident #15's wheelchair fitting appointment on 11/30/23 was canceled because the facility was in the middle of a COVID-19 outbreak and was in contingency staffing at that time. Follow-up interview on 12/20/23 at 3:08 P.M. with the Administrator and DON confirmed Resident #15's appointment on 11/30/23 for a custom wheelchair fitting was canceled due to the facility being unable to secure transportation. Both verified Resident #15 had missed some, but not many, outside appointments due to being unable to secure transportation. Interview via telephone on 12/20/23 at 3:31 P.M. with Resident #15's wife revealed the facility had discussed potential difficulty with securing transportation to outside appointments for Resident #15 prior to his admission. Resident #15's wife stated she had expressed the importance of Resident #15 getting to his appointments and the facility admitted him. Resident #15's wife stated the facility canceled transportation on 09/18/23 for a 09/19/23 urology appointment due to the resident being in the hospital. Resident #15's wife stated she had informed the facility Resident #15 would be discharged from the hospital on 09/18/23 and would be able to keep the 09/19/23 appointment and they canceled it anyway. On 11/30/23, Resident #15 had an appointment to be fitted for a custom wheelchair. The facility arranged transportation with a local company and had told Resident #15's wife they would be sending a Respiratory Therapist (RT) with the resident. Approximately two hours before the scheduled pick up time on 11/30/23, the facility canceled transportation because they did not have an RT to send with Resident #15. The appointment was rescheduled for 01/04/24. Resident #15's wife stated it was important for the resident to have kept the appointment on 11/30/23 due to private insurance costs and deductibles prior to the new benefit year starting. Resident #15's wife stated the facility was aware of the appointment three to four weeks in advance to ensure transportation was available. This deficiency represents non-compliance investigated under Complaint Number OH00148646.

Based on observation, staff interviews and catheter procedure review, the facility failed to maintain infection control procedures during incontinence care for residents. This affected two (#11 and #12) of three reviewed for incontinence care. The facility census was 34. Findings include: 1. Review of medical record for Resident #11 revealed an admitted [DATE] and admitted to Hospice on 10/05/22. Medical diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was significantly impaired cognition and required extensive two-person assistance for bed mobility, total dependence for transfer, toileting and independent for eating. Documentation revealed she was always incontinent of urine and stool. 2. Review of medical record for Resident #12 revealed admitted [DATE] and admitted to hospice on 10/08/22. Medical diagnoses included Alzheimer's Disease, depression, and lung cancer. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely impaired cognition and required total dependence for bed mobility, transfers, eating and toileting. Documentation revealed she was always incontinent of urine and bowel. Observation on 08/24/23 at 5:25 A.M., revealed State tested Nurse Assistant (STNA) #20 provided incontinence care for Residents #11 and #12 without providing privacy by shutting the door or pulling the privacy curtain in between them. STNA #20 was observed to provide urine incontinence care for Resident #11, while the resident was in bed. The privacy curtain was not drawn and the door to the room was left open. Resident #11's genital areas were exposed. STNA #20 was observed to bring to bedside one soapy and one wet wash cloth, and one towel. The same part of the soapy washcloth was used to cleanse the entire vaginal area. The soapy cloth was then placed on one end of the towel and the second wet wash cloth was used to rinse in the same manner then placed on the same end of the towel as the other washcloth. The opposite end of the towel was used to dry the perineal area. Resident #11 was then assisted onto her right side and the same cloths were used to cleanse her buttocks. The used clothes were place in a bag on the floor. Without removing her soiled gloves, STNA #20 repositioned Resident #11, covered her with a sheet and used the bed remote to adjust the bed and turned out the light. STNA #20 then removed her gloves and washed her hands and proceeded to prepare to provide incontinence care for Resident #12, who resided in the same room. Observation continued at 5:32 A.M., for Resident #12 who was incontinent of urine. The door and curtain remained open, while STNA #20 provided care. STNA #20 was observed to repeat the same procedure of using the washcloths to clean the entire vaginal area and then laying the used washcloths on the towel. STNA #20 used the opposite end of the towel to dry the resident. Then proceeded to use the soiled washcloths to clean the buttocks. However, the incontinence product for Resident #12 ripped and STNA #20 removed her gloves and without providing hand hygiene, reached into a drawer to grab a replacement incontinent product, applying new gloves before finishing care. Interview on 08/24/23 at 5:42 A.M., STNA #20 verified she provided incontinence care for both Resident #11 and #12 and reused linens during peri care. STNA #20 verified she did not remove gloves after providing incontinence care for Resident #11 prior to repositioning the resident. STNA #20 verified she did not perform hand hygiene after removing gloves during Resident #12's care. Interview on 08/24/23 at 9:02 A.M., with the Administrator revealed the facility had no policy for incontinence care. However, the Administrator did supply an undated catheter care procedure provided to staff during orientation. Which documented privacy and dignity would be provided by closing the door, privacy curtain and blinds. The task in step three documented to wash the outer peri area moving front to back and use new area of cloth as many times as necessary to remove urine and use new cloth to wash inner labia. The Administrator verified what the procedure indicated what staff were to do during incontinence care. This was an incidental finding discovered during the investigation of Complaint Number OH00145298.

Based on observations and staff interview, the facility failed to provide privacy during residents receiving incontinence care. This affected two (#11 and #12) of three residents reviewed for incontinence care. The facility census was 34. Findings include: 1. Review of medical record for Resident #11 revealed an admitted [DATE] and admitted to Hospice on 10/05/22. Medical diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was significantly impaired cognition and required extensive two-person assistance for bed mobility, total dependence for transfer, toileting and independent for eating. Documentation revealed she was always incontinent of urine and stool. 2. Review of medical record for Resident #12 revealed admitted [DATE] and admitted to hospice on 10/08/22. Medical diagnoses included Alzheimer's Disease, depression, and lung cancer. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely impaired cognition and required total dependence for bed mobility, transfers, eating and toileting. Documentation revealed she was always incontinent of urine and bowel. Observation on 08/24/23 at 5:25 A.M., revealed State tested Nurse Assistant (STNA) #20 provided incontinence care for Residents #11 and #12 without providing privacy by shutting the door or pulling the privacy curtain in between them. STNA #20 was observed to provide urine incontinence care for Resident #11, while the resident was in bed. The privacy curtain was not drawn and the door to the room was left open. Resident #11's genital areas were exposed. After finishing incontinence care for Resident #11, STNA #20 proceeded to move to Resident #12's bed. Resident #12 was provided incontinent care, in bed, while the privacy curtain and the door to the room remained opened. Resident #12's genital areas were exposed. Interview on 08/24/23 at 5:42 A.M., with STNA #20 verified she provided incontinence care for both Resident #11 and #12 without providing privacy and they were exposed. This was an incidental finding discovered during the investigation of Complaint Number OH00145298.

Based on medical record review and staff interview, the facility failed to ensure vital signs were monitored per the plan of care. This affected one resident (#35) of three residents sampled for skilled care. The facility census was 30. Findings include: Review of the medical record for Resident #35 revealed she was admitted on [DATE] and discharged on [DATE]. Diagnoses included occlusion and stenosis of bilateral carotid arteries, congestive heart failure, hypothyroidism, chronic pain, hypertension, and hyperlipidemia. Review of the plan of care dated 04/22/23 revealed Resident #35 had hypertension. Interventions included to give antihypertensive medications as ordered, monitor for effectiveness, and monitor for side effects including orthostatic hypotension and increased heart rate. Review of the Minimum Data Set (MDS) 04/27/23 revealed Resident #35 had intact cognition. She was independent with eating and required extensive assistance for activities of daily living (ADL). Review of the skilled daily medically complex assessments, which included vital signs were completed 04/25/23, 04/26/23, 04/27/23, 04/28/23, 05/04/23, 05/05/23, 05/08/23, 05/09/23, 05/13/23, and 05/14/23. During an interview on 05/31/2023 at 3:56 P.M. Registered Nurse (RN) #196 confirmed the skilled charting including vital signs were not completed for Resident #35 on 04/29/23, 04/30/23, 05/01/23, 05/02/23, 05/03/23, 05/06/23, 05/07/23, 05/10/23, 05/11/23, and 05/12/23. RN #196 stated nurses were supposed to assess vital signs and document skilled charting every day for Resident #35. During an interview on 06/01/23 at 9:14 A.M., the Director of Nursing (DON) said the nurses were supposed to assess vital signs daily and record the results in the skilled charting. The DON said sometimes instead of documenting in the skilled assessment, the nurse documented vital signs in a narrative nurse's note. The DON verified Resident #35 had no daily vital signs recorded in the progress notes on the dates skilled charting was omitted. This deficiency represents non-compliance investigated under Master Complaint Number OH00142965.

Based on medical record review, hospital record review, staff interview, and facility policy review, the facility failed to ensure a resident received adequate supervision and assistive devices to prevent an avoidable fall. This resulted in actual harm when Resident #32 had a fall and sustained a fractured left mandibular condyle (a portion of the lower jaw bone) and a laceration to her forehead requiring stitches. This affected one resident (#32) of three reviewed for falls. The facility census was 29. Findings include: Medical record review revealed Resident #32 was admitted to the facility on [DATE] and was sent to the hospital on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #32's plan of care dated 02/07/19 revealed the resident was at risk for falls related to impaired gait, mobility, poor safety awareness, and restlessness. The goal was the resident would not sustain serious injury and would be free from falls. Interventions listed on the care plan included bed in lowest position when not providing care and a fall mat to the side of the bed. Review of the comprehensive assessment dated [DATE] revealed Resident #32 was severely cognitively impaired and was totally dependent on two plus staff for transfer, locomotion on and off unit, dressing and personal hygiene. The resident's surface to surface transfer was not steady and she was only able to stabilize with human assistance. Resident #32's medical record revealed she had falls on 02/05/19, 02/12/19, 02/21/19, 02/25/19, and 03/07/19. Review of a progress note dated 02/21/19 revealed at approximately 5:50 P.M., Resident #32 was found on the floor, face first, by a State tested Nurse Aide (STNA). The Licensed Practical Nurse (LPN) went in and assessed the resident and found her lying in a pool of blood, and a laceration was found to her forehead. The resident was sent to the hospital for further evaluation. Review of the hospital records dated 02/21/19 revealed Resident #32 had a fractured left mandibular condyle, and it was displaced. The resident also had a laceration to the forehead which required stitches. Review of the facility fall investigation dated 02/21/19 revealed a STNA heard Resident #32's roommate yell out and walked into the room. Resident #32 was found on the floor. Her bed was noted to raised and there were no fall mats in place. The investigation verified the bed was not in low position and the fall mats were not in place. The investigation revealed the outside x-ray technician did not return the bed to low position after completing x-rays on the resident. Interview with the Director of Nursing (DON) on 04/17/19 at 12:00 P.M., verified Resident #32 had a fall, sustained a broken jaw and required stitches to a [MEDICAL CONDITION]. The DON stated she was unsure what time the mobile x-ray company was in the facility and they did not sign in. She stated they did not have a policy about checking residents after outside services were completed. The DON revealed they trained the staff after the incident, however they did not identify like residents at risk for falls, or set up any new monitoring. Interview with LPN #10 on 04/17/19 at 12:25 P.M., revealed she was working on 02/21/19 when Resident #32 fell . LPN #10 stated she was unsure of how much time passed once the x-ray technician left until the resident fell , however it was less than an hour. She revealed the facility did not have a procedure or policy prior to the fall regarding rechecking a resident after receiving ancillary services. Review of the facility Fall policy dated 06/01/18 revealed fall interventions should be developed and implemented per the assessed needs. This deficiency substantiates Complaint Number OH 652.