Every finding on record at Arc at Trotwood LLC

Based on medical record review, staff interview, and review of the facility policy, the facility failed to notify resident guardians of new physician's orders. The affected one (Resident #59) of three residents reviewed for participation in care planning. The facility census was 99 residents. Findings include: Review of the medical record for Resident #59 revealed an admission date of 12/10/24 with diagnoses including schizophrenia, depression, and diabetes mellitus type two. Resident #59 had a court-appointed guardian of person since 2022 Review of the Minimum Data Set (MDS) assessment for Resident #59 dated 04/01/26 revealed the resident was moderately cognitively impaired and independently mobile. Resident had court appointed guardian of person since 2022. Review of the physician's orders for Resident #59 revealed an order dated 04/03/26 transcribed by Licensed Practical Nurse (LPN) #374 indicating the resident may leave the facility leave of absence (LOA). Interview on 05/18/26 at 1:46 P.M. with LPN #374 confirmed he transcribed a physician's order on 04/03/26 for Resident #59 to go on LOA but did not notify the guardian of the newly written order. LPN #374 stated when a resident receives a new order, the guardian of the resident should be notified. Interview on 05/18/26 at 2:24 P.M. with Regional Nurse (RN) #704 confirmed a guardian should be notified if a resident receives a new order. Regional Nurse #704 confirmed the facility had no documentation to demonstrate a previous guardian gave permission for Resident #59 to leave the facility. Interview on 05/18/26 at 2:28 P.M. with the Director of Nursing (DON) confirmed the facility nurse did notify Resident #59's guardian of the LOA order written on 04/03/26. Review of facility policy titled Therapeutic Leave of Absence revised April 2007 revealed residents leaving should be signed out on leave of absence. This deficiency represents noncompliance investigated under Complaint Number 2973107.

Based on medical record review, review of the facility investigation, review of the Self-Reported Incident (SRI), staff interview, and policy review, the facility failed to timely report an allegation of neglect to the state agency. This affected one (Resident #59) of three residents reviewed for elopement. The facility census was 99 residents. Findings include: Review of the medical record for Resident #59 revealed an admission date of 12/10/24 with diagnoses including schizophrenia, type two diabetes mellitus, and depression.Review of the Minimum Data Set (MDS) assessment for Resident #59 dated 04/01/26 revealed the resident was moderately cognitively impaired and independently mobile. Review of the facility's investigation dated 05/01/26 revealed on 05/01/26 at 7:50 P.M. staff were unable to locate Resident #59. Staff initiated a search and implemented their missing resident protocol, which included contacting the local police department.Review of the SRI for Resident #59 dated 05/04/26 revealed the resident left the faciity on [DATE] and had not returned. The SRI indicated the facility initiated a search of the facility as well as the surrounding area and contacted the local police department for assistance, but were unable to locate the resident.Interview on 05/19/26 at 9:41 A.M. with Regional Nurse (RN) #704 confirmed the facility did not file the SRI for Resident #59 who went missing on 05/01/26 until 05/04/26. Review of the facility policy titled Emergency Procedure - Missing Resident revised August 2018 revealed incident of possible abuse and neglect should be reported to the state agency in the appropriate time frame.

Based on medical record review, staff interview, physician interview, and policy review, the facility failed to transcribe and implement physician orders in a timely manner. This affected one (Resident #102) of three residents reviewed for change in condition. The facility census was 99 residents. Findings include: Review of the medical record for Resident #102 revealed an admission date of 04/10/26 with diagnoses including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, malignant neoplasm of the lung, and a discharge date of 04/20/26. Review of the Minimum Data Set (MDS) assessment for Resident #102 dated 04/14/26 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the physician's progress note for Resident #102 dated 04/16/26 per Physician #702 revealed the doctor gave telephone orders to Assistant Director of Nursing (ADON) #429 for the resident to have a chest x-ray, urinalysis, and complete blood count to be completed in two days.Review of the physician's orders for Resident #102 dated 04/16/26 to 04/20/26 revealed there were no orders transcribed for the resident to have a chest x-ray, urinalysis, and complete blood count. Interview on 05/20/26 at 3:21 P.M. via telephone with Physician #702 confirmed she provided orders on 04/16/26 at 8:04 A.M. to ADON #429 for Resident #102 for a chest x-ray and urinalysis to be completed on 04/16/26 and then another complete blood count two days later. Physician #702 stated she did not believe the orders were entered, because she had followed up with ADON #429. Physician #702 reported ADON #429 told the physician she had not entered the orders written on 04/16/26 because the nurse ran out of time. Interview on 05/20/26 at 4:34 P.M. with ADON #429 verified she had not transcribed any orders from Physician #702 for Resident #102 on 04/16/26. Review of the facility policy titled Telephone Orders revised February 2014 revealed verbal telephone orders must be transcribed in writing by the person receiving the order and recorded in the medical record.This deficiency represents noncompliance investigated under Complaint Number 2991724.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure residents received adequate supervision and failed to ensure failed to provide the appropriate level of assistance during resident transfers . This affected two (Residents #59 and #103) of three residents reviewed for accidents and hazards. The facility census was 99 residents. Findings include: Review of the medical record for Resident #59 revealed admission date of 12/10/24 with diagnoses including schizophrenia, depression, and diabetes mellitus type two. Resident #59 had a court appointed guardian of person since 2022. Review of the Minimum Data Set (MDS) assessment for Resident #59 dated 04/01/26 revealed the resident was moderately cognitively impaired and independently mobile. Resident had court appointed guardian of person since 2022. Review of the physician's order for Resident #59 revealed an order dated 04/03/26 transcribed by Licensed Practical Nurse (LPN) #374 for resident may leave the facility on leave of absence (LOA.) Review of the care plan for Resident #59 dated 04/07/26 revealed the resident had a diagnosis and history of severe mental illness. Interventions included staff should monitor resident for aggressive behavior, noise levels, friendship patterns, common rehabilitative goals or services, sleep patterns, interests, recreational pursuits, and vulnerability as needed. Review of the medical record for Resident #59 revealed it did not include an assessment of the resident's appropriateness to leave the facility on an independent LOA. Review of facility investigation for Resident #59 dated 05/01/26 revealed the resident was discovered to be missing from the facility on 05/01/26 for the evening med pass. The facility initiated a search and implemented the missing resident protocol which included contacting local police department. Interview on 05/18/26 at 1:46 P.M. with Unit Manager (UM) #374 confirmed the facility did not conduct an assessment to determine if Resident #59 was safe to leave the facility on an independent LOA. UM #374 stated the facility conducted Brief Interview of Mental Status (BIMS) assessments on all of the residents on or around 04/03/26 and the decision to implement the order for the resident go on an independent LOA was based solely on the resident BIMS score and did not include other safety factors. Interview on 05/18/26 at 2:24 P.M. with Regional Nurse (RN) #704 confirmed the facility could not provide any evidence that Resident #59's former guardian gave the facility permission for resident to leave the facility independently. Interview on 05/18/26 at 2:28 P.M. with the Director of Nursing (DON) verified the facility did not contact Resident #59's guardian regarding the LOA order written on 04/03/26. The DON confirmed Resident #59 did not sign out the day he left the faciity on [DATE]. Interview on 5/19/26 at 9:37 A.M. with RN #704 confirmed resident returned to facility on 5/18/26 after leaving on 05/01/26. Regional Nurse #704 reported the resident did not disclose to facility staff where he has been staying while he was out of the facility for the past eighteen days. Interview on 5/19/26 at 11:13 A.M. with the Assistant Director of Nursing (ADON) verified LPN #348 notified her on 05/01/26 that Resident #59 was missing from the facility and had not signed himself out. The ADON confirmed Resident #59 was gone from facility from 05/01/26 and did not return until the evening of 05/18/26 and the resident did not disclose to the facility did not know where he had been while on LOA. Review of facility policy titled Therapeutic Leave of Absence revised April 2007 revealed residents could go out on therapeutic leave of absence when appropriate. 2.Review of medical record for Resident #103 revealed an admission date of 01/27/26 with diagnoses including traumatic subdural hemorrhage, hemiplegia and hemiparesis, and encounter for orthopedic aftercare. Review of the MDS assessment for Resident #103 dated 05/05/26 revealed the resident was dependent for shower/bathing, toileting hygiene, personal hygiene, and chair-to-bed-chair transfers. Review of care plan for Resident #103 dated 01/28/26 revealed the resident was at an increased risk for falls due to hemiplegia and hemiparesis and was to be transferred using via mechanical lift with two people. Interview on 05/21/26 at 9:12 A.M. with Certified Nurse Assistant (CNA) #409 confirmed she had provided care to Resident #103 in April 2026. CNA #409 confirmed she had transferred Resident #103 by herself without use of mechanical lift several times from bed to chair and chair to bed. CNA #409 confirmed that sometimes when she used mechanical lift, the second person assisting her would leave the room while the mechanical lift was still being used to transfer a resident. CNA #409 confirmed she was not aware Resident #103 was care planned to be transferred by two people via mechanical lift. Review of facility policy titled Using a Mechanical Lift dated 2001 revealed at least two nursing assistants are needed to safely move a resident with mechanical lift when transferring a resident from bed to chair. This deficiency represents noncompliance investigated under Complaint Number 3000603.

Based on medical record review, review of the facility investigation, review of the Self-Reported Incident (SRI), staff interview, and policy review, the facility failed to ensure medical records were accurate and complete. This affected one (Resident #59) of three residents reviewed for documentation. The facility census was 99 residents. Findings include:Review of the medical record for Resident #59 revealed an admission date of 12/10/24 with diagnoses including schizophrenia, type two diabetes mellitus, and depression.Review of the Minimum Data Set (MDS) assessment for Resident #59 dated 04/01/26 revealed the resident #59 had moderately impaired cognition and was independently mobile. Review of the progress notes for Resident #59 dated 04/30/26 to 05/18/26 revealed there was no documentation that indicated the resident had left the facility without staff knowledge and without signing himself out and that his whereabouts from 05/01/26 to 05/18/26 were unknown.Review of the facility's investigation dated 05/01/26 revealed Resident #59 was unable to be located on 05/01/26 at around 7:50 P.M. which prompted staff to initiate a search and implement their missing resident protocol which included contacting the local police department.Review of the SRI dated 05/04/26 revealed Resident #59 left the faciity on [DATE] and had not returned. The SRI indicated the facility initiated a search of the facility as well as the surrounding area and contacted the local police department for assistance.Interview on 05/19/26 at 9:41 A.M. with Regional Nurse (RN) #704 verified there were no progress notes detailing the incident in Resident #59's medical record.Interview on 05/19/26 at 11:13 A.M. with Assistant Director of Nursing (ADON) #429 confirmed there should be a detailed progress note in the medical record regarding any leaves of absence from the facility.Review of the facility policy titled Charting and Documentation revised July 2017 revealed events or incidents involving residents were to be documented in the medical record.

Based on observations and staff interview, the facility failed to ensure kitchen was kept in a clean and sanitary manner. This had the potential to affect all the residents who received trays from the kitchen, the facility identified two residents (#108 and #125) who did not receive meal trays. The facility census was 102. Findings include:Observation on 02/10/26 at 7:40 A.M. of the kitchen revealed grease had run down the grill from the drip pan into a metal pan and onto some towels on the floor. The observation revealed the drip pan had overflowed and the grease along the grill and in the metal pan and towels had solidified.Interview on 02/10/26 at 7:45 A.M. with Dietary Manager (DM) #108 confirmed the drip pan for the grill had overflowed and the grease had run down the grill into a metal pan and towels on the floor. DM #108 stated the handle to the drip pan had been broken for about four months. DM #108 stated usually maintenance would come to the kitchen daily to open the drip pan for the kitchen staff so the drip pan could be emptied. DM #108 confirmed the drip pan had not been emptied for a few days. The facility confirmed all residents receive meals from the kitchen, except two residents (#108 and #125).This deficiency represents non-compliance investigated under Complaint Number 2692596.

Based on observation and staff interview, the facility failed to ensure an Automated External Defibrillator (AED) device had new pads available for use in the event of a medical emergency. This had the affect on 18 out 19 residents the facility identified as a full code on the Rehab Hall. The census was 102. Findings include: Observation on 01/29/26 at 12:01 P.M. with Assistant Director of Nursing (ADON) of crash cart on Rehab Hall revealed AED (a portable life-saving device) was lying on top of crash cart with no pads connected to the AED. Observations revealed no pads were in the compartments of the AED or in the crash cart. On top of the crash cart was an items listed for daily checks. All items were checked off daily. There were no check off box to check AED for working order or if pads were in place. Interview on 01/29/26 at time of finding with revealed ADON verified no pads for AED were ready available. The facility confirmed 18 out of the 19 residents on the Rehab Hall are Full Code and this is the crash cart/AED that would be used in the event of an emergency or code situation. This deficiecny represents non-compliance investigated under Complaint Number 2725566.

Based on medical record, staff interview, and policy review, the facility failed to notify family of a resident's change of condition and/or regarding new physician orders. This affected one (#114) out of three residents reviewed for change of condition. The facility census was 102. Findings include: Record review for Resident #114 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: anoxic brain damage, human immunodeficiency virus, end stage renal disease, dependence on renal dialysis, heart failure, tracheostomy, and sepsis. Resident #114 was Full Code. Review of Minimum Data Set (MDS) assessment dated [DATE] Medicare 5-day revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 99. Unable to respond, Trach, pain regiment, feeding tube, pressure ulcer, continuous oxygen therapy, hemodialysis, anticoagulant, anticonvulsant. Review of progress notes for Resident for Resident #114 on 01/28/26 Licensed Practical Nurse (LPN) #123 noted at 8:26 A.M, Resident #114 had a bounding heart rate of 140, respirations 36, blood pressure, 95/62, temperature 98.9 degrees Fahrenheit, oxygen at 93% with trach in place, and using accessory muscles. The physician was contacted a verbal order given to administer Lopressor 50 milligrams (mg) and to repeat vital signs in thirty minutes. The physician was contacted of a heart rate of 112, respirations 24, and blood pressure 80/50. A new order to give midodrine 10 mg now and every six hours as needed, complete blood count and basic metabolic panel lab work complete now. Urinalyses with culture and sensitivity and chest radiograph to be completed now. No family was notified of change of condition or new orders. Interview on 01/28/25 at 8:41 A.M. with Director of Nursing verified no family was notified of Resident #114's change of condition or regarding the new orders. Review of facility policy Change in a Resident's Condition of Status, dated February 2001, revealed nurse will notify the resident's representative changes in medical care of nursing treatments and significant changes in mental or physical condition. This deficiency represents non-compliance investigated under Complaint Numbers 2740073 and 2725566.

Based on medical record reviews, staff and resident interviews, and policy review, the facility failed to ensure baths/showers were offered or completed as scheduled. This affected two (#85 and #112) out of three residents reviewed for activities of daily living (ADLs). The facility census was 102. Findings include: 1. Review of the medical record for Resident #85 revealed an admission date of 03/28/25 with medical diagnoses of cirrhosis of the liver, left above the knee amputation, diabetes mellitus (DM). Review of the medical record for Resident #85 revealed a quarterly Minimum Data Set (MDS) assessment, dated 01/01/26, which indicated Resident #85 was cognitively intact and required supervision for toilet hygiene, transfers, and set-up for eating and bed mobility. Review of the medical record for Resident #85 revealed shower documentation from 01/02/26 to 02/06/26 indicated the following: 01/02/26 refused, 01/09/26 completed, 01/16/26 completed, 01/20/26 refused, 01/23/26 completed, 01/27/26 completed and 02/06/26 completed. Further review revealed no documentation to support staff offered or provided a bath/shower after 01/02/26 until 01/09/26 and after 01/27/26 until 02/06/26. 2. Review of the medical record for Resident #112 revealed an admission date of 12/09/24 with medical diagnoses of chronic obstructive pulmonary disease, morbid obesity, diabetes mellitus, and chronic respiratory failure. Review of the medical record for Resident #112 revealed an annual Minimum Data Set (MDS) assessment, dated 12/11/25, indicated Resident #112 was cognitively intact and was independent with eating, bed mobility, toileting hygiene, and set-up assistance with showers and transfers. Review of medical record for Resident #112 revealed shower documentation from 01/07/26 to 02/07/26 indicated the following: 01/07/26 resident not available, 01/14/26 refused, 01/17/26 completed, 01/21/26 resident not room, 01/28/26 completed, 01/31/26 completed, 02/04/26 refused, and 02/07/26 completed. Further review revealed no documentation to support staff offered or provided a bath/shower after 01/07/26 until 01/14/26 and after 01/14/26 until 01/28/26. Interview on 02/09/26 at 2:03 P.M. with Resident #112 stated staff do not provide assistance with showers as scheduled. Interview on 02/11/26 at 9:21 A.M. with Director of Nursing (DON) stated if a resident was not available at the time of scheduled bath/shower then staff were to offer the opportunity to bath/shower the next day and staff were to document any refusals. DON confirmed the medical records for Residents #85 and #112 did not have documentation to support bath/showers were provided or offered as scheduled. Review of the policy stated, Activities of Daily Living (ADLs), revised April 2025 stated residents who are unable to carry out ADLs independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The policy stated cares/services included hygiene (bathing, dressing, grooming, and oral care), mobility (transfers and ambulation), elimination (toileting), dining (eating, including meals and snacks), and communication. The policy stated if resident refuses care that the resident was offered alternative interventions to minimize further decline and the refusals and details of the interventions refused are documented in the resident's clinical record. This deficiency represents non-compliance investigated under Complaint Number 2692596, 2705548, and 2725566.

Based on medical record reviews, observation, staff and resident interviews, review of facility incident/accident log, and policy and procedure review, the facility failed to ensure smoking/vaping devices were properly secured and not at bedside. This affected one (#85) out of three residents reviewed for smoking. The facility also failed to ensure a resident's fall was investigated and interventions were implemented and failed to ensure neurological checks were completed after a unwitnessed falls. This affected one (#115) out of three residents reviewed for falls. The facility census was 102. Findings include:1.Review of the medical record for Resident #85 revealed an admission date of [DATE] with medical diagnoses of cirrhosis of the liver, left above the knee amputation, diabetes mellitus (DM). Review of the medical record for Resident #85 revealed a quarterly Minimum Data Set (MDS) assessment, dated [DATE], which indicated Resident #85 was cognitively intact and required supervision for toilet hygiene, transfers, and set-up for eating and bed mobility. Review of the medical record for Resident #85 revealed a Smoking Safety evaluation, dated [DATE], which indicated Resident #85 used tobacco and required staff supervision for smoking and was not able to store smoking materials. The smoking evaluation stated Resident #85 did not use electronic cigarettes/vaping devices. Review of the medical record for Resident #85 revealed a smoking care plan which stated Resident #85 was a smoker but did not indicate if Resident #85 was independent or required staff supervision with smoking. Observation with interview on [DATE] at 8:36 A.M. revealed Resident #85 lying in bed and a vaping device was noted to be lying on the bed near Resident #85's hand. Interview with Resident #85 confirmed that was his vape and that he used it sometimes in his room. Interview on [DATE] at 8:38 A.M. with MDS nurse #103 confirmed Resident #85 had a vaping device lying on his bed next to him. MDS nurse #103 stated she was not aware that Resident #85 used a vaping device and thought he only used tobacco products. MDS #103 also confirmed Resident #85's smoking evaluation had not been updated since [DATE]. 2.Review of the medical record for Resident #115 revealed an admission date of [DATE] with medical diagnoses of hypertensive heart and chronic kidney disease, end stage renal disease, and anemia. Review of the record revealed Resident #115 expired on [DATE]. Review of the medical record for Resident #115 revealed a quarterly MDS assessment, dated [DATE], which indicated Resident #115 was cognitively intact and required partial/moderate staff assistance with bathing, bed mobility, and transfers and supervision with toilet hygiene. Review of the medical record for Resident #115 revealed a Fall Risk assessment, dated [DATE], which indicated Resident #115 only had one to two falls in the past three months and was not at risk for falls. Review of the medication record for Resident #115 revealed nursing notes which stated Resident #115 had falls on 10//04/25, [DATE], [DATE], and [DATE]. Review of nurse's note on [DATE] stated Resident #115 sustained an unwitnessed fall. Further review of the medical record revealed no documentation to support the facility initiated neurological checks after the unwitnessed fall. Review of the medical record revealed a Change of Condition evaluation dated [DATE] which stated Resident #115 had an unwitnessed fall but did contain any nurse progress notes related to the fall. Further review revealed the facility had not initiated neurological checks after the unwitnessed fall on [DATE]. Review of the facility incident log revealed no documentation to support the facility completed an investigation into or implemented interventions for Resident #115's fall on [DATE]. Interview on [DATE] at 1:50 P.M. with Licensed Practical Nurse (LPN) #192 confirmed Resident #115's medication record did not contain documentation to support neurological checks were initiated after falls on [DATE] or [DATE]. LPN #192 stated the facility had not investigated or implemented any interventions for Resident #115's fall on [DATE]. Review of the facility policy titled, Smoking- Residents, revised [DATE] stated smoking is only permitted in designated resident smoking areas, which are located outside of the building. The policy stated smoking is not allowed inside the facility under any circumstances. The policy continued to state electronic cigarettes and smokeless tobacco are permitted in designated areas only. Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc, except under direct supervision. The policy stated electronic cigarettes (e-cigarettes) are not considered smoking devices with respect to the risk of ignition, but they are considered a risk for residents related to potential health effects for the smoker, second-hand aerosol exposure, nicotine overdose by ingestion or contact with the skin, and explosion or fire caused by the battery. To prevent accidents associated with e-cigarettes and to respect the rights of residents who do not want to be exposed to second-hand aerosol, residents are permitted to use e-cigarettes with supervision and in designated smoking areas only. Review of the facility form titled, Procedure: Resident Fall Response and Documentation, stated the purpose was to ensure consistent, timely, and complete response to resident falls, including resident safety, family and physician communication, and documentation in Point Click Care (PCC). Stated nursing staff are to assess the resident immediately for injuries and vital signs, to notify the attending physician or on-call immediately, to notify family or responsible party of any falls or injuries, complete a fall risk event entry in PCC, to enter all required interventions into PCC and document narrative notes that include circumstances of the fall, resident's condition after the fall, interventions performed, and notifications completed. The procedure stated to initiate and document neurological checks per protocol for head injury/unwitnessed falls, reassess the resident's fall risk level and update care plan accordingly. This deficiency represents non-compliance investigated under Complaint Number 2692596.

Based on medical record review, staff and resident interviews, and policy review, the facility failed to administer medications as per physician orders. This affected one (#112) out of three residents reviewed for medication administration. The facility census was 102. Findings include: Review of the medical record for Resident #112 revealed an admission date of 12/09/24 with medical diagnoses of chronic obstructive pulmonary disease, morbid obesity, diabetes mellitus, and chronic respiratory failure. Review of the medical record for Resident #112 revealed an annual Minimum Data Set (MDS) assessment, dated 12/11/25, indicated Resident #112 was cognitively intact and was independent with eating, bed mobility, toileting hygiene, and set-up assistance with showers and transfers. Review of the medical record for Resident #112 revealed a physician order dated 12/09/24 for metformin 500 milligram (mg) one tablet by mouth two times per day, orders dated 12/10/24 for ferrous sulfate 325 mg one tablet by mouth daily, loratadine 10 mg one tablet by mouth daily, Theragran-M one tablet by mouth daily, and montelukast sodium 10 mg one tablet by mouth daily. Further review revealed physician orders dated 10/01/25 for ibuprofen 800 mg one tablet by mouth three times per day, 10/02/25 for methocarbamol 750 mg one tablet by mouth three times daily, and 01/16/25 for Os-Cal 500-150 mg one tablet by mouth daily. Review of the medical record for Resident #112 revealed the November 2025 Medication Administration Record (MAR) which had no documentation to support medications were administered as ordered on 11/12/15, 11/21/25, 11/25/25, 11/27/25, and 11/28/25. Review of the January 2026 MAR revealed no documentation to support Resident #112 received medications as ordered on 01/22/26 and 01/23/26. Interview on 02/09/26 at 2:03 P.M. with Resident #112 stated he does not get his medications at times. Interview on 02/11/26 at 9:50 A.M. with Administrator confirmed the medical record for Resident #112 did not have documentation to support medications were administered as ordered on 11/12/15, 11/21/25, 11/25/25, 11/27/25, 11/28/25, 01/22/26, and 01/23/26. Review of the facility policy titled, Administering Medications, revised April 2019 stated medication are administered in a safe and timely manner and as prescribed. The policy stated medications are administered in accordance with prescriber's orders, including any required time frame. This deficiency represents non-compliance investigated under Complaint Number 2705548.

Based on medical record review, staff interviews, and policy review, the facility failed to administer insulin as ordered and to ensure blood pressure medications were administered per the ordered parameters resulting in significant medication errors. This affected one (#64) out of three residents reviewed for medications. The facility census was 102. Findings include: Review of the medical record for Resident #64 revealed an admission date of 10/18/25 with medical diagnoses of acute and chronic respiratory failure, dysphagia, chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), and end stage renal disease (ESRD). Review of the medical record for Resident #64 revealed an admission Minimum Data Set (MDS) assessment, dated 10/31/25, which indicated Resident #64 was cognitively intact and required substantial/maximum assistance with toilet hygiene and bathing, was dependent upon staff for transfers, and required supervision with bed mobility. Review of the medical record for Resident #64 revealed a physician order dated 10/20/25 for midodrine 10 mg one tablet via percutaneous endoscopic gastrostomy tube (peg-tube) three times per day for hypotension and to hold if systolic blood pressure (SBP) was greater than 110, an order dated 10/22/25 for insulin lispro solution pen-injector 100 units per milliliter (ml) to inject 8 units subcutaneously (SQ) before meals and at bedtime, an order dated 10/27/25 for allopurinol 100 milligram (mg) one tablet via peg-tube daily, and orders dated 10/28/25 for metoprolol 25 milligram (mg) one tablet via peg-tube two times per day for hypertension and to hold if SBP was less than 100 or diastolic blood pressure (DBP) was less than 60, apixaban 5 mg one tablet via peg-tube daily, rifaximin 550 mg one tablet via peg-tube two times per day for encephalopathy, acetaminophen 650 mg via peg-tube three times per day, and ipratropium-albuterol inhalation solution 3 mg per ml to inhale 3 ml orally every four hours. Further review of the physician orders revealed an order dated 10/30/25 for lansoprazole 3 mg per ml to give 10 ml via peg-tube daily, an order dated 11/02/25 for Lantus Solostar solution pen-injector 100 units per ml to inject 28 units SQ two times per day, and an order dated 11/10/25 for Advair discus inhalation aerosol powder breath activated 100-50 micrograms per activation one puff inhale two times per day for asthma. Review of the medical record for Resident #64 revealed the Medication Administration Record (MAR) for December 2025 revealed no documentation to support medications were administered as ordered on 12/10/25- 12/12/25, 12/15/25, 12/29/25, or 12/30/25. Review of the January 2026 MAR revealed documentation to support blood pressure medications (metoprolol and midodrine) were administered outside of blood pressure parameters on 01/03/26, 01/06/26, 01/07/26, 01/11/26, 01/13/26, 01/14/26, 01/15/26, and 01/16/26. Interview on 01/29/26 at 9:42 A.M. with Registered Nurse (RN) #275 confirmed the medical record for Resident #64 revealed no documentation to support Resident #64 received medications, including insulin, as ordered on 12/10/25-12/12/25, 12/15/25, 12/29/25, or 12/20/25. RN #275 confirmed Resident #64 was administered blood pressure medications outside of blood pressure parameters on 01/03/26, 01/06/26, 01/07/26, 01/11/26, 01/13/26, 01/14/26, 01/15/26, and 01/16/26. Review of the facility policy titled, Administering Medications, revised April 2019 stated medication are administered in a safe and timely manner and as prescribed. The policy stated medications are administered in accordance with prescriber's orders, including any required time frame. This deficiency represents non-compliance investigated under Complaint Number 2727077 and 2705548.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were administered in a way to avoid cross contamination. This affected one resident (#86) of five residents observed during medication administration. The Facility census was 89. Findings Include: Medical record review for Resident #86 revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to chronic obstructive pulmonary disease, epilepsy, and nontraumatic intracerebral hemorrhage. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #86 dated 08/12/25 revealed intact cognition. Resident #86 required set up assistance to moderate assistance for activities of daily living. Review of the physician orders for Resident #86 for the month of August 2025 revealed resident had an order for Aspirin enteric coated delayed release 81 milligram (mg) tablet, give one tablet one time a day dated 12/15/24. Observation of medication pass on 08/26/25 at 7:47 A.M. with Licensed Practical Nurse (LPN) #278 revealed hand hygiene was completed then the nurse was observed to retrieved medication cart keys, unlocked medication cart, pulled open cart drawer and touch multiple bottles before opening a stock bottle of aspirin. LPN #278 dispensed one tablet into the lid of the stock bottle and in the process dropped one tablet onto the medication cart. LPN #278 picked up the aspirin from the surface of the medication cart and put it back in the multiple dose bottle, securing the cap and was observed to place the bottle back in the medication cart. Interview on 08/26/25 at 7:57 A.M. with LPN #278 verified she picked up the tablet and put it back into the bottle with the other tablets. LPN #278 stated she probably should have thrown the tablet away. Interview on 08/26/25 at 2:41 P.M. with the Director of Nursing (DON) verified nurses are not to touch medications with bare hands. Review of the facility policy titled Administering Medication dated 04/2019 states staff follows established facility infection control procedures for the administration of medications. This violation represents non-compliance investigated under Complaint Number 1377238.

Based on observation, interview, medical record and facility policy review, the facility failed to ensure the medical record was accurate. The facility documented medication as administered by facility staff when it was self-administered by the resident without nursing supervision. This affected one resident (#57) of five reviewed for medication administration. The facility census was 89.Findings Include:Review of the medical record for Resident #57 revealed an admission date of 01/22/25 with diagnoses including but not limited to dysphagia following cerebral infarction, type two diabetes, hemiplegia and hemiparesis affected the non-dominant side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #57 revealed an intact cognition. Resident #57 required set up assistance for eating. Resident #57 was totally dependent on staff for toileting, transfers and bed mobility.Review of the physician orders for Resident #57 revealed an order stating resident required assistance from staff to complete self-care and mobility due to hemiplegia dated 06/17/25 and an order for Fluticasone Propionate Nasal Suspension 50 micrograms two spray in both nostrils two times a day for allergies dated 05/16/25. The resident did not have an order to self-administer medications.Observation on 08/26/25 at 8:18 A.M. of medication administration with Licensed Practical Nurse (LPN) #281 revealed nurse prepared medication for Resident #57 including gathering the Fluticasone Propionate Nasal Suspension 50 micrograms nasal spray and entered the resident room. LPN #281 attempted to administer Fluticasone Propionate Nasal Suspension 50 micrograms to resident when he responded that he already did that pointing a bottle of nasal spray which was sitting on his bedside table, Resident #57 stated the night shift left the nasal spray in his room the night before. Observation on 08/26/25 at 8:23 A.M. LPN #281 was observed to sign the medication administration record (MAR) for Resident #57 for Fluticasone Propionate Nasal Suspension 50 micrograms indicating it was administered by LPN #281. Interview on 08/26/25 at 2:41 P.M. with Director of Nursing (DON) verified the nurse should not have documented the Fluticasone Propionate Nasal Suspension 50 micrograms as administered in the MAR when it was not witnessed by the nurse as being administered. Review of the facility policy titled Administering Medications dated 04/2019 states the individual administering the medication initials the resident MAR on the appropriate line after giving each medication and before administering the next one. This violation represents non-compliance investigated under Complaint Number 2575242.

Based on observation, interview, medical record and facility policy review, the facility failed to securely store medications. This affected one resident (#57) of five reviewed for medication administration. The facility census was 89.Findings include:Review of the medical record for Resident #57 revealed an admission date of 01/22/25 with diagnoses including but not limited to dysphagia following cerebral infarction, type two diabetes, hemiplegia and hemiparesis affected the non-dominant side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #57 revealed an intact cognition. Resident #57 required set up assistance for eating. Resident #57 was totally dependent on staff for toileting, transfers and bed mobility.Review of the physician orders for Resident #57 revealed an order stating resident required assistance from staff to complete self-care and mobility due to hemiplegia dated 06/17/25 and an order for Fluticasone Propionate Nasal Suspension 50 micrograms two spray in both nostrils two times a day for allergies dated 05/16/25. The resident did not have an order to self-administer medications. Observation on 08/26/25 at 8:18 A.M. of medication administration with Licensed Practical Nurse (LPN) #281 revealed nurse prepared medication for Resident #57 including gathering the Fluticasone Propionate Nasal Suspension 50 micrograms nasal spray and entered the resident room. LPN #281 attempted to administer Fluticasone Propionate Nasal Suspension 50 micrograms to resident when he responded that he already did that pointing a bottle of nasal spray which was sitting on his bedside table. Resident #57 stated the night shift left the nasal spray in his room the night before. LPN #281 administered the other prescribed medications, removing the bottle of Fluticasone Propionate Nasal Suspension 50 micrograms off of the resident's bedside table when she left the room.Interview on 08/26/25 at 8:25 A.M. with LPN #281 verified the bottle of Fluticasone Propionate Nasal Suspension 50 micrograms should not have been in the room and verified the resident did not have a physician order for medication self-administration. Interview on 08/26/25 at 2:41 P.M. with Director of Nursing (DON) verified medications should not be left in the resident's room. Review of the facility policy titled Medication Labeling and Storage dated 02/2023 states that medications and biologicals are in locked in compartments and only authorized personnel have access to keys.

Based on interview and record review, the facility failed to notify residents that the amount of funds in their accounts was 200 dollars less than the Medicaid resource limit and that the residents may lose eligibility for Medicaid. This affected six (#10, #43, #5, #29, #27 and #11) out of seven residents reviewed for personal funds. The facility census was 97. Findings include: On 05/21/25 at 12:11 PM, during review of the list of resident funds documentation provided by the facility during the survey it was noted that Resident #10, #43, #5, #29, #27 and #11 were all Medicaid recipients and all had balances over $2,000 dollars in their funds accounts. Interview with Business Office Manager (BOM) #4 confirmed Resident #10, #43, #5, #29, #27 and #11 were Medicaid recipients and their balances were over the maximum amount allowed by Medicaid. BOM #4 was asked to provide spend down notification letters that were sent to the residents. BOM #4 stated that there were no spend down notification letters sent to the residents. BOM #4 stated that letters were on her desk but have not been sent.

Based on interview, record review, facility policy review, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within 92 days of the prior MDS assessment for 1 (Resident #49) of 9 residents reviewed for the resident assessment task. In addition, the facility failed to ensure quarterly MDS assessments were signed as complete within 14 days of the Assessment Reference Date (ARD) for 3 (Residents #4, #34, and #46) of 9 residents reviewed for the resident assessment task. Findings included: A facility policy titled, MDS Completion and Submission Timeframes, revised 10/2023, revealed, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The policy specified, 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. The CMS Long-Term Care Facility RAI 3.0 User's Manual, Version 1.19.1, dated 10/2024, revealed, Chapter 2: Assessments for the RAI, section 05. Quarterly Assessments, specified The Quarterly assessment is an OBRA [Omnibus Budget Reconciliation Act] non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. The manual specified, The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days). 1. An admission Record revealed the facility admitted Resident #49 on 05/20/2020. According to the admission Record, the resident had a medical history that included diagnoses of acute on chronic diastolic (congestive) heart failure and type two diabetes mellitus without complications. Resident #49's MDS history contained within their electronic health record (EHR) revealed their most recently completed MDS was a quarterly MDS, with an ARD of 01/02/2025. The MDS history indicated the resident's next quarterly MDS was 27 days overdue. According to the MDS history, a quarterly MDS, with an ARD of 04/02/2025, had a status of, In Progress. During an interview on 05/17/2025 at 2:00 PM, the Director of Nursing (DON) stated quarterly MDS assessments were due every 92 days. During an interview on 05/18/2025 at 8:15 AM, the Administrator stated he was aware the facility was behind on some MDS assessments. He said this was due to staff transitions, and the MDS Coordinator had only been in the role for about two weeks. During an interview on 05/18/2025 at 2:42 PM, the Administrator stated he expected the MDS assessments to be completed timely, according to the RAI manual. 2. An admission Record indicated the facility admitted Resident #4 on 02/02/2018. According to the admission Record, the resident had a medical history that included diagnoses of unspecified dementia and type two diabetes mellitus without complications. Resident #4's quarterly MDS, with an ARD of 04/03/2025, revealed the assessment was not signed as complete until 05/16/2025. During an interview on 05/17/2025 at 2:00 PM, the Director of Nursing (DON) stated MDS assessments should be completed within 14 days of the ARD. During an interview on 05/18/2025 at 8:15 AM, the Administrator stated he was aware the facility was behind on some MDS assessments. He said this was due to staff transitions, and the MDS Coordinator had only been in the role for about two weeks. During an interview on 05/18/2025 at 2:42 PM, the Administrator stated he expected the MDS assessments to be completed timely, according to the RAI manual. 3. An admission Record indicated the facility admitted Resident #34 on 01/18/2016. According to the admission Record, the resident had a medical history that included diagnoses of unspecified cerebral infarction and essential (primary) hypertension. Resident #34's quarterly MDS, with an ARD of 04/01/2025, revealed the assessment was not signed as complete until 05/16/2025. During an interview on 05/17/2025 at 2:00 PM, the Director of Nursing (DON) stated MDS assessments should be completed within 14 days of the ARD. During an interview on 05/18/2025 at 8:15 AM, the Administrator stated he was aware the facility was behind on some MDS assessments. He said this was due to staff transitions, and the MDS Coordinator had only been in the role for about two weeks. During an interview on 05/18/2025 at 2:42 PM, the Administrator stated he expected the MDS assessments to be completed timely, according to the RAI manual. 4. An admission Record indicated the facility admitted Resident #46 on 11/01/2024. According to the admission Record, the resident had a medical history that included diagnoses of unspecified stage three chronic kidney disease and cerebrovascular disease. Resident #46's quarterly MDS, with an ARD of 04/03/2025, revealed the assessment was not signed as complete until 05/16/2025. During an interview on 05/17/2025 at 2:00 PM, the Director of Nursing (DON) stated MDS assessments should be completed within 14 days of the ARD. During an interview on 05/18/2025 at 8:15 AM, the Administrator stated he was aware the facility was behind on some MDS assessments. He said this was due to staff transitions, and the MDS Coordinator had only been in the role for about two weeks. During an interview on 05/18/2025 at 2:42 PM, the Administrator stated he expected the MDS assessments to be completed timely, according to the RAI manual.

Based on interview, record review, facility document review, and facility policy review, the facility failed to resolve a concern in a timely manner for 1 (Resident #66) of 2 residents reviewed for grievances. In addition, the facility failed to document concerns, ensure resolution, and provide feedback for 1 (Resident #57) of 2 residents reviewed for grievances. Findings included: A facility policy titled, Grievances, effective 03/2024, revealed, Purpose: To ensure prompt resolution of all grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their stay at this campus. The Grievances policy specified, Grievances may be filed orally (meaning spoken), in writing, or anonymously. The policy revealed, Every effort shall be made to resolve grievances in a timely manner, usually within 5 business days (excludes weekends and holidays). 1. An admission Record revealed the facility admitted Resident #66 on 03/07/2025. According to the admission Record, the resident had a medical history that included diagnoses of left non-dominant side hemiplegia (paralysis) and hemiparesis (muscle weakness) and cerebral infarction (stroke). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/14/2025, revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed Resident #66 had functional limitations in range of motion, impairment on one side of their upper and lower extremities and utilized a wheelchair for a mobility device. Resident #66's Care Plan Report, included a focus area initiated 03/08/2025, that revealed the resident had an activities of daily living (ADL) self-care performance deficit. Interventions directed staff to offer to assist the resident out of bed into a wheelchair daily (initiated 04/11/2025). A Concern/Compliment Form, dated 04/16/2025, revealed Resident #66 and their family member reported a concern via phone. The form specified, Nature of Concern/Compliment: Wheelchair 'Hydraulics' system is Broken. The Concern/Compliment Form revealed the facility's findings were that the wheelchair was the resident's personal wheelchair, and the facility's maintenance staff could not do anything with it. The form indicated a representative of the wheelchair manufacturer would be called. The Concern/Compliment Form revealed the facility followed up with Resident #66 on 04/21/2025, but the document was incomplete as it did not indicate whether the resident was satisfied with the outcome and actions taken. The form was signed by the notifying staff, the Administrator/Assistant Administrator, and the Grievance Official. During an interview on 05/12/2025 at 10:48 AM, Resident #66 stated they and their family member spoke to facility staff regarding their wheelchair not working properly. Resident #66 stated that the wheelchair's hydraulic system did not work. During an interview on 05/16/2025 at 9:16 AM, Resident #66 stated that the functions on the wheelchair control panel did not always work. Resident #66 stated they were told the therapy department would assist with their wheelchair. During an interview on 05/19/2025 at 9:43 AM, Family Member (FM) #40 stated the hydraulic system of Resident #66's wheelchair had not worked properly for a couple of months. FM #40 said they contacted the wheelchair company at the telephone numbers that were listed on the sticker on the wheelchair, and they were told the facility would have to make contact to get the wheelchair repaired. FM #40 confirmed they spoke to the Social Services Director (SSD) regarding the resident's wheelchair and the SSD stated she was not aware of the concern but would look into getting the wheelchair repaired. FM #40 stated they spoke to maintenance staff who stated they could not fix the wheelchair, and did not know what to tell the resident. FM #40 stated they told the Administrator that nothing was being done about the resident's wheelchair, and he stated he would look into it, but had not provided any response. During an interview on 05/16/2025 at 9:29 AM, the SSD confirmed Resident #66 filed a concern form regarding their wheelchair not working properly. The SSD stated the concern form was completed on 04/16/2025, but she had not contacted the wheelchair manufacturer's representative to come out and service the wheelchair. During an interview on 05/16/2025 at 9:49 AM, the Maintenance Director stated the facility did not complete repairs on residents' personal wheelchairs, but facility staff would contact the wheelchair manufacturer's representative to complete service and repairs. The Maintenance Director stated that the therapy department was responsible for contacting the representative. During an interview on 05/16/2025 at 10:14 AM, the Rehabilitation Director stated the facility would reach out to the durable medical equipment supplier for repair of a resident's personal wheelchair. The Rehabilitation Director stated she was not aware of a concern form regarding Resident #66's wheelchair needing repairs. She said maintenance staff could have notified the supplier's representative as there was a sticker (on the wheelchair) with the supplier's name and contact information. During an interview on 05/17/2025 at 10:34 AM, the Maintenance Director stated he would normally inform the therapy department about a broken wheelchair. The Maintenance Director stated he had not contacted a wheelchair company representative to have Resident #66's wheelchair repaired. The Maintenance Director stated the resident's concern was discussed in the morning meeting on 04/21/2025, but he did not know if there was any follow-up to ensure the wheelchair was repaired. During an interview on 05/17/2025 at 1:50 PM, the Director of Nursing (DON) stated he was not aware of any unresolved grievances for Resident #66 and was not aware that the resident's wheelchair needed to be repaired. During an interview on 05/18/2025 at 8:15 AM, the Administrator stated he was not aware of a concern regarding Resident #66's wheelchair. 2. An admission Record indicated the facility admitted Resident #57 on 07/02/2023. According to the admission Record, the resident had a medical history that included diagnoses of cerebral palsy, heart failure, and chronic obstructive pulmonary disease (COPD). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/23/2025, revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #57 required substantial to maximal assistance with showers and bathing themselves and was dependent on staff for personal hygiene and chair/bed-to-chair transfers. Resident #57's Progress Notes, dated 03/13/2025, revealed a Behavior note that indicated the resident stated she had not received any medication since the prior afternoon. The note indicated the resident accused the nurse of stealing their albuterol inhaler that the day shift nurse left on their table. Resident #57's Progress Notes, dated 03/26/2025, revealed a Behavior note that indicated the resident was angry that a state tested nurse aide (STNA) would not change them every 45 minutes as indicated by the wound physician, per the resident. The note revealed Resident #57 stated Licensed Practical Nurse (LPN) #21 broke their nebulizer on purpose and their oxygen tubing had a hole. The note indicated the supply room was locked, but nurses retrieved oxygen tubing from the resident's drawer, replaced the tubing, and attempted to redirect them. The note revealed the resident stated they had issues on the day shift as all STNA's in the facility were lazy. The note indicated the Director of Nursing (DON) was notified of the resident's behaviors. Resident #57's Progress Notes, dated 04/01/2025 at 6:16 PM, revealed a Behavior note that indicated the resident was at the nurses' station and complained they had not received a breathing treatment or pain medication, and had been waiting to be changed since 4:00 PM. The note indicated LPN #21 placed the medication in the nebulizer and the resident yelled that the machine did not work, and that the nurse broke it. The note indicated that during change of shift report, the day shift nurse informed LPN #21 that Resident #57 had continuous behaviors on the day shift, and LPN #21 notified the Assistant Director of Nursing (ADON) of continued behaviors. During an interview on 05/19/2025 at 8:32 AM, Resident #57 stated they spoke with the Assistant Director of Nursing (ADON) in March (2025) about concerns. Resident #57 stated staff did not listen to them when they needed to be changed, and they were upset about how staff hung their clothes. During an interview on 05/19/2025 at 9:14 AM, STNA #16 stated if a resident had complaints or concerns, she would inform nurses, but she did not file grievances on behalf of residents. According to STNA #16, Resident #57 had a lot of complaints and complained to everyone. She stated the resident had concerns about not getting their medications if they were given five minutes after they were due, getting out of bed, and not being changed fast enough. STNA #16 said the nurses and the DON were aware of the resident's concerns. STNA #16 stated she did not have the time to write down all the resident's concerns and did not always communicate the concerns to nursing staff. During an interview on 05/19/2025 at 8:48 AM, the Social Services Director (SSD) revealed that any concerns shared with nursing staff, whether from a resident or a family member, must be reported. The SSD stated complaints could be verbal or written, and if the concern was filed verbally, it would be placed on a concern form. The SSD stated she expected STNA's to handle issues, but if an issue were ongoing, it would go to the next level and the concern should be reported to the nurse in charge. According to the SSD, she was only aware of Resident #57's concern regarding hearing aids, which the facility already addressed. The SSD stated she was not aware of Resident #57's concerns related to oxygen tubing not being available, not receiving timely incontinence care, not receiving timely response to their call light, or that staff were not getting them out of bed. During an interview on 05/19/2025 at 11:19 AM, LPN #15 revealed Resident #57 always had complaints about something, and staff did not always document the resident's concerns. LPN #15 stated she did not know why she did not document or report the concerns, but the resident was always speaking with the DON and management staff, so she assumed the concerns were shared. LPN #15 stated Resident #57's concerns included not having supplies available, staff not getting them up quickly enough, not getting their medications on time, activities, and not having things to do at the facility. LPN #15 confirmed she had not documented the concerns in progress notes or on a complaint form. During an interview on 05/19/2025 at 12:58 PM, the ADON stated a grievance form would be completed if the residents' concerns could not be rectified immediately. The ADON stated residents' concerns should be reported to the charge nurse, the DON, or the Administrator. He stated the facility addressed residents' concerns in the morning meetings; department heads worked on the concerns and returned the form within five days. According to the ADON, he was not informed of any concern for Resident #57 regarding supplies, timely incontinent care, STNA's, staff not getting the resident out of bed, not getting medications or treatments, and activities. He stated he would have expected staff to document or provide details about the resident's concerns. During an interview on 05/19/2025 at 1:28 PM, the DON stated residents' concerns must be reported to the nursing staff and they would write them on concern forms, or residents could express their concerns verbally. The DON stated he was not aware of any of Resident #57's concerns and would have expected staff to inform him of the concerns. The DON confirmed the facility did not have documentation of Resident #57's concerns. He stated accountability in the facility was lacking. During an interview on 05/19/2025 at 1:49 PM, the Administrator stated that when a resident shared concerns with the nursing staff, the concerns needed to get to the managers. He stated if staff could fix the issues right away, then no concern form should be completed, but if the concern could not be immediately resolved, then a concern form would be completed. The Administrator stated he was not aware of any concerns regarding Resident #57, and he would have expected the concerns to be documented on the concern form. This deficiency represents non-compliance investigated under Complaint Number OH00164128.

Based on interview, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded related to the use of a non-invasive mechanical ventilator for 1 (Resident #57) of 2 residents reviewed for respiratory services. Findings included: A facility policy titled, Certifying Accuracy of the Resident Assessment, revised 11/2019, indicated, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. The policy revealed, 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. An admission Record indicated the facility admitted Resident #57 on 07/02/2023. According to the admission Record, the resident had a medical history that included diagnoses of heart failure, chronic obstructive pulmonary disease (COPD), sleep apnea, lobar pneumonia, and dependence on supplemental oxygen. A quarterly Minimum Data Set (MDS), with an Assessment Reference date (ARD) of 04/23/2025, revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident received oxygen therapy and did not use a non-invasive mechanical ventilator. Resident #57's Care Plan Report, included a focus area initiated 06/25/2024, that indicated the resident had altered respiratory status/difficulty breathing related to respiratory failure, shortness of breath, sleep apnea, and COPD. Resident #57's April 2025 Treatment Administration Record [TAR], revealed a transcription of an order with a start date of 07/21/2024 and a discontinue date of 04/17/2025, for Treatment CPAP [continuous positive airway pressure, a non-invasive mechanical ventilator] at night at setting of 8. at bedtime. The TAR revealed staff documented that the CPAP was administered on 04/09/2025, 04/10/2025, 04/11/2025, 04/12/2025, and 04/16/2025 which was during the 14-day look-back period for the quarterly MDS with an ARD of 04/23/2025. During an interview on 05/18/2025 at 12:33 PM, the Director of Nursing (DON) stated it was important for MDS assessments to accurately reflect residents' conditions. He stated the information (for the MDS assessments) came from documentation and interviews. The DON stated observations of the resident should also be done. The DON confirmed the use of CPAP machines should be included in MDS assessments and MDS staff should see the machines when they did their observations of residents. During an interview on 05/18/2025 at 1:48 PM, the Administrator stated that the accuracy of MDS assessments was important because it provided a snapshot of the resident. He stated that the information for the MDS came from assessments, documents, interviews, and observations by different departments. The Administrator confirmed that the use of non-invasive mechanical ventilators should be captured on MDS assessments.

Based on interview, record review, and facility policy review, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) accurately reflected all diagnosed mental disorders and prescribed psychotropic medications for 2 (Resident #16 and Resident #92) of 4 residents reviewed for PASARR requirements. Findings included: A facility policy titled, Preadmission Screening and Annual [sic] Resident Review (PASARR), effective 03/2024, indicated, It is the policy to screen all potential admissions on an individualized basis. As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review (PASARR) screening process (Level I) for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorder (SMI/SMD) [serious mental illness/serious mental disorder], intellectual disability (ID) or related condition. 1. An admission Record revealed the facility originally admitted Resident #16 on 02/21/2025 and most recently admitted the resident on 04/19/2025. According to the admission Record, the resident had a medical history that included diagnoses of post-traumatic stress disorder; major depressive disorder, recurrent severe without psychotic features; and a history of a suicide attempt. The admission Record indicated each of these diagnoses were classified as, Present on Admission. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/06/2025, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident had active diagnoses at the time of the assessment that included depression, post-traumatic stress disorder, and suicide attempt. The MDS indicated Resident #16 received antipsychotic, antianxiety, and antidepressant medications during the seven-day assessment look-back period. Resident #16's 02/2025 Medication Administration Record (MAR) revealed the transcription of the following orders: - an order started on 02/22/2025 and discontinued on 03/14/2025 for aripiprazole (an atypical antipsychotic medication) 5 milligrams (mg) once daily for depression; - an order started on 02/22/2025 and discontinued on 03/06/2025 for duloxetine hydrochloride delayed release (an antidepressant medication) 60 mg, two capsules in the morning for depression; - an order started on 02/22/2025 and discontinued on 03/14/2025 for escitalopram oxalate (an antidepressant medication) 20 mg in the morning for depression; - an order started on 02/22/2025 and discontinued on 03/14/2025 for amitriptyline hydrochloride (an antidepressant medication) 50 mg twice daily for depression; and - an order started on 02/22/2025 and discontinued on 03/06/2025 for buspirone hydrochloride (an anti-anxiety medication) 15 mg three times daily for anxiety. Resident #16's Level I PASARR, signed by the Social Services Director on 03/18/2025, revealed a Resident Review was completed due to an expiring hospital exemption. The Level I PASARR indicated Resident #16 had not received psychotropic medications including antipsychotic, antidepressant, and antianxiety medications in the past six months. During an interview on 05/17/2025 at 2:44 PM, the Social Service Director (SSD) stated she completed Resident #16's PASARR form and she confirmed it did not reflect the psychotropic medications the resident received. The SSD stated she did not know who currently reviewed PASARR forms for accuracy. During an interview on 05/18/2025 at 7:43 AM, the Director of Nursing (DON) stated admissions staff and the social worker were responsible for the PASARR process. The DON stated the PASARR process was to ensure residents' mental health issues were recognized and addressed. The DON stated he expected PASARR forms to be complete and accurate. The DON reviewed Resident #16's PASARR form and stated it was not accurate, because the resident received psychotropic medications. During an interview on 05/18/2025 at 12:09 PM, the Administrator stated he expected residents' PASARR forms to be accurate. The Administrator stated the purpose of the PASARR was to determine if residents needed a Level II review to determine if they needed more services. 2. An admission Record revealed the facility admitted Resident #92 on 12/10/2024. According to the admission Record, the resident had a medical history that included a diagnosis of schizophrenia, which was present at the time of admission. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/17/2024, revealed Resident #92 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident had a diagnosis of schizophrenia and received antipsychotic, antidepressant, and anticonvulsant medications in the prior seven days. Resident #92's Order Summary Report, listing active orders as of 05/15/2025, included the following orders: - an order dated 12/10/2024 for divalproex sodium extended release (an anti-seizure medication sometimes used as a mood stabilizer) 250 milligrams (mg), one tablet once daily for behaviors; - an order dated 12/10/2024 for divalproex sodium extended release 250 mg, three tablets at bedtime for behaviors; - an order dated 12/15/202 for haloperidol (an antipsychotic medication) 5 mg three times daily for behaviors; - an order dated 12/10/2024 for sertraline hydrochloride (an antidepressant medication) 150 mg once daily for depression; and - an order dated 12/10/2024 for olanzapine (an antipsychotic medication) 20 mg at bedtime for behaviors. Resident #92's Level I PASARR, dated 12/06/2024, indicated Resident #92 had none of the listed diagnoses of mental disorders, which included schizophrenia. The screening form indicated the resident had not received psychotropic medications including antipsychotic, antidepressant, and mood stabilizer medications in the past six months. During an interview on 05/17/2025 at 2:44 PM, the Social Services Director (SSD) stated admissions staff were responsible for ensuring the PASARR was correct before the resident got to the facility. During an interview on 05/18/2025 at 7:43 AM, the Director of Nursing (DON) stated admissions staff and the social worker were responsible for the PASARR process. The DON stated the PASARR process was to ensure residents' mental health issues were recognized and addressed. The DON stated he expected PASARR forms to be complete and accurate. The DON reviewed Resident #92's PASARR form and confirmed there were no mental health diagnoses checked, and the form indicated no psychotropic medications were prescribed for the resident. The DON stated that upon admission to the facility, Resident #92 had orders for Zyprexa (olanzapine) and Depakote (divalproex sodium) which should have been noted on the PASARR form. The DON said the resident's PASARR was wrong (on admission), and the facility should have submitted another Level I PASARR form. During an interview on 05/18/2025 at 12:09 PM, the Administrator stated he expected residents' PASARR forms to be accurate. The Administrator stated the purpose of the PASARR was to determine if residents needed a Level II review to determine if they needed more services.

Based on review of medical records, review of the emergency squad run report, review of hospital records, review of email communications, review of policies on Lab and Diagnostic Test Results - Clinical Protocol, Adverse Consequences and Medication Errors and Change in a Resident's Condition or Status, staff interviews, physician interview, family interview, interview with the hospital social worker, and interview with pharmacy staff, the facility failed to ensure one resident (Resident #79) was free from neglect when the facility staff failed to provide appropriate services to ensure the resident received his intravenous (IV) antibiotic as ordered for a surgical wound infected with Methicillin-resistant Staphylococcus aureus (MRSA), failed to ensure laboratory tests were completed and results reported for medication dosing, and failed to ensure accurate assessments were being completed. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries and/or death, when Resident #79 was found by the transport company staff upon arriving at the facility to be confused, aphasic, and had abnormal vital signs. The resident was determined to be in an emergent situation and was taken to the emergency room at which time his body temperature was 88.9 degrees Fahrenheit (F) and wounds were noted on bilateral inner thighs, left posterior thigh and excoriated areas on the buttocks, that the facility was unaware of. Upon admission to the emergency room , the resident was diagnosed with altered mental status, septic shock, leukocytosis with multiple sources of infection: including indwelling catheter, intravenous cite red and warm, wounds on back and groin area with erythematous, urinary tract infection, hypothermia, acute renal failure, metabolic acidosis, and hyperkalemia and was admitted to critical care. This affected one (#79) of three residents (#78, #79, and #80) reviewed for change in condition. The facility census was 74. On 02/14/23 at 5:34 P.M., the Administrator, Director of Nursing (DON), Regional [NAME] President #10, Regional Nurse #500 and Campus Executive Director #50 were notified Immediate Jeopardy began on 11/20/22 when Resident #79 was admitted to the facility from the hospital with a physician order for Vancomycin that was not administered for five days (11/20/22, 11/21/22, 11/22/22, 11/23/22, 12/15/22), and on 12/21/22, he was administered the medication when it was placed on hold; then from 12/22/22 to 12/30/22 he did not receive the medication for a period of eight days. Consequently, on 12/30/22, Resident #79 was found by the Emergency Medical Technician (EMT), who was there to take him home, to be severely confused with incoherent speech and was hypotensive. He was taken emergently to the hospital resulting in the resident receiving peripheral vasoconstrictor, intravenous fluids, warming protocol, and multiple antibiotics which led to the resident being placed in the intensive care unit (ICU). Resident #79 was admitted with diagnoses including altered mental status, septic shock, leukocytosis with multiple sources of infection: including indwelling catheter, intravenous cite red and warm, wounds on back and groin area with erythematous, urinary tract infection, hypothermia, acute renal failure, metabolic acidosis, and hyperkalemia and was admitted to critical care. The Immediate Jeopardy was removed on 02/15/23, when the facility implemented the following corrective actions: On 12/30/22 at approximately 6:30 P.M., Resident #79 was discharged from the facility. On 02/07/23 at approximately 12:00 P.M., the DON had discussed the communication process from the pharmacy to the facility with Registered Nurse (RN) #420, Account Representative for [NAME]'s Pharmacy. They collaboratively established a contingency plan in the event the pharmacy is unable to contact the facility directly. This plan included a call to the cell phone of the DON. If unable to reach the DON, the pharmacy is to call the cell phone of the Administrator. If unable to reach the Administrator, the pharmacy is to call the cell phone of the Regional Director of Clinical Operations (RDCO) #208. On 02/08/23 at approximately 4:30 P.M., an audit was completed by the DON of all current residents' medical records, and it was determined there were no current patients on IV antibiotics. On 02/08/23, an audit was completed by the DON of all residents with current orders for antibiotics, to include all routes of administration, and to verify all doses were being administered as prescribed. Beginning on 02/08/23, education was completed by the DON with all nurses regarding the company policy titled Medication Utilization and Prescribing-Clinical Protocol. On 02/08/23 at approximately 5:00 P.M., an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was conducted with the Administrator, the DON, RDCO #208 and Medical Director (MD) #100 (via phone). A root cause analysis was conducted during this meeting with the same team members. On 02/14/23 at 10:00 A.M., the DON, the Administrator, and RDCO #208 met in person with pharmacy representatives including Owner #440 of [NAME] Pharmacy, RN #420 Account Representative, and Pharmacist #400 to confirm an on-going communication plan is in place to monitor and address any issues or concerns. On 02/14/23, at approximately 8:00 P.M., the DON completed an audit of all current laboratory orders to ensure they were completed as ordered. On 02/14/23, at approximately 8:00 P.M. the DON completed the on-going audit of all residents with current orders for antibiotics, to include all routes of administration, and to verify all doses were administered as prescribed. On 02/14/23, during the night shift, staff nurses completed a physical assessment to include vital signs and a full body skin inspection on all residents. On 02/14/23, at approximately 9:00 P.M., the DON provided all licensed nurses in-servicing on obtaining laboratory tests and reporting results, administering medication per orders, discharge assessment, and any changes to policy and procedures, specifically education on policies titled Administering Medications, Lab and Diagnostic Test Results-Clinical Protocol, and Change in a Residents Condition or Status. On 02/14/23 at 6:00 P.M., an ad hoc QAPI meeting was conducted with the Administrator, the DON, RDCO #208 and MD #100 (via phone). Review of the root cause analysis that had been completed on 02/08/23 was reviewed and remains unchanged. On 02/14/23 at approximately 7:00 P.M., the Administrator initiated education to all staff regarding the facility abuse policy titled Abuse Policy and Reporting. On 02/15/23, an audit of all residents Medication Administration Records (MAR) was conducted to ensure medications were administered as ordered. This was completed by Licensed Practical Nurse (LPN) #260. On 02/15/23, all residents without cognitive impairment were interviewed by members of the Intradisciplinary Team (IDT) to ensure neglect was not present. Beginning on 02/15/23, the DON or designee will complete the following audits 2x/week for 4 weeks, then monthly thereafter: Antibiotic Administration, Laboratory Orders and Notifications, Medication Administration, Change of Resident Condition and Skin Integrity. Results will be reported and reviewed by the facility QAPI committee with the need for continuance evaluated and determined at that time On 02/15/23, interviews were conducted over various shifts with LPN #200, LPN #202, LPN #280, and LPN #284 who verified they had all received the training regarding medication administration, obtaining laboratory tests, reporting laboratory test results to the pharmacy or physician, completing body audits, recognizing change of condition and abuse and neglect. Although the Immediate Jeopardy was removed on 02/15/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #79 revealed an admitted [DATE] with admitting diagnoses including sepsis, MRSA in surgical wound, diabetes mellitus and neuromuscular dysfunction of bladder. The resident was discharged to the hospital on 12/30/22. Review of the Minimum Data Set (MDS) assessment, dated 11/24/22, for Resident #79 revealed a brief interview for mental status (BIMS) score of 00, indicating severe impaired cognition. Resident #79 was totally dependent on staff for all care. Resident #79 did not have any pressure ulcers but had a surgical wound, had an indwelling foley catheter and was always incontinent of bowel. Review of the care plan for Resident #79 revealed the resident had potential for skin breakdown. The care plan contained individualized interventions such as treatment and preventative treatment per orders, inspect and chart skin weekly and as needed (PRN), with measurable goals. Review of the Braden scale risk assessment, dated 11/08/22, revealed Resident #79 had a score of 15, which indicated at risk for development of pressure ulcers. Review of the physician's orders for Resident #79 revealed an order dated 11/18/22 for weekly skin and body assessment per nurse and document any new negative findings in nurse's notes on day shift. A physician order dated 11/18/22 for Vancomycin (antibiotic) 1.5 gram (gm) IV solution per 1750 milliliters (ml) to be infused over 75 minutes daily for two weeks, Vancomycin trough (measures how much medication is in the blood) stat (immediately) on 11/19/22, fax results to pharmacy for dosing. A physician order dated 11/21/22 for Vancomycin IV 1 gm per 200 ml with 0.9 % Normal Saline to be infused over 75 minutes. A physician order dated 11/23/22 for laboratory tests of Complete Blood Count (CBC), Basic Metabolic Panel (BMP), Pre-Albumin and Vancomycin trough (measures how much medication is in the blood) every Friday. A physician order dated 12/03/22 for Vancomycin IV 750 milligram (mg) per150 ml, to infuse 150 ml over 75 minutes for two doses. A physician order dated 12/06/22 for Vancomycin IV 750 mg per 150 ml to be infused over 75minutes. Review of a physician ordered treatment, dated 11/18/22, revealed to change out wound vacuum to right shoulder every other day. An order dated 12/22/23 revealed to cleanse wound to back of right shoulder with normal saline then pat dry, apply calcium alginate, and cover with foam dressing, every shift. There were no physician orders to address the dressing to the Peripherally Inserted Central Catheter (PICC) intravenous line dressing. Review of the Treatment Administration Record (TAR) for Resident #79 revealed the resident received all treatments for the wound on the back as ordered. The TAR revealed weekly skin assessments were completed and no other wounds were noted. Review of the Wound Assessment Reports for Resident #79 revealed at admission on 11/18/22, the right shoulder surgical wound measured 6.4 centimeters (cm) by 4.20 cm by 1.5 cm. On the last assessment on 12/22/22 it measured 6.19 cm by 4.05 cm by 1.25 cm with the wound status improving. This was documented on every week and showed continued improvement. This was the only wound the facility had documentation about. Review of the Medication Administration Record (MAR) for November 2022 for Resident #79 revealed there was no evidence of the administration of the IV Vancomycin at 9:00A.M. on 11/20/22, 11/21/22, 11/22/22, 11/23/22, 12/15/22 and from 12/22/22 to 12/30/22. Interview on 02/06/23 at 3:30 P.M. with the DON revealed the pharmacy calls and informs the facility if they are to hold or administer the Vancomycin. When the DON was asked about the process of dosing Vancomycin and the missed doses from 12/20/22 to 12/30/22, he explained We follow the pharmacy's recommendations, and we only have this one document dated 12/20/22 which says to hold the dose until labs are drawn. Interview on 02/07/23 at 10:43 A.M., the DON stated he was not able to receive any further documents from pharmacy to explain why the doses were held. When asked why the doses were missed in November and December 2022, the DON did not respond to the question. The DON verified there was Vancomycin in the E-box (emergency box) which could have been accessed by the staff. The DON verified the medication Resident #79 required would have been in the E-box for the staff to be able to administer. Interview on 02/07/23 at 12:30 P.M. with Resident #79's Family Member #12 revealed Resident #79 had passed away on 01/20/23 at Miami Valley hospital. Per Family Member #12, Resident #79 was supposed to come home on 12/30/22 and the facility called and said he was not acting right. Family Member #12 stated she told them to send Resident #79 to the emergency room . Resident #79 was admitted for being septic due to the wounds and a urinary tract infection. Family Member #12 stated she was unaware of any other wounds other than the one on his shoulder but was told he had them on his buttocks. Resident #79 was placed in ICU and put on a lot of antibiotics, developed a rash and he was sent to Miami for the burn wound unit. Interview on 02/07/23 at 12:44 P.M. with Social Worker #300 (from the hospital) revealed the resident was admitted to the intensive care unit with sepsis and a urinary tract infection. He had multiple wounds on his buttocks, and she was not sure when these wounds were documented, but there were four extensive wounds. Interview on 02/09/23 at 10:50 A.M. with Pharmacist #400 from [NAME]'s pharmacy revealed the pharmacy had a hold on the Vancomycin and had requested a trough to be completed on 12/22/22. The pharmacy never received the trough level and no communication from the facility. The pharmacy had many problems with the facility getting trough levels when requested during this time. The facility requested for a rundown on 02/08/23 of administration and laboratory results from the pharmacy. Pharmacist #400 stated this was sent to the DON who informed Pharmacist #400, the DON would not pass this information on to the surveyor who asked for the information. Pharmacist #400 stated she would send the surveyor a rundown of when the pharmacy spoke to facility; Vancomycin troughs; doses the pharmacy recommended; and the lack of the facility to get back to them with a trough after 12/20/22. Pharmacist #400 stated she would forward an email from the facility they received on 02/06/23, with all the resident's laboratory values. Pharmacist #400 verified Resident #79 would have been given Vancomycin for the dates of 12/22/22 to 12/30/22, based on these trough values, if they had received them at the time the trough levels were obtained. Review of the document sent from Pharmacist #400 revealed the following breakdown of the Vancomycin laboratory orders and dosing: On 11/18/22, order received for Vancomycin 1.5 gram (g) with instructions for trough to be obtained on 11/19/22. Vancomycin sent on evening delivery of 11/18/22. On 11/18/22 at 8:38 P.M, on call service received call from Friendship Village Nursing Home, LPN #280 requesting a consultation. She believed that patient got a Vancomycin rash from mid shoulders to mid-thigh and won't stop scratching - bleeding from the scratching. Please note, at this time the Vancomycin had not been delivered to building. Friendship Village Nursing Home later stated they felt that this was due to the linens/hygiene. On 11/19/22 at 2:29P.M., Pharmacist #400 was able to get in touch with LPN #284. LPN #284 stated that the Vancomycin was not administered until the morning hours of 11/19/22, which resulted in them being unable to pull a trough. At this time, pharmacy requested troughs to be obtained, so that pharmacy could appropriately and effectively dose the Vancomycin. Trough was collected on 11/19/22 at 10:50 P.M. and results were finalized on 11/20/22 at 1:07 P.M. Fax containing the trough was sent to pharmacy on 11/21/22 at 6:46 AM., with trough being 20.5. On 11/21/22 at 1:50 P.M., Pharmacist #400 spoke with LPN #244 who confirmed trough was drawn on 11/20/22. At this time, Resident #79's weight and height were verified. Vancomycin was dosed at 1000 mg every 24 hours with extended infusion time given previous rash, though little evidence supporting a rash due to Vancomycin as patient had not been given Vancomycin at the facility. Another trough was requested on the morning of 11/22/22. Vancomycin sent to Friendship Village Nursing Home for administration on 11/21/22. On 11/22/22, Vancomycin trough drawn at 1:00 PM and reported to the pharmacy at 5:41 PM as pending. On 11/23/22 to 11/25/22, Vancomycin sent to Friendship Village Nursing Home by pharmacy despite no trough. On 11/23/22, bags sent for 11/24/22 and 11/25/22. On 11/25/22 bags were sent for 11/26/22, 11/27/22, and 11/28/22. On 11/30/22, trough received at 10:12 A.M. This was the trough drawn on 11/22/22 at 1:00 P.M. Trough resulted at 4.8. Pharmacy concerned with inconsistencies in trough obtained. (Trough obtained from 11/19/22 was at 10:50 P.M., this trough obtained was at 1:00 P.M. - please note, this was with 24-hour dosing). Given the very low trough, we requested further information from the Director of Nursing, including timing of doses in relation to troughs being obtained and if the patient had received consistent doses. Nurse Account Manager attempted to contact the DON on 11/30/22, with no response. On 12/03/22 per nurse RN #244, a trough was finally drawn on 12/02/22 at 3:30 A.M., and resulted at 20.7. DON stated the 1gm dose has been given at 9:00A.M. for at least the past three days while he worked. Based on pharmacy dispense history, he would have missed the last 3 doses since starting on 11/22/22. Pharmacist #400 requested a repeat trough on Monday, 12/05/22. It was recommended to hold the 12/03/22 dose and then start 750 mg every 24 hours for two doses until trough received. On 12/05/22, trough level was not received despite being requested on 12/03/22. Stat trough order requested, and 750 mg dose sent to facility. On 12/06/22, trough level obtained at 5:18 A.M. and resulted at 16.5. Pharmacist #400 instructed facility to continue 750 mg every 24 hours. On 12/15/22, the trough level was sent to pharmacy. Collected at 7:07 A.M., reported at 11:56 A.M. and sent to pharmacy at 3:44 P.M. Trough level results at 15.4. Pharmacist #400 spoke with RN #244. RN #244 stated resident missed 12/14/22 dose and 12/15/22 dose. At this time, Pharmacist #400 advised that enough Vancomycin will be sent to get the resident through Monday but that Saturday (12/17/22) a trough level needed to be obtained. On 12/20/22 at 11:58 A.M., the trough level was reported that was obtained on 12/19/22 at 2:21 A.M. The level was sent to the pharmacy. On 12/20/22 at 5:04 A.M., the trough level resulted at 26.2. At this time, pharmacy called and faxed facility stating to hold Vancomycin doses and to take another trough level on Thursday (12/22/22) for further doses and instructions. On 12/23/22, still no trough level received. Pharmacist#400 called multiple times and re-faxed request for tough levels twice with no response. Pharmacist #400 emailed the nurse account manager who then passed email along to the DON to get assistance. Pharmacist #400 email to nurse account manager: I have tried to contact FVSN (Friendship Village Skilled Nursing) via phone calls and fax multiple times to get a new trough since the last one we received on 12/19/22 that was supratherapeutic. However, I have not received any communication on this. Could you check with DON to see if a trough level is something we can get today or tomorrow? Nurse account manager email to DON and ADON: Good morning! Could you assist with the below? Please let me know if you have any questions or concerns Pharmacy never received further troughs, response, or communication from the facility following the email on 12/23/22. Review of the email communication from RN #420 (pharmacy RN) to Friendship Village Nursing Home dated 11/28/22, revealed an onsite visit to stock Nexus and IV supplies. During the visit she met with LPN #272 to advise of the need for a trough level. Reviewed concerns regarding managing the trough levels and previous laboratory issues and timing of getting laboratory levels for Resident #79. She advised she would investigate the issue. On 11/30/22, called Friendship Village Nursing Home and advised still needed trough levels. Called and spoke to LPN #272 and she advised she would get them faxed over. Review of the American Health Associates (AHA) laboratory report sent from the pharmacy dated 12/19/22 at 11:58 A.M. for Resident #79, revealed the notes on 12/20/22 (Tuesday) holding dose, will call facility later to tell them to get another trough on Thursday, for further doses or instructions. The pharmacy called and faxed facility stating to hold vancomycin and take another trough on 12/22/22. On 12/23/22, (Friday) still no trough received at the pharmacy. The pharmacists called multiple times and refaxed request for laboratory test twice, with no response and emailed facility. The call to the facility was made multiple times and faxed, with no response. The pharmacist emailed nurse account manager at facility, who passed along the email to the DON to get assistance. The email from the pharmacist stated I have tried to contact FVSN (Friendship Village Nursing Home) via phone calls and fax multiple times to get a new trough, since that last one we received on 12/19/22 was supratherapeutic. However, I have not received any communication on this. Could you check with the DON to see if trough is something we can get tomorrow? The pharmacy never received further troughs, response or communication from the facility following the email sent on 12/23/22. Review of Resident #79's discharge summary, dated 12/30/22, included a vital signs section which listed a pulse of 64 beats per minute (bpm) and respirations at eight per minute were obtained on 12/30/22 at 2:20 A.M. The blood pressure (BP) on the form was documented as obtained on 11/18/22 and identified the BP to be 137/87 millimeters of mercury (mmHg). No temperature was listed on the form. This was signed by Licensed Social Worker #600, LPN #272 with a notation of verbal education given to spouse on 12/30/22 at 11:55 A.M. The record contained no evidence any of the resident's vital signs were obtained after 2:20 A.M. on 12/30/22. Review of the progress note for Resident #79 dated 12/30/22 at 6:45 P.M., revealed the resident was scheduled to be discharged home with his wife. The EMT arrived and expressed concerns about getting him safely into the apartment. Resident #79 was disoriented, confused, and unable to respond to them. This nurse spoke with the wife, and she would like him sent to the hospital. Review of the Patient Care Report dated 12/30/22 at 6:06 P.M., revealed the EMT documented the resident's BP was 72/46 mmHg, pulse 66 bpm, respirations 20, and oxygen level was 92% on room air. At 6:16 P.M., BP was 74/44 mmHg, pulse 63 bpm, respirations 20, and oxygen level was 92% on room air. Upon arrival on scene Resident #79 was severely confused with incoherent speech. Resident #79's stroke scale positive with unequal grip, facial droppage and aphasia. Report from nursing home staff is this is not normal for Resident #79. EMT crew advised nursing home staff that for the safety of Resident #79 and well-being, transport to emergency room would be best. Given Resident #79's status and vitals, decision made to upgrade run from non-emergent to emergent. Review of the hospital report dated 12/30/22 at 6:42 P.M., revealed Resident #79 arrived from the nursing home with midline insertion site and right upper extremity noted to be red. It appears infected where the midline IV dressing had not been changed since 12/24/22 per dressing sticker. Resident #79 is yelling and screaming, not saying words, or answering questions. Resident #79's vital signs were: BP 142/78 mmHg, temperature 88.9 degrees F, and pulse was 44 bpm. A consult with internal medicine revealed the ill appearing elderly man presently from Friendship Village. Based on Resident #79's appearance, report from EMT, and an old bandage from PICC line, there is concerns for neglect at the Extended Care Facility (ECF). Resident #79 is hypothermic (low body temperature) and bradycardic (slow heart rate). The hospital was initiating warming protocol. Blood pressure was marginal but improving with IV fluids. Blood Pressure was 92/61, temperature was 91.8 F, respirations were nine. Treated with antibiotics due to thickness of his urine. Resident #79 is hyperkalemic (elevated potassium level) which is likely to be contributing to his bradycardia dysrhythmia. Resident #79's medical condition was assessed as severe deterioration that posed to be life threatening which required critical care to be rendered. Resident #79's diagnoses included septic shock, urinary tract infection, hypothermic, acute renal failure, metabolic acidosis, and leukocytosis with multiple sources of infection from indwelling urinary catheter; PICC line was warm and red; wounds on back and groin with erythematous in multiple areas and was recently hospitalized for MRSA abscess requiring debridement and Vancomycin. Resident #79's urine was described as chocolate milk colored urine. Review of the pictures of the wounds taken in the emergency room revealed two posterior left thigh open wounds. The upper wound measuring approximately 2 cm by 1 cm, right lower wound approximately 2 cm by 2 cm and both appear to have slough. The anterior right inner thigh measuring approximately 6 cm by 0.5 cm appears to have slough. The left anterior inner thigh had a wound measuring approximately 4 cm by 0.5 cm with red serous drainage. The buttocks were observed to be bright red with blood and bowel noted on the depends. Interview on 02/07/23 at 2:01 P.M. with Medical Director (MD) #100, revealed when Resident #79 was seen in the emergency room , he was in septic shock. MD #100 stated his body temperature was 88 degrees F and his pulse was around 50. Review of the nursing document titled Skin Inspection Report for Resident #79 revealed the assessments were completed on 11/18/22 which identified skin as not intact-existing (area was previously present). On 11/25/22 and 12/02/22 the assessment identified skin as intact. On 12/09/22, 12/16/22, and 12/23/22 the report identified skin as not intact-existing and on 12/30/22 the assessment continued to identify the resident's skin to be not intact-existing area. There was not a time listed on the 12/30/22 inspection identifying when the assessment was completed. None of the skin inspection reports identified any description of the non-intact skin. Interview on 02/09/23 at 3:45 P.M. with Regional Nurse #500 verified she only had knowledge of Resident #79 having the wound on the shoulder. The facility was not aware of any other wound on the resident. When asked to look at facility skin assessments, Regional Nurse #500 stated what she gave for wounds was all they had. Regional Nurse #500 explained the only thing the skin assessment has is a check off box which states either Skin intact, Skin not intact - existing or Skin not intact new. Regional Nurse #500 verified the skin reports reviewed only had Skin not intact-existing and Skin Intact marked. Interview on 02/13/23 at 1:30 P.M. with STNA #300 revealed she was the primary aide for the rehabilitation unit where Resident #79 was located. STNA #300 verified she was applying cream to the buttocks of resident due to redness and she did not recall any open wound on him. Resident #79 did not refuse any type of care for her during his stay. Interview on 02/13/23 at 4:15 P.M. with RDCO #208 stated the facility bears their responsibility for this occurring but the pharmacy needs to bear their own responsibility by not contacting upper management in the facility about the missing Vancomycin troughs. RDCO #208 stated LPN #242 who took care of Resident #79 was fired due to lack of assessments of the resident. Review of the policy titled Change in a Resident's Condition or Status, dated April 2014, revealed our facility shall promptly notify the resident, his or her attending Physician, and representative, consistent with his or her authority of changes in the resident's medical or mental condition and or status. Review of the policy titled Lab and Diagnostic Test Results - Clinical Protocol, dated September 2012, revealed the staff will process test requisitions and arrange for tests, a nurse will review all results and will identify the urgency of communicating with the attending physician based on physician request, the seriousness of abnormality, and the individual's current condition. Review of the facility policy titled Abuse Prevention/Reporting Policy and Procedure, last updated 05/09/18 revealed every resident has the right to be free from mistreatment, neglect, and misappropriation of property. Neglect was defined as the failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. This represents non-compliance related to Master Complaint Number OH00139489, Complaint Number OH00139264, and Complaint Number OH00139095.

Based on observations, review of medical records, review of the emergency squad run report, review of hospital records, review of email communications, review of policies on Lab and Diagnostic Test Results - Clinical Protocol, Adverse Consequences and Medication Errors and BD Auto Shield Duo Safety Pen Needles, staff interviews, physician interview, and interview with pharmacy staff, the facility failed to ensure one resident (Resident #79) was free from significant medication errors when Resident #79 was admitted to the facility with diagnosis of sepsis with Methicillin-Resistant Staphylococcus Aureus?(MRSA) in a surgical wound and was not administered the intravenous (IV) antibiotic medication as ordered and failed to ensure laboratory tests were completed and results reported to the pharmacy for dosing of the IV antibiotic. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries and/or death, when Resident #79 was found by the transport company staff upon arriving at the facility, to be confused, aphasic, and had abnormal vital signs. The resident was determined to be in an emergent situation and was taken to the emergency room at which time his body temperature was 88.9 degrees Fahrenheit(F) and he was subsequently taken to the Intensive Care Unit (ICU) for septic shock. Upon admission to emergency room , the resident was diagnosed with altered mental status, septic shock, leukocytosis with multiple sources of infection: including indwelling catheter, intravenous cite red and warm, wounds on back and groin area with erythematous, urinary tract infection, hypothermia, acute renal failure, metabolic acidosis, and hyperkalemia and was admitted to critical care. Additionally, the facility failed to ensure insulin medications, administered via Flex Pen, were primed prior to dialing up the ordered dose for two residents (#48 and #72) resulting in the residents not receiving the correct amount of medication as ordered by the physician that placed these residents at potential risk for more than minimal harm that is not Immediate Jeopardy. This affected two (#48 and #72) of five residents reviewed for medication administration. The facility census was 74. On 02/14/23 at 5:34 P.M., the Administrator, Director of Nursing (DON), Regional [NAME] President #10, Regional Nurse #500 and Campus Executive Director #50 were notified Immediate Jeopardy began on 11/20/22 when Resident #79 was admitted to the facility from the hospital with a physician order for Vancomycin that was not administered not administered for five days (11/20/22, 11/21/22, 11/22/22, 11/23/22, 12/15/22), and on 12/21/22, he was administered the medication when it was placed on hold; then from 12/22/22 to 12/30/22 he did not receive the medication for a period of eight days. Consequently, on 12/30/22, Resident #79 was found by the Emergency Medical Team (EMT), who was there to take him home, to be severely confused with incoherent speech and was hypotensive. He was taken emergently to the hospital resulting in the resident receiving peripheral vasoconstrictor, intravenous fluids, warming protocol, and multiple antibiotics which lead to the resident being placed in the ICU. Resident #79 was admitted with diagnoses including altered mental status, septic shock, leukocytosis with multiple sources of infection: including indwelling catheter, intravenous cite red and warm, wounds on back and groin area with erythematous, urinary tract infection, hypothermia, acute renal failure, metabolic acidosis, and hyperkalemia and was admitted to critical care. The Immediate Jeopardy was removed on 02/15/23 when the facility implemented the following corrective actions: On 12/30/22 at approximately 6:30 P.M., Resident #79 was discharged from the facility. On 02/07/23 at approximately 12:00 P.M., the DON, had discussed the communication process from the pharmacy to the facility with Registered Nurse (RN) #420, Account Representative for [NAME]'s Pharmacy. They collaboratively established a contingency plan in the event the pharmacy is unable to contact the facility directly. This plan included a call to the cell phone of the DON. If unable to reach the DON, the pharmacy is to call the cell phone of the Administrator. If unable to reach the Administrator, the pharmacy is to call the cell phone of the Regional Director of Clinical Operations (RDCO) #208. On 02/08/23 at approximately 4:30 P.M., an audit was completed by the DON of all current residents' medical records, and it was determined that there were no current patients on IV antibiotics. On 02/08/23, an audit was completed by the DON of all residents with current orders for antibiotics, to include all routes of administration, and to verify all doses were being administered as prescribed. Beginning on 02/08/23, education was completed by DON, with all nurses regarding the company policy titled Medication Utilization and Prescribing-Clinical Protocol. On 02/08/23 at approximately 5:00 P.M., an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was conducted with the Administrator, the DON, RDCO #208 and Medical Director (MD) #100 (via phone). A root cause analysis for medication errors was conducted during this meeting with the same team members. On 02/14/23 at 10:00 A.M., the DON, the Administrator, and RDCO #208 met in person with pharmacy representatives including Owner #440 of [NAME] Pharmacy, RN #420 Account Representative and Pharmacist #400 to confirm an on-going communication plan is in place to monitor and address any issues or concerns. On 02/14/23 at approximately 8:00 P.M., the DON completed an audit of all current laboratory orders to ensure they were completed as ordered. On 02/14/23 at approximately 8:00 P.M., the DON completed the on-going audit of all residents with current orders for antibiotics, to include all routes of administration, and to verify all doses were administered as prescribed. On 02/14/23, at approximately 9:00 P.M., the DON provided all licensed nurses in-servicing on obtaining laboratory tests and reporting results, administering medication per orders, and any changes to policy and procedures, specifically education on policies titled Administering Medications, and Lab and Diagnostic Test Results-Clinical Protocol. On 02/14/23 at 6:00 P.M., an ad hoc QAPI meeting was conducted with the Administrator, the DON, RDCO #208 and MD #100 (via phone). Review of the root cause analysis for medication errors that had been completed on 02/08/23 was reviewed and remains unchanged. On 02/15/23, an audit of all resident Medication Administration Records (MAR) was conducted for antibiotics and laboratory tests being completed. This was completed by Licensed Practical Nurse (LPN) #260. Beginning on 02/15/23, the DON or designee will complete the following audits 2x/week for 4 weeks, then monthly thereafter. Results will be reported and reviewed by the facility QAPI committee with the need for continuance evaluated and determined at that time: Antibiotic Administration; Laboratory Orders and Notifications, and Medication Administration. On 02/15/23, interviews were conducted over various shifts with LPNs #200, #202, #280, and #284 who verified they had all received the training regarding medication administration, obtaining laboratory tests, and reporting laboratory test results to the pharmacy or physician. Although the Immediate Jeopardy was removed on 02/15/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of the closed medical record for Resident #79 revealed an admitted [DATE] with admitting diagnoses including sepsis, MRSA in surgical wound, diabetes mellitus and neuromuscular dysfunction of bladder. The resident was discharged to the hospital on 12/30/22. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #79 revealed a brief interview for mental status (BIMS) score of 00 indicating severe impaired cognition. Resident #79 was totally dependent on staff for all care. Review of the physician's orders for Resident #79 revealed an order dated 11/18/22 for weekly skin and body assessment per nurse and document any new negative findings in nurse's notes on day shift. A physician order dated 11/18/22 for Vancomycin (antibiotic) 1.5-gram (gm) IV solution per 1750 milliliters (ml) to be infused over 75 minutes daily for two weeks, Vancomycin trough (measures how much medication is in the blood) stat (immediately) on 11/19/22, fax results to pharmacy for dosing. A physician order dated 11/21/22 for Vancomycin IV 1 gm per 200 ml with 0.9 % Normal Saline to be infused over 75 minutes. A physician order dated 11/23/22 for Vancomycin trough every Friday. A physician order dated 12/03/22 for Vancomycin IV 750 milligram (mg) per 150 ml, to infuse 150 ml over 75 minutes for two doses. A physician order dated 12/06/22 for Vancomycin IV 750 mg per 150 ml to be infused over 75minutes. Review of the MAR for November 2022 for Resident #79 revealed there was no evidence of the administration of the Vancomycin at 9:00A.M. on 11/20/22, 11/21/22, 11/22/22, 11/23/22, 12/15/22 and from 12/22/22 to 12/30/22. There was no indication as to why the medications was not administered. Review of the American Health Associates (AHA) laboratory test for Resident #79 revealed a Vancomycin trough result dated 12/23/22 of 20.2 micrograms per milliliter (mcg/mL) with a normal range of 10 mcg/mL to 20 mcg/mL. Vancomycin trough result on 12/26/22 was 19.0 mcg/mL and on 12/30/22 was 19.6 mcg/mL. There was no evidence these results were sent to the pharmacy for dosing. Review of the nurse's progress notes on 12/28/22 at 3:15 P.M., revealed the nurse spoke to pharmacy person in reference to Vancomycin current order of Vancomycin IV 750 mg per 150 ml to be infused over 75minutes. This writer was advised Vancomycin still on hold. Pharmacy needs trough results, then pharmacy can send out Vancomycin. Interview on 02/06/23 at 3:30 P.M. with the DON revealed the pharmacy calls and informs the facility if they are to hold or administer the Vancomycin. When the DON was asked about the process of dosing Vancomycin and the missed doses for 12/20/22 to 12/30/22, he explained We follow the pharmacy's recommendations, and we only have this one document dated 12/20/22 which says to hold the dose until labs are drawn. Interview on 02/09/23 at 10:50 A.M. with Pharmacists #400 from [NAME]'s pharmacy revealed the pharmacy had a hold on the Vancomycin and had requested a trough to be completed on 12/22/22. The pharmacy never received the trough level and there was no communication from the facility. The pharmacy had many problems with the facility obtaining trough levels when requested by the pharmacy during this time. The facility requested a rundown on 02/08/23 of administration and laboratory results from the pharmacy. Pharmacist #400 stated this was sent to the DON who informed Pharmacist #400, the DON would not pass this information on to the surveyor who asked for the information. Pharmacist #400 stated she would send the surveyor a rundown of when the pharmacy spoke to facility; the Vancomycin troughs; the doses the pharmacy recommended; and the lack of the facility to get back to them with a trough after 12/20/22. Pharmacist #400 stated she would forward an email from the facility they received on 02/06/23, with all the resident's laboratory values. Pharmacist #400 verified Resident #79 would have been given Vancomycin for the dates of 12/22/22 to 12/30/22, based on these trough values, if they had received them at the time the trough levels were obtained. Review of the document sent from the Pharmacist #400 revealed the following breakdown of the Vancomycin laboratory orders and dosing: On 11/18/22, order received for Vancomycin 1.5 gram (g) with instructions for trough to be obtained on 11/19/22. Vancomycin sent on evening delivery of 11/18/22. On 11/18/22 at 8:38 P.M, on call service received call from Friendship Village Nursing Home, LPN #280 requesting a consultation. She believed that patient got a Vancomycin rash from mid shoulders to mid-thigh and won't stop scratching - bleeding from the scratching. Please note, at this time the Vancomycin had not been delivered to building. Friendship Village Nursing Home later stated they felt that this was due to the linens/hygiene. On 11/19/22 at 2:29P.M., Pharmacist #400 was able to get in touch with LPN #284. LPN #284 stated that the Vancomycin was not administered until the morning hours of 11/19/22, which resulted in them being unable to pull a trough. At this time, pharmacy requested troughs to be obtained, so that pharmacy could appropriately and effectively dose the Vancomycin. Trough was collected on 11/19/22 at 10:50 P.M. and results were finalized on 11/20/22 at 1:07 P.M. Fax containing the trough was sent to pharmacy on 11/21/22 at 6:46 AM., with trough being 20.5. On 11/21/22 at 1:50 P.M., Pharmacist #400 spoke with LPN #244 who confirmed trough was drawn on 11/20/22. At this time, Resident #79's weight and height were verified. Vancomycin was dosed at 1000 mg every 24 hours with extended infusion time given previous rash, though little evidence supporting a rash due to Vancomycin as patient had not been given Vancomycin at the facility. Another trough was requested on the morning of 11/22/22. Vancomycin sent to Friendship Village Nursing Home for administration on 11/21/22. On 11/22/22, Vancomycin trough drawn at 1:00 PM and reported to the pharmacy at 5:41 PM as 'pending'. On 11/23/22 to 11/25/22, Vancomycin sent to Friendship Village Nursing Home by pharmacy despite no trough. On 11/23/22, bags sent for 11/24/22 and 11/25/22. On 11/25/22, bags sent for 11/26/22, 11/27/22, and 11/28/22. On 11/30/22, trough received at 10:12 A.M. This was the trough drawn on 11/22/22 at 1:00 P.M. Trough resulted at 4.8. Pharmacy concerned with inconsistencies in trough obtained. (Trough obtained from 11/19/22 was at 10:50 P.M., this trough obtained was at 1:00 P.M. - please note, this was with 24-hour dosing). Given the very low trough, we requested further information from the Director of Nursing, including timing of doses in relation to troughs being obtained and if the patient had received consistent doses. Nurse Account Manager attempted to contact the DON on 11/30/22, with no response. On 12/03/22 per nurse RN #244, a trough was finally drawn on 12/02/22 at 3:30 A.M., and resulted at 20.7. DON stated that the 1g dose has been given at 9:00A.M., for at least the past three days while he worked. Based on pharmacy dispense history, he would have missed the last 3 doses since starting on 11/22/22. Pharmacist #400 requested a repeat trough on Monday, 12/05/22. It was recommended to hold the 12/03/22 dose and then start 750 mg every 24 hours for two doses until trough received. On 12/05/22, trough level was not received despite being requested on 12/03/22. Stat trough order requested, and 750 mg dose sent to facility. On 12/06/22, trough level obtained at 5:18 A.M. and resulted at 16.5. Pharmacist #400 instructed facility to continue 750 mg every 24 hours. On 12/15/22, the trough level was sent to pharmacy. Collected at 7:07 A.M., reported at 11:56 A.M. and sent to pharmacy at 3:44 P.M. Trough level results at 15.4. Pharmacist #400 spoke with RN #244. RN #244 stated resident missed 12/14/22 dose and 12/15/22 dose. At this time, Pharmacist #400 advised that enough Vancomycin will be sent to get the resident through Monday but that Saturday (12/17/22) a trough level needed to be obtained. On 12/20/22 at 11:58 A.M., the trough level was reported that was obtained on 12/19/22 at 2:21 A.M. The level was sent to the pharmacy. On 12/20/22 at 5:04 A.M., the trough level resulted at 26.2. At this time, pharmacy called and faxed facility stating to hold Vancomycin doses and to take another trough level on Thursday (12/22/22) for further doses and instructions. On 12/23/22, still no trough level received. Pharmacist#400 called multiple times and re-faxed request for tough levels twice with no response. Pharmacist #400 emailed the nurse account manager who then passed email along to the DON to get assistance. Pharmacist #400 email to nurse account manager: I have tried to contact FVSN (Friendship Village Skilled Nursing) via phone calls and fax multiple times to get a new trough since the last one we received on 12/19/22 that was supratherapeutic. However, I have not received any communication on this. Could you check with DON to see if a trough level is something we can get today or tomorrow? Nurse account manager email to DON and ADON: Good morning! Could you assist with the below? Please let me know if you have any questions or concerns Pharmacy never received further troughs, response, or communication from the facility following the email on 12/23/22. Review of the email communication from RN #420 (pharmacy RN) to Friendship Village Nursing Home dated 11/28/22, revealed an onsite visit to stock Nexus and IV supplies. During the visit she met with LPN #272 to advise of the need for a trough level. Reviewed concerns regarding managing the trough levels and previous laboratory issues and timing of getting laboratory levels for Resident #79. She advised she would investigate the issue. On 11/30/22, called Friendship Village Nursing Home and advised still needed trough levels. Called and spoke to LPN #272 and she advised she would get them faxed over. Review of the American Health Associates (AHA) laboratory report sent from the pharmacy dated 12/19/22 at 11:58 A.M., for Resident #79 revealed the notes on 12/20/22 (Tuesday) holding dose, will call facility later to tell them to get another trough on Thursday, for further doses or instructions. The pharmacy called and faxed facility stating to hold vancomycin and take another trough on 12/22/22. On 12/23/22, (Friday) still no trough received at the pharmacy. The pharmacists called multiple times and refaxed request for laboratory test twice, with no response and emailed facility. The call to the facility was made multiple times and faxed, with no response. The pharmacist emailed nurse account manager at facility, who passed along the email to the DON to get assistance. The email from the pharmacist stated I have tried to contact FVSN (Friendship Village Nursing Home) via phone calls and fax multiple times to get a new trough, since that last one, we received on 12/19/22 was supratherapeutic. However, I have not received any communication on this. Could you check with the DON to see if trough is something we can get tomorrow? The pharmacy never received further troughs, response or communication from the facility following the email sent on 12/23/22. Review of the progress note for Resident #79 dated 12/30/22 at 6:45 P.M., revealed the resident was scheduled to be discharged home with his wife. The EMT arrived and expressed concerns about getting him safely into the apartment. Resident #79 was disoriented, confused, and unable to respond to them. This nurse spoke with the wife, and she would like him sent to the hospital. Review of the Patient Care Report dated 12/30/22 at 6:06 P.M., revealed the EMT documented the blood pressure (BP) was 72/46 mmHg, pulse 66 beats per minute (bpm), respirations 20, and oxygen level was 92% on room air. At 6:16 P.M., BP was 74/44 mmHg, pulse 63 bpm, respirations 20, and oxygen level was 92% on room air. Upon arrival on scene Resident #79 was severely confused with incoherent speech. Resident #79's stroke scale positive with unequal grip, facial droppage and aphasia. Report from nursing home staff is this is not normal for Resident #79. EMT crew advised nursing home staff that for the safety of Resident #79 and well-being, transport to emergency room would be best. Given Resident #79's status and vitals, decision made to upgrade run from non-emergent to emergent. Review of the hospital report dated 12/30/22 at 6:42 P.M., revealed Resident #79 arrived from the nursing home with midline insertion site and right upper extremity noted to be red. It appears infected where the midline IV dressing had not been changed since 12/24/22 per dressing sticker. Resident #79 is yelling and screaming, not saying words, or answering questions. Resident #79's vital signs were: BP 142/78 mmHg, temperature 88.9 degrees F, and pulse was 44 bpm. A consult with internal medicine revealed the ill appearing elderly man presently from Friendship Village. Based on Resident #79's appearance, report from EMT, and an old bandage from PICC line, there is concerns for neglect at the Extended Care Facility (ECF). Resident #79 is hypothermic (low body temperature) and bradycardic (slow heart rate). The hospital was initiating warming protocol. Blood pressure was marginal but improving with IV fluids. Blood Pressure was 92/61, temperature was 91.8 F, respirations were nine. Treated with antibiotics due to thickness of his urine. Resident #79 is hyperkalemic (elevated potassium level) which is likely to be contributing to his bradycardia dysrhythmia. Resident #79's medical condition was assessed as severe deterioration that posed to be life threatening which required critical care to be rendered. Resident #79's diagnoses included septic shock, urinary tract infection, hypothermic, acute renal failure, metabolic acidosis, and leukocytosis with multiple sources of infection from indwelling urinary catheter; PICC line was warm and red; wounds on back and groin with erythematous in multiple areas and was recently hospitalized for MRSA abscess requiring debridement and Vancomycin. Resident #79's urine was described as chocolate milk colored urine. Interview on 02/07/23 at 2:01 P.M., with Medical Director (MD) #100, revealed when Resident #79 was seen in the emergency room , he was in septic shock. MD #100 stated his body temperature was 88 degrees F and his pulse was around 50 bpm. Interview on 02/07/23 at 10:43 A.M. with the DON he stated he was not able to receive any further documents from pharmacy to explain why the doses were held. When asked why the doses were missed in November and December 2022, he did not respond to the question. He verified there was Vancomycin in the E-box (emergency box) which could have been accessed by the staff. The DON verified the medication Resident #79 required would have been in the E-box for the staff to be able to administer. Interview on 02/13/23 at 4:15 P.M. with RDCO #208 stated the facility bears their responsibility for this occurring but the pharmacy needs to bear their own responsibility by not contacting upper management in the facility about the missing Vancomycin troughs. 2) Review of the medical record for Resident #48 revealed an admitted [DATE] with a diagnosis of diabetes mellitus. Review of the MDS assessment for Resident #48 dated 01/09/23, revealed she had moderate impaired cognition and received insulin seven days a week. Review of the plan of care for Resident #48 revealed a plan for potential for hypoglycemia or hyperglycemia with an intervention which included administer insulin as ordered. Review of the physician's order for Resident #48 revealed an order dated 03/09/22, for Lantus 100 unit per ml vial, to give eight units subcutaneously in the morning. Observation of medication administration on 02/01/23 at 8:45 A.M. with LPN #200, revealed he took the Lantus 100 unit per ml out of the cart for Resident #48. LPN #200 cleansed the end with alcohol pad with a gloved hand, then proceeded to dial up eight units of Lantus. LPN #200 did not prime the needle with two units of insulin. Interview on 02/01/23 at 10:20 A.M. with LPN#200 verified he did not prime the needle for Resident #48 due to the needle is already primed. 3) Review of the medical record for Resident #72 revealed an admitted [DATE] with a diagnosis including diabetes mellitus. Review of the MDS assessment for Resident #72 dated 01/11/23, revealed she had moderate impaired cognition and received insulin seven days a week. Review of the plan of care for Resident #72 revealed a plan for diabetes with an intervention which included administer insulin as ordered. Review of the physician's orders for Resident #72 revealed an order for Basaglar insulin 100 unit per ml Kwik pen, to give 25 units subcutaneous daily. Observation on 02/01/23 at 10:15 A.M. revealed LPN #200 pulled Resident #72's Basaglar insulin 100 unit per ml out of the medication cart. LPN #200 cleaned the end of pen with gloved hand then dialed up 25 units of the Basaglar insulin. Before entering the room, the surveyor asked LPN #200 if he needed to prime the pen prior to dialing up the 25 units and LPN #200 explained he did not need to prime the needle because it was already primed. LPN #200 proceeded to give the 25 units of Basaglar insulin. Interview on 02/01/23 at 10:25 A.M. with RDCO #208 verified the needles for the flex pens are not pre-primed and need to be primed with two units prior to dialing up the dose per physician's order. She will call the doctor and inform him of the residents who did not receive their full dose and see if the doctor wants the two units given to these residents. Observation on 02/01/23 at 10:35 A.M. with Clinical Team Manger (CTM) #204 of the insulin needle containers which are used for flex pens verified it did not indicate the needles were a pre-primed insulin needle. CTM #204 opened the box and the instructions inside indicated to dial up two units and push down then put in the dose of insulin required by the physician. Review of the undated form titled BD Auto Shield Duo Safety Pen Needles revealed the instructions for use in section one to check if the pen needle is attached correctly then dial two units, point the pen up and press the thumb button. If liquid does not appear at the needle tip, repeat this step as recommended by the pen instructions. If liquids still do not appear, change the needle, and repeat the above steps. To performing the injection, dial the prescribed dose on the pen. Review of the policy titled Adverse Consequences and Medication Errors, dated April 2014, revealed a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's order or manufacturer's specifications such as wrong dose or failure to follow manufacturer's instructions. Review of the policy titled Lab and Diagnostic Test Results - Clinical Protocol, dated September 2019 revealed the staff will process test requisitions and arrange for tests, a nurse will review all results and will identify the urgency of communicating with the attending physician based on physician request, the seriousness of abnormality, and the individual's current condition. This represents non-compliance found with Master Complaint Number OH00139489 and Complaint Number OH0039424.

Based on medical record review, review of a facility investigation, staff interview and policy review, the facility failed to ensure a cognitively impaired resident received adequate supervision to prevent elopement from the facility and an avoidable fall with injury. This resulted in actual harm when Resident #58 eloped from the facility in her wheelchair, rolled down a paved driveway leading to the facility parking lot, the resident struck a parked car with her legs resulting in the resident falling from her wheelchair and subsequently Resident #58 sustained a laceration to the right calf requiring five sutures and a [MEDICAL CONDITION] tibia and fibula. This affected one (#58) out of three residents sampled for supervision during the survey. Facility census was 108. Findings include: Review of Resident 58's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Further review of Resident #58's medical record revealed the resident resided on the dementia unit (East) at the facility that had two alarmed, locked doors. The hallway leading from the East unit to the South unit had two large steel fire doors, that divided the units. The doors were kept closed most of the time but were not locked. Review of Resident #58's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident experienced both short and long-term memory loss and had severely impaired decision-making skills. She required extensive assistance of staff with bed mobility, transferring, dressing, toilet use, and personal hygiene tasks. Resident #58 was able to feed herself with supervision and set up. The resident used a wheelchair for locomotion on the unit and was independent with locomotion after set-up help. Off of the unit, the resident required limited assistance of staff and was highly involved in the mobility. Review of Resident #58's fall prevention care plan, revealed the resident had a potential for falls related to unsteady gait, cognitive deficits, and impaired safety awareness. Pertinent interventions included keeping call light and personal items within reach, anticipate and meet needs as possible, the use of non-skid footwear, assisting with transfers, assisting with wheelchair mobility as needed, the use of dycem in wheelchair seat, and offering to lay down after meals. Review of the Elopement Risk Assessment, revealed on 03/16/18, 06/13/18, 07/03/18, 09/27/18, 03/08/19, 06/10/19, and 09/16/19, the resident had no exit seeking behaviors and no attempts at elopement. A preventive care plan for elopement was not developed due to her low risk. Review of nursing notes from 05/08/19 through 12/09/19, revealed no attempts at elopement. Review of the physician progress notes [REDACTED].#58 had no attempts at elopement. Review of the facility's investigation revealed on 12/09/19 at 2:50 P.M., Resident #58 left her unit with several other residents, accompanied by activity staff when they came onto her unit to take residents to play bingo. Instead of proceeding to the activity room with the other residents, the resident veered left from the activity area and mobilized herself to the front of the South/West halls and went out to the parking lot through double automatic sliding doors. Resident #58 then rolled down the hill to the right side of the parking lot (approximately 50 feet), hit a parked car with her knees, then fell out of her wheelchair onto the pavement next to a parked car. According to the facility's timeline which was part of the investigation, on 12/09/19 at 2:52 P.M., a delivery man and a maintenance worker arrived at the scene of the incident, as both were outside when the incident occurred. Review of Resident #58's nursing progress notes revealed on 12/09/19 at 2:53 P.M., three nurses, who were working at the facility responded to the maintenance worker's call for help over the facility ' s walkie talkie system. On 12/09/19 at 2:55 P.M., a call was made to the emergency squad. The resident was offered comfort and provided a blanket as staff awaited the emergency squad. On 12/09/19 at 3:00 P.M., the paramedics arrived and transported the resident to the hospital. Review of Resident #58's nursing progress notes revealed on 12/10/19 at 4:00 [NAME]M., the resident returned from the hospital. The resident sustained [REDACTED]. She also was diagnosed with [REDACTED]. On 12/10/19, the physician progress notes [REDACTED]. The physician documented the resident mobilized in a wheelchair and resided on the dementia unit. The resident has no prior history of elopement and she never gets off the hallways and remains presently confused. Yesterday, the resident went through the main entrance of the building on the southwest unit, which has sliding doors that open automatically when someone approaches, went downhill into the parking area, and hit a parked car with her knees with rapid acceleration-deceleration type injury. The resident was taken to the hospital and was found to have a proximal right tibial and fibular diaphyseal fracture. The femur x-ray showed a large lipoma hemarthrosis and confirmed oblique [MEDICAL CONDITION] tibial metadiaphysis without angulation and also a distal fibular diaphysis fracture with tricompartmental arthritis. She also had a computed tomography (CT) scan of the head which showed no [MEDICAL CONDITION] or acute infarct or mass. The right lower extremity laceration was repaired, and the tibia-fibula fracture was left to be managed non-operatively. She was placed on an antibiotic, Keflex 500 milligrams (mg) four times a day for five days, to help prevent infection with instructions to wear knee immobilizer at all times. During an interview with the Administrator on 12/17/19 at approximately 3:30 P.M., he confirmed the above incident involving Resident #58. The Administrator stated Resident #58 resided on a dementia unit that was not locked. There are two doors dividing the east unit where Resident #58 resided from the south unit. The doors are kept closed at times. The Administrator stated on 12/09/19 at 2:50 P.M., activity staff went over to the east unit, to transport residents to the activity area at the end of the south unit. The Administrator stated Resident #58 followed the activity staff and the other residents, however when they reached the activity area located in a dining room on the right side at the end of the south unit, Resident #58 proceeded to veer left and wheeled herself up to the double automatic sliding glass doors and rolled down the hill into the parking lot and hit a car, fracturing her leg. The Administrator confirmed the activity staff did not supervise Resident #58 to ensure she made it to the activity room. Review of the facility's Elopement Policy and Procedure, states staff shall promptly report any resident who tries to leave a safe place or is suspected of being missing to the Charge Nurse, Director of Nursing, or Director of Assisted Living. If an employee observes a resident leaving a safe place, he/she should attempt to prevent the departure in a courteous manner and get help from other staff in the immediate vicinity if necessary. This deficiency substantiates Complaint Number OH 811.

Based on record review, observation, staff interview, review of the national pressure ulcer advisory panel (NPUAP), and policy review, the facility failed to timely assess and identify skin alterations and complete treatments as ordered for two (Residents #70 and #72) of four identified with facility acquired pressure ulcers. This resulted in actual harm for one resident (Resident #70) when he developed an unavoidable pressure ulcer with adherent devitalized infected necrotic tissue. The facility census was 102. Findings included: 1. Review of the medical record for the Resident #70 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/21/19, revealed the resident had intact cognition. The resident required extensive assistance of two staff for bed mobility, transfers, and positioning. The assessment indicated the resident had no pressure ulcers at the time. Review of the pressure ulcer risk assessment dated [DATE] revealed the resident was at high risk for the development of pressure ulcers. Review of the plan of care, updated 08/22/19, revealed the resident was at risk for pressure ulcers due to [MEDICAL CONDITION], history of previous pressure ulcers and [MEDICAL CONDITION]. Interventions included treatments as ordered, complete skin checks weekly, encourage resident to reposition frequently, and assist to change brief after each incontinence episode. Review of physician orders [REDACTED]. On 09/19/19 an order for [REDACTED]. Review of the wound monitoring sheets dated (MONTH) 2019 revealed the weekly skin round on 09/14/19 was not completed as ordered. Review of the treatment administration record (TAR) dated (MONTH) 2019 documented treatments to the left ischium pressure ulcer were not completed 17 times in the month; crucial times of not completing were dated 09/16/19, 09/17/19, 09/18/19, and 09/19/19. Review of the nursing notes dated 09/01/19 to 10/02/19 documented no identification of any new skin breakdown or pressure injuries. Review of the wound evaluation and management summary dated 09/19/19 revealed during wound rounds, Wound Medical Doctor (MD) #115 found an unstageable pressure ulcer (Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed.), with necrosis and devitalized tissue that measured 0.6 centimeters (cm) by 2.1 cm on the coccyx. Surgical debridement was completed to remove infected thick adherent eschar (a black/brown leathery skin), and devitalized tissue. The goal of this wound was healing and a new treatment order to apply calcium alginate to the wound bed and cover with a dry dressing daily. Review of the physician order [REDACTED]. Review of the TAR dated from 09/19/19 to 09/27/19 revealed treatment orders for the unstageable coccyx wound were not placed on the TAR. Review of the wound evaluation and management summary dated 09/26/19 revealed the coccyx wound had slough and measured 1 cm by 1 cm by 0.1 cm. Surgical debridement was completed to remove infected tissue. This wound was staged by wound MD #115 as a stage III pressure ulcer. It was documented as healing as the surface area had decreased, and recommendations to continue the treatment. The treatment to Resident #70's wounds was observed on 10/03/19 at 7:45 [NAME]M., with Licensed Practical Nurses (LPN) #98 and #101 and MD #115. The old dressing was removed and there was no odor. The wound bed was pink granulation tissue, no slough or eschar was observed at this time. The wound measured 0.5 cm by 2.0 cm by 0.1 cm. He had a new low air loss mattress in place at this time. During interview 10/01/19 at 1:13 P.M., Resident #70 ¿¿¿¿stated he did not like to turn and reposition all the time because it was painful. He had a healed area on his right hip. He further stated he had refused treatments a couple of times, but they often do not come in and complete his treatments. During interview on 10/02/19 at 10:30 [NAME]M., Regional Quality Specialist (RQS) #111 was made aware of the concerns with the lack of follow up on pressure ulcer care. She verified they had noted some concerns with their documentation of the pressure ulcers and verified the lack of follow through with the treatment order of the newly found pressure injury. During interview on 10/02/19 at 10:58 [NAME]M., LPN #98 stated she rounded with MD #115 and as far as she knew he was the one who found the necrotic area to Resident #70's coccyx. Staff did not identify the area in between wound rounds. She also stated MD #115 gave treatment orders. The orders are in written form and given to the floor nurse. They are processed and placed in the computer, and placed on the TAR. She verified these steps did not happen and the treatment order for the coccyx pressure area was not entered and not completed. During interview on 10/03/19 at 7:35 [NAME]M., MD #115 stated he found the unstageable necrotic area on the coccyx during his rounds. Staff rolled Resident #70 over to review the ischium and there it was. He said it had been there for seven days and would have started with discoloration prior to having eschar on it. He did say he thought with his co-morbidities, nutritional status, and refusals at times this pressure ulcer was unavoidable, however someone doing his other treatment should have been able to identify this area sooner. He was not aware his original treatment orders had not been implemented and he did have to debride the wound on the second visit, but he did assess it as healing and it continued to heal. 2. Review of the medical record for Resident #72 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the comprehensive MDS assessment dated [DATE] revealed he had impaired cognition, he rejected care frequently, he was totally dependent on staff for bed mobility and transfer. He had a stage III pressure ulcer. Review of the physician orders [REDACTED]. Review of the TAR dated (MONTH) 2019 documented 13 days the treatments were not completed, and the resident had refused an additional three days. The weekly skin assessment was missed on 09/14/19 and 09/28/19. Review of the wound evaluation and management summary dated 09/26/19 revealed the pressure ulcer to the left buttocks was healing. During observation of the ulcer treatment on 10/02/19 at 1:40 P.M., with LPN #98 and #101 revealed he was laying on a low air loss mattress. There there was no malodor. The wound to the left buttocks was pink granulation treatment and appeared to be healing. There was no concern with the treatment completed at this time. During interview on 10/03/19 at 7:35 [NAME]M., MD #115 stated Resident #72 had chronic wounds and they were healing despite his refused treatments. Review of facility policy titled Wound Care, dated 11/26/16, revealed a weekly skin assessment will be performed by nursing and any areas of skin breakdown will be documented in the medical record. If skin breakdown is identified and treatment is required, verify there is a physicians order for the procedure, the medical record should note the date, time the treatment as completed and by whom. Review of the NPUAP revealed the definition of a Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. This deficiency substantiates Complaint Number OH 144.

Based on medical record review, observations, staff and resident interviews, policy review and review of medication information from Medscape, the facility failed to ensure a resident's pain was properly managed. This resulted in actual harm when Resident #24 experienced uncontrolled severe pain and had difficulty sleeping. This affected one (#24) of two residents reviewed for Pain Management during the survey. The facility census was 113. Findings include: Review of the medical record revealed Resident #24 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had moderate cognitive impairment, Brief Interview for Mental Status (BIMS) score of 11, with no noted behavior and/or rejection of care noted. Review of Section J-Health Conditions revealed the resident had frequent pain, with scheduled and as need pain medication regimen. Review of Section N-Medication revealed the resident received opioids on four of the seven days. Review of Resident #24's Social Services progress note dated 06/14/19 and again on 06/24/19 revealed the resident was alert and oriented, with a BIMS of 15, which revealed the resident was cognitively intact. Review of Resident #24's care plan dated 05/14/19 revealed the resident had pain related to her [DIAGNOSES REDACTED]. The goal was to maintain her pain at a tolerable level with interventions including assess pain, observe for nonverbal signs of pain, discuss what precipitates pain, and administer pain medications as ordered and monitor for effectiveness. Review of Physician Orders revealed Resident #24 was ordered [MEDICATION NAME] (pain medication), ordered 06/17/19, 5-325 milligram (mg) tablet every six hours as needed, and [MEDICATION NAME] (muscle relaxer) every six hours as needed. Review of the Medication Admission Record (MAR) for 06/19 revealed the resident had received the [MEDICATION NAME], on 06/17/19 at 10:57 A.M. and 8:42 A.M., on 06/18/19 at 8:47 A.M., on 06/19/19 at 1:30 A.M., 8:01 A.M., and at 9:13 P.M., and on 06/20/19 at 8:07 A.M. Further review of the medical record revealed the resident did not receive her [MEDICATION NAME] again until 06/25/19. Review of the physician response fax dated 06/23/19 revealed the on-call physician received a fax request for Resident #23's [MEDICATION NAME] 5-325 mg refill. The returned fax noted the on-call physician replied, our office does not refill narcotics on the weekend please address with tomorrow for the facility physician. Interview and observation conducted on 06/24/19 at 2:56 P.M. with Resident #24 revealed the resident was observed in her wheelchair at her bedside, grimacing and rubbing her hands, and stated the facility had been out of her pain medication since 06/21/19 and they still have not gotten it in yet. During a follow-up interview conducted on 06/27/19 at 1:31 P.M. with Resident #24 she stated over the weekend her pain was so bad she would rate it between a seven and eight (out of 10 pain scale, with ten being the worst pain) during the day but it was worse in the morning and she would rate it at a nine. Resident #24 stated during the mornings she could barely move her hands, elbow and shoulder, knees and back. Resident #24 stated her RA and Lupus cause her a lot of pain. Resident #24 stated she usually asked for her pain medicine in the morning and again at night. Resident #24 stated she was asking for her pain medicine over the weekend and the staff told her the doctor didn't sign the prescription. Resident #24 stated when she gets her pain medication her pain level is a five or six out of 10. Resident #24 stated it was hard for her to sleep without her pain medication, and when she finally received her medication she was in pain and ended up throwing up her first dose. Resident #24 stated she was finally feeling better after receiving her second dose of her medication. Interview conducted on 06/26/19 at 11:06 A.M. with Licensed Practical Nurse (LPN) #499 revealed Resident #24 had chronic pain all the time. LPN #499 verified the facility was out of Resident #24's pain medication since Friday 06/21/19. LPN #499 stated the resident ran out of her medication, a fax was sent over, and the on-call physician would not order the medication over the weekend. LPN #499 verified the facility physician did not sign an order for [REDACTED].#499 stated at that time, the pharmacy was able to approve for an emergency pull from the facility supply and the medication was then provided to Resident #24. Interview conducted on 06/27/19 at 1:24 P.M. with LPN #411 revealed Resident #24 was completely alert and oriented, and was able to inform staff when she had pain and needed medication. LPN #411 stated the resident had pain over the weekend and requested medication, but there was no signed order. LPN #411 stated they never had an issue with the on-call physicians signing for pain medication prior to the incident with Resident #24 over the weekend. LPN #411 verified the MAR indicated [REDACTED]. Interview conducted on 06/27/19 at 2:58 P.M. with Unit Manager (UM) #402 revealed she spoke with Resident #24 on 06/24/19 and she was very upset and having a lot of pain. UM #402 stated she would expect for her staff to obtain a prescription from the doctor and not accept the response provided by the on-call doctor. UM #402 stated she would have called and gotten something, and the on-call physician can give short term prescriptions until the staff was able to reach the physician on Monday. Review of the facility policy, Pain-Clinical Protocol dated 03/18 revealed when a resident has pain, the physician would order appropriate non-pharmacologic and medication interventions to address the individual's pain. Review of medication information from Medscape revealed [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) is an opioid [MEDICATION NAME] used for moderate-to-severe pain. The medication should be taken as prescribed by the physician. Further review revealed precise and systematic pain assessment is required to make the correct [DIAGNOSES REDACTED]. During a Pain Assessment the resident's pain is assessed on a zero to 10 scale with zero being no pain and 10 being the most severe pain. It was also indicated that pain medications work best if used at first signs of pain, if delay the medication may not work as well.

Based on observation, medical record review, staff and resident interview, review of facility policy and review of medication information from Medscape, the facility failed to ensure a resident on anti-coagulation therapy received adequate monitoring of blood coagulation time via laboratory testing as ordered by the physician. This resulted in actual harm when Resident #110 experience a critically high blood coagulation time after bi-weekly blood coagulation monitoring tests had not been completed over a two week period and subsequently required administration of Vitamin K to reverse the over-anticoagulation of the resident's blood. This affected one (#110) of five residents reviewed for unnecessary medications. The facility census was 113. Findings include: Review of Resident #110's medical record revealed the resident was originally admitted to the facility on [DATE], and readmitted on [DATE]. [DIAGNOSES REDACTED]. The facility completed a Minimum Data Set (MDS) 3.0 assessment of the resident's cognitive and physical functional status dated 05/01/19. The assessment identified the resident as having moderate cognitive impairment, and requiring the physical assistance of one staff person for bed mobility, transfer, and personal hygiene, and as receiving anti-coagulant medication on six out of the seven assessment days. Review of Resident #110's comprehensive plan of care revealed a plan of care was initiated on 05/10/19, after the resident had sustained a critically high blood coagulation time on 04/30/19. The plan of care specified the resident was at risk for injury related to anticoagulant therapy, bruising easily, prolonged bleeding, and tarry stools. The goal was for the resident to be free of bruising, bleeding, or injury. The goal for the resident to have a therapeutic blood clotting time, i.e. International Normalized Ratio (INR) was not included. The interventions included monitoring the resident's laboratory reports. Review of Resident #110's physician's orders [REDACTED]. The resident's current order was for a total of 3.5 milligrams (mgs) of [MEDICATION NAME] daily. In addition, the resident was receiving 75 mgs of [MEDICATION NAME] (an anti-platelet medication) daily since 04/03/19. Review of Resident #110's physician ordered laboratory tests revealed an order written [REDACTED]. On 06/18/19, the physician changed the order for the PT/INR to be checked weekly on Monday. The resident had a PT/INR laboratory test done on 04/11/19 which indicated the resident's PT/INR was within acceptable range for this resident and the physician did not order any changes to her anti-coagulant medication. Further review of Resident #110's medical record failed to revealed any laboratory testing to monitor the resident's blood clotting times via the physician ordered PT/INR for the resident on Mondays and Thursdays. There was no documentation to support that the PT/INR had been tested for the resident since 04/11/19 until 04/30/19. This represented 18 consecutive days the resident's blood coagulation tendencies were not monitored to ensure the safety and efficacy of the use of the anti-coagulant medication. Review of Resident #110's completed PT/INR laboratory tests revealed that on 04/30/19 the residents PT was 88.1 which was reported High, and her INR was 7.7 which was reported as Critically High. The laboratory report dated 04/30/19 indicated that a normal range for PT is 9.5 to 11.8 seconds, and that an INR of 2.5 to 3.5 represented aggressive anti-coagulant therapy. The physician was notified and ordered to hold the [MEDICATION NAME] for three days, and to check the resident's PT/INR again on 05/01/19 and 05/02/19. On 05/01/19 the resident's PT/INR was tested again which revealed the resident's PT as 88.1 which was reported as High, and an INR of 8.2 which was reported as Critically High. The resident's physician was notified and ordered for the resident to receive a 5 milligram tablet of vitamin K related to an elevated INR of 8.2. The residents PT/INR was rechecked on 05/02/19 and her PT was 60.8 and the INR was 5.6 reported as Critically High. The resident's PT/INR was tested on [DATE] and resulted in a PT of 37.7 and and INR of 3.5. Further review of Resident #110's PT/INR [MEDICATION NAME] ([MEDICATION NAME]) flow record affirmed that no PT/INR laboratory tests were completed for this resident between 04/11/19 and 04/30/19. Resident #110 was observed and interviewed on 06/25/19 at 9:15 A.M. The resident was alert to herself with some confusion. Resident #110 could not recall if she was taking a blood thinning medication but stated she did bruise easily. Observations revealed there were no obvious areas of bruising or bleeding noted to the resident at the time of the interview. An interview was conducted with the Director of Nursing (DON) ON 06/26/19 at 4:20 P.M. During the interview, Resident #110's PT/INR laboratory reports scheduled to have been completed on 04/22/19 and 04/25/19 were requested. The DON reported that the PT/INR laboratory reports for 04/22/19 and 04/25/19 were not drawn. The DON was asked to provide evidence that the PT/INR laboratory reports scheduled to have been completed for the resident on 04/15/19 and 04/18/19 were completed. During a follow up interview, on 06/27/19 at 8:46 A.M. the DON reported that Resident #110's PT/INR laboratory tests scheduled for 04/15/19 and 04/18/19 were not done. The DON confirmed there was no PT/INR monitoring between 04/11/19 and 04/30/19 and the faciliy continued to administer [MEDICATION NAME]. The DON further confirmed when Resident #110's INR was obtained on 04/30/19 it was 7.7 representing a critically high level. The DON confirmed Resident #110 required the administration of Vitamin D. The facility's Clinical Protocol for Anticoagulation was requested and reviewed. The Anticoagulation protocol under the monitoring and follow-up section specified the physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications; for example, periodically checking hemoglobin/hematocrit, platelets, PT/INR, and stool for occult blood. Staff should use a [MEDICATION NAME] ([MEDICATION NAME]) flow sheet or comparable monitoring tool to follow trends in anticoagulant dosage and response. Review of medication information from Medscape revealed [MEDICATION NAME] is an anticoagulant used to treat venous [MEDICAL CONDITIONS] embolism, stroke, [MEDICAL CONDITION], cardiac valve replacement, post-[MEDICAL CONDITION] infarction, rheumatic valve disease. According to Medscape [MEDICATION NAME] can cause major or fatal bleeding and bleeding is more likely to occur with higher doses resulting in higher INR's. Regular monitoring of INR should be performed on all patients. Further review of Medscape revealed Vitamin K is used to reverse [MEDICATION NAME] effects.

Based on medical record review, review of a facility Self-Reported Incident (SRI), review of an employee timecard, observations, review of personnel files, staff, resident and police detective interview and review of the Abuse, Neglect and Exploitation policy and procedure, the facility failed to ensure a cognitively impaired resident was free from mental and emotional abuse by a staff member during the provision of care. This resulted in Immediate Jeopardy and the potential for psychosocial harm to one resident (#50) when State tested Nurse Aide (STNA) #600 engaged in an act meant to humiliate and dehumanize a resident by taking an inappropriate photograph and posting it to the social media website Facebook. This photograph was taken without the resident's/resident's representative permission and not in accordance with facility policy. This picture was posted on a social media website, Facebook, resulting in outcomes which one would expect a reasonable person in a similar situation to suffer, subsequently treating the resident as an inanimate object having no emotions or feelings and causing embarrassment and shame for the resident. On 05/01/19 at 5:09 P.M., the Administrator, Executive Director and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 04/25/19 at approximately 11:27 A.M. when STNA #600 took and posted an inappropriate photograph to the social media website Facebook. The photograph was an unknown female resident lying in bed with her lower body completely nude from the waist down. The unknown female resident was noted in the photograph to have feces coming from her rectum and a derogatory comment was added to the photo when posted to STNA #600's Facebook. The facility thoroughly investigated the incident and identified the unknown resident as Resident #50 in photograph posted to STNA #600's Facebook. The Immediate Jeopardy was removed on 04/26/19 when staff education was provided regarding the identification of abuse, the abuse policy and procedures, maintaining the residents' rights to privacy and confidentiality during the provision of personal care and utilization of cell phones and/or photographing mobile devices, and the facility implemented the following corrective actions: · On 04/25/19 at 11:27 A.M., the DON became aware of the social media violation Facebook post of Resident #50. The DON was informed by the STNA #100, who provided a copy of the screenshot of STNA #600's Facebook posting. The DON informed the Administrator immediately. · On 04/25/19, the facility immediately began the investigation and received a written statement from STNA #100 who reported the potential abuse and privacy violation. STNA #100 provided the facility with the screenshot of the photograph posted to STNA #600's Facebook. · On 04/25/19, the Medical Director was notified of the incident. · On 04/25/19, the Administrator informed the Executive Director via telephone. The facility held a Quality Assurance Performance Improvement (QAPI) meeting and reviewed the social media policy and abuse policy to ensure compliance. The Administrator, Medical Director, DON, Executive Director and Regional Team participated in the meeting. The DON and Unit Managers were educated on each policy. The education was conducted by the Administrator. · On 04/25/19, STNA #600's Facebook account was reviewed by the Administrator, and the inappropriate posting in question was no longer available. · On 04/25/19 at 1:20 P.M., the facility determined the unknown resident in the screenshot photograph of STNA #600's Facebook post was Resident #50. · On 04/25/19 at 1:50 P.M., the social media policy and abuse policy were reviewed with South and West hall nursing staff members. The education was conducted by the Administrator, Executive Director, and DON. All the team members were questioned regarding other policy violations, and all indicated they were not aware of any further violations. · On 04/25/19 at 2:15 P.M., the social media policy and abuse policy were reviewed with North and East hall nursing staff members. The education was conducted by the Administrator, Executive Director, and DON. All the team members were questioned regarding other policy violations, and all indicated they were not aware of any further violations. · On 04/25/19 at 2:40 P.M., the social media policy and abuse policy were reviewed with rehabilitation staff members. The education was conducted by the Administrator, Executive Director, and DON. All the team members were questioned regarding other policy violations, and all indicated they were not aware of any further violations. · On 04/25/19 at 2:55 P.M., the Administrator, Executive Director, and DON met with STNA #600. STNA #600 denied taking the photograph in question. STNA #600 indicated she felt the posted picture, which she indicated was of her grandmother, was appropriate to post because it did not show her face. The Administrator provided education regarding the social media and abuse policy to STNA #600 and she denied any additional social media violations. The Administrator then informed STNA #600 she was suspended immediately pending investigation. STNA #600 immediately left the premises. She had no further contact with any residents as of 4/25/19 when her shift ended at 6:05 A.M. · On 04/25/19 at 3:50 P.M., education continued for staff members regarding the social media policy and abuse policy. The education was conducted by the Administrator, Executive Director, and DON. All the team members were questioned regarding other policy violations, and all indicated they were not aware of any further violations. · On 04/25/19 at 4:10 P.M., the nursing team members and the Administrator met with Resident #50. Resident #50 had no signs and symptoms of distress, and physical assessment revealed no negative findings. All like residents were also reviewed and showed no signs and symptoms of distress, or negative physical findings. Further review indicated there were no additional social media violations within the past year. · On 04/26/19 at 9:30 A.M., the social media policy and abuse policy were reviewed with managers and support staff. The education was conducted by the Administrator, Executive Director, and DON. All the team members were questioned regarding other policy violations, and all indicated they were not aware of any further violations. The same education and questioning continued throughout the day for all departments. · On 05/01/19, the Administrator contacted the police to file a police report. The police came out promptly and began their investigation. · On 5/01/19, the QAPI committee conducted a review of the event and the status of the corrective action. · On 05/01/19, the facility conducted interviews with interviewable residents. The interview included but was not limited to if the resident's privacy was respected, if they were aware of a photo taken of them without their consent, and if they are able to verbalize issues and concerns to staff. There were no indications of policy violation during the interviews. · On 05/01/19, the DON or designee implemented audits including questions regarding resident privacy, social media and the abuse policy. The audits will be completed weekly for one month and then monthly for one quarter. The results will be reported to the QAPI committee. · On 05/02/19 between 9:47 A.M. and 9:52 A.M., three (#9, #82 and #83) residents were interviewed and their medical records were reviewed. There were no concerns identified with privacy or abuse. · On 05/02/19 between 9:09 A.M. and 9:54 A.M., Licensed Practical Nurse (LPN) #400, LPN #500, STNA #100 and STNA #300 were all interviewed regarding resident privacy and abuse. There were no negative findings identified and all were knowledgeable regarding the privacy and abuse training. · Review of three personnel files for the DON, STNA #100 and STNA #600 revealed they all had appropriate social media abuse training prior to the incident. There also was documentation that verified the Bureau of Criminal Investigation (BCI) background checks were completed prior to hire and appropriate reference checks were completed. · On 05/20/19, the facility had completed all audits for residents and staff and there were no further issues were identified. · On 05/20/19, a review of the SRI's revealed no further issues were identified. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 05/20/19. Findings include: Review of the medical record for Resident #50 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #50 as severely cognitively impaired with impaired long-term and short-term memory loss. She also was assessed as being unable to make herself understood and sometimes understands others with simple and direct communication. Further review of the MDS assessed her as requiring total assistance from staff for toileting and personal care needs. Review of an SRI dated 04/25/19 documented Resident #50 was emotionally abused by STNA #600 when it was discovered through investigation that STNA #600 posted a derogatory photograph of Resident #50 to her Facebook page. Further review documented Resident #50 was non-responsive and unaware of the situation. The abuse allegation was substantiated by the facility which documented the facility had determined the picture was taken at Friendship Village in one of the resident's rooms. This was based on the photograph containing the same room set up as Resident #50 by viewing the chair that was in the room, the type of bed the resident was in, the type of floor tile in the room and the blankets on the bed. The screenshot photograph did not contain Resident #50's face. STNA #600 denies taking the picture at Friendship Village but does not deny posting it. Further review of several staff statements obtained during the investigation confirmed staff were able to identify the resident in the photo as Resident #50. Upon review of the screenshot photograph posted to Facebook revealed STNA #600's Facebook posting was undated. Further review of the photograph documented the photograph was posted for approximately five hours previously to the screen shot of the photograph being taken. The screenshot photograph was of Resident #50 lying in bed with her lower body completely nude from the waist down. Resident #50 was also noted in the photograph to have feces coming from her rectum. A pattern of a chair was visualized with colored circles, a hand rail with controller, and the floor tile were observed which appeared cream with a speckled pattern and a purple night gown could be viewed. The resident's face was not in the photo. There was also a caption on the Facebook screenshot photograph reading Man (with two emoji faces) yea I'm ready to go it's[***]EVERYWHERE. Review of the employee time card report for STNA #600 documented she clocked in at 6:03 P.M. on 04/24/19 and clocked out at 04/25/19 at 6:05 A.M. On 05/01/19 at 1:45 P.M., interview with the DON verified she received a screenshot via text message of the photograph posted on STNA #600's Facebook the morning of 04/25/19. The DON indicated the photograph was sent to her by STNA #100. She revealed STNA #100's daughter was friends with STNA #600 and she had seen the photograph on her Facebook page and sent the screenshot to STNA #100 that morning. The DON revealed she notified the Administrator immediately and contacted STNA #600 to come in for an interview. She verified STNA #600 returned to the facility around 2:00 P.M. and was suspended immediately. According to the DON, STNA #600 revealed she removed the Facebook post the morning of 04/25/19. The DON stated STNA #600 told the facility the photograph was of her grandmother and adamantly denied it was Resident #50 in the photograph. She then revealed STNA #600 had no other evidence to prove it was her grandmother in the photograph. The DON verified the screenshot of the photo was not dated but had a time of being posted for approximately five hours which is the approximate time from when STNA #600's shift ended, and when she received the screen shot via text message. The DON verified she felt the photograph was of Resident #50 due to the bed rail with controller being the same one Resident #50 currently had, the circled chair pattern in the background, the floor tiles in the room and the purple night gown that could be seen in the Facebook screenshot photograph. On 05/01/19 at 2:54 P.M., interview with the Administrator verified he believed it was Resident #50 in the Facebook screenshot photograph due to the hand rail with the controller, the fabric of a chair in the background which had colored circles, and the floor tile in the room. He also verified he felt STNA #600 posted the photograph on 04/25/19 but confirmed the screen shot did not contain the date, only the approximate time of the photo, and that it had been posted for approximately five hours which was the approximate time STNA #600's shift ended. He verified STNA #600 adamantly denied the photo was of Resident #50 and told them it was of her grandmother but was unable to provide any further evidence of it being her grandmother. He confirmed STNA #600 was suspended immediately on 04/25/19 pending investigation. The Administrator verified STNA #600's termination will be set up since the investigation was substantiated on 04/30/19. The Administrator verified the substantiation of the facility's SRI was based on all the evidence and statements of other staff members which identified Resident #50 as the resident in the screenshot photograph of STNA #600's Facebook posting. On 05/01/19 at 3:08 P.M., an observation was made of Resident #50 and her room in comparison with the screenshot photograph posted to STNA #600's Facebook. The observation revealed Resident #50 was covered up with a blanket lying in bed. The hand rail with bed controller appeared to be the same in the screenshot photograph except in the screen shot it was cut in half. The observation also revealed the pattern of the chair beside Resident #50's bed had a circular pattern with different colors which was the same circular pattern with different colors observed in comparison with the screenshot photograph. Also, the floor in Resident #50's room was observed to be the same flooring in the screenshot photograph which was cream in color with a speckled pattern. Resident #50 was unable to communicate and was severely cognitively impaired as she was unable to answer when asked her name or how she was doing. On 05/01/19 at 3:32 P.M., interview with STNA #200 revealed she had seen the screenshot photograph of Resident #50. She verified she is not sure if STNA #600 took the photo or not because she did not see her take any photos on 04/25/19. STNA #200 verified she took over for STNA #600 the morning of 04/25/19 and had no concerns with Resident #50. STNA #200 revealed she was shown the screenshot photograph and thought it was a different resident at first, but they had different flooring. STNA #200 then verified she looked at the picture more and felt it was Resident #50 because of the room set up and she has had loose bowel movements recently. STNA #200 verified she could see Resident #50 had a purple night gown in the screenshot photograph. STNA #200 further verified Resident #50 was wearing the purple night gown on 04/25/19 when she worked because she took the night gown off the resident that morning. On 05/02/19 at 9:13 A.M., interview with STNA #100 verified she received a screenshot photograph from her daughter on 04/25/19 of Resident #50 who was nude from the waist down and had feces coming from her rectum. STNA #100 verified STNA #600 had it on her Facebook. STNA #100 revealed her daughter and STNA #600 are Facebook friends. STNA #100 further revealed once she received the screenshot of the photograph, she sent the screenshot photograph to the DON via text message on 04/25/19. STNA #100 verified Resident #50 was identified in the photograph because of the flooring, the pattern of the chair in the background and the hand rail with the controller were all the same as Resident #50 had in her room currently. STNA #100 verified she could see a purple night gown in the screenshot photograph which Resident #50 wore to bed frequently. On 05/02/17 at 9:20 A.M., an observation was made of Resident #50's light purple night gown hanging in her closet. This night gown was also observed in the Facebook screenshot photograph as identifiable evidence belonging to Resident #50. On 05/02/19 at 11:04 A.M., a call was made to the Police Department and a message was left for Police Detective #700 who was assigned to the investigation. Police Detective #700 did not return the call. On 05/02/19 at 4:04 P.M., interview with STNA #600 via the telephone revealed the resident in the screenshot photograph posted on her Facebook was her grandmother who lives in a nursing home in another state. STNA #600 provided no further information regarding the Facebook post or information to prove the photo was of her grandmother and not Resident #50. Review of the personnel file for STNA #600 documented a hire date of 03/15/19 for the facility's Assisted Living as a care provider. Further review documented she had abuse and resident rights training completed on 03/15/19 upon hire. It was also documented she completed the Nurse's Aide Training and Competency Evaluation Program on 04/08/19 at which time she started working as an STNA. Further review documented STNA #600 was suspended on 04/25/19 pending an abuse investigation regarding a photograph taken of Resident #50 that was posted to her Facebook page. Review of facility's policy and procedure titled Abuse, Neglect and Exploitation revised 04/23/18 documented a resident has a right to personal privacy including accommodations and personal care. Further review revealed taking photographs or recordings of a resident without the resident or residents' representative permission is a violation of the resident's right to privacy and confidentiality. The policy also documented keeping or distributing photographs or recordings through multimedia messages or on social media networks is a violation of the resident's rights to privacy and confidentiality. The policy also included a resident has the right to be free of mental abuse. Mental abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident humiliation, intimidation, fear, shame, or degradation. This included taking photographs or recordings that are demeaning and humiliating and keeping or distributing them on social media. Further review documented a lack of response by the resident does not mean that mental abuse did not occur; in this instance the facility would evaluate how the reasonable person would react under such circumstances. This deficiency substantiates Complaint Number OH 095.

Based on medical record review, review of a facility Self-Reported Incident (SRI), review of an employee timecard, observations, review of personnel files, staff, resident and police detective interviews and review of the Abuse, Neglect and Exploitation policy and procedure, the facility failed to ensure a cognitively impaired resident's rights to privacy and confidentiality were maintained by a facility staff member during the provision of care. This resulted in Immediate Jeopardy and the potential for psychological harm for one resident (#50) when State tested Nurse Aide (STNA) #600 engaged in an act to humiliate and dehumanize a resident by taking an inappropriate photograph and posting the picture to the social media website Facebook. This photograph was taken without the resident's/resident's representative permission and not in accordance with facility policy. This picture was posted on a social media website, Facebook, resulting in outcomes which one would expect a reasonable person in a similar situation to suffer, subsequently treating the resident as an inanimate object having no emotions or feelings and causing embarrassment and shame for the resident. This affected one (#50) of four residents reviewed for privacy and confidentiality. The facility census was 108. On 05/01/19 at 5:09 P.M., the Administrator, Executive Director and the Director of Nursing (DON) were notified that Immediate Jeopardy began on 04/25/19 at approximately 11:27 A.M. when STNA #600 took and posted an inappropriate photograph to the social media website Facebook. The photograph was an unknown female resident lying in bed with her lower body completely nude from the waist down. The unknown female resident was noted in the photograph to have feces coming from her rectum and a derogatory comment was added to the photo when posted to STNA #600's Facebook. The facility thoroughly investigated the incident and identified the unknown resident as Resident #50 in photograph posted to STNA #600's Facebook. The Immediate Jeopardy was removed on 04/26/19 when staff education was provided regarding the identification of abuse, the abuse policy and procedures, maintaining the residents' rights to privacy and confidentiality during the provision of personal care and utilization of cell phones and/or photographing mobile devices, and the facility implemented the following corrective actions: · On 04/25/19 at 11:27 A.M., the DON became aware of the social media violation Facebook post of Resident #50. The DON was informed by the STNA #100, who provided a copy of the screenshot of STNA #600's Facebook posting. The DON informed the Administrator immediately. · On 04/25/19, the facility immediately began the investigation and received a written statement from STNA #100 who reported the potential abuse and privacy violation. STNA #100 provided the facility with the screenshot of the photograph posted to STNA #600's Facebook. · On 04/25/19, the Medical Director was notified of the incident. · On 04/25/19, the Administrator informed the Executive Director via telephone. The facility held a Quality Assurance Performance Improvement (QAPI) meeting and reviewed the social media policy and abuse policy to ensure compliance. The Administrator, Medical Director, DON, Executive Director and Regional Team participated in the meeting. The DON and Unit Managers were educated on each policy. The education was conducted by the Administrator. · On 04/25/19, STNA #600's Facebook account was reviewed by the Administrator, and the inappropriate posting in question was no longer available. · On 04/25/19 at 1:20 P.M., the facility determined the unknown resident in the screenshot photograph of STNA #600's Facebook post was Resident #50. · On 04/25/19 at 1:50 P.M., the social media policy and abuse policy were reviewed with South and West hall nursing staff members. The education was conducted by the Administrator, Executive Director, and DON. All the team members were questioned regarding other policy violations, and all indicated they were not aware of any further violations. · On 04/25/19 at 2:15 P.M., the social media policy and abuse policy were reviewed with North and East hall nursing staff members. The education was conducted by the Administrator, Executive Director, and DON. All the team members were questioned regarding other policy violations, and all indicated they were not aware of any further violations. · On 04/25/19 at 2:40 P.M., the social media policy and abuse policy were reviewed with rehabilitation staff members. The education was conducted by the Administrator, Executive Director, and DON. All the team members were questioned regarding other policy violations, and all indicated they were not aware of any further violations. · On 04/25/19 at 2:55 P.M., the Administrator, Executive Director, and DON met with STNA #600. STNA #600 denied taking the photograph in question. STNA #600 indicated she felt the posted picture, which she indicated was of her grandmother, was appropriate to post because it did not show her face. The Administrator provided education regarding the social media and abuse policy to STNA #600 and she denied any additional social media violations. The Administrator then informed STNA #600 she was suspended immediately pending investigation. STNA #600 immediately left the premises. She had no further contact with any residents as of 4/25/19 when her shift ended at 6:05 A.M. · On 04/25/19 at 3:50 P.M., education continued for staff members regarding the social media policy and abuse policy. The education was conducted by the Administrator, Executive Director, and DON. All the team members were questioned regarding other policy violations, and all indicated they were not aware of any further violations. · On 04/25/19 at 4:10 P.M., the nursing team members and the Administrator met with Resident #50. Resident #50 had no signs and symptoms of distress, and physical assessment revealed no negative findings. All like residents were also reviewed and showed no signs and symptoms of distress, or negative physical findings. Further review indicated there were no additional social media violations within the past year. · On 04/26/19 at 9:30 A.M., the social media policy and abuse policy were reviewed with managers and support staff. The education was conducted by the Administrator, Executive Director, and DON. All the team members were questioned regarding other policy violations, and all indicated they were not aware of any further violations. The same education and questioning continued throughout the day for all departments. · On 05/01/19, the Administrator contacted the police to file a police report. The police came out promptly and began their investigation. · On 5/01/19, the QAPI committee conducted a review of the event and the status of the corrective action. · On 05/01/19, the facility conducted interviews with interviewable residents. The interview included but was not limited to if the resident's privacy was respected, if they were aware of a photo taken of them without their consent, and if they are able to verbalize issues and concerns to staff. There were no indications of policy violation during the interviews. · On 05/01/19, the DON or designee implemented audits including questions regarding resident privacy, social media and the abuse policy. The audits will be completed weekly for one month and then monthly for one quarter. The results will be reported to the QAPI committee. · On 05/02/19 between 9:47 A.M. and 9:52 A.M., three (#9, #82 and #83) residents were interviewed and their medical records were reviewed. There were no concerns identified with privacy or abuse. · On 05/02/19 between 9:09 A.M. and 9:54 A.M., Licensed Practical Nurse (LPN) #400, LPN #500, STNA #100 and STNA #300 were all interviewed regarding resident privacy and abuse. There were no negative findings identified and all were knowledgeable regarding the privacy and abuse training. · Review of three personnel files for the DON, STNA #100 and STNA #600 revealed they all had appropriate social media abuse training prior to the incident. There also was documentation that verified the Bureau of Criminal Investigation (BCI) background checks were completed prior to hire and appropriate reference checks were completed. · On 05/20/19, the facility had completed all audits for residents and staff and there were no further issues were identified. · On 05/20/19, a review of the SRI's revealed no further issues were identified. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 05/20/19. Findings include: Review of the medical record for Resident #50 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #50 as severely cognitively impaired with impaired long-term and short-term memory loss. She also was assessed as being unable to make herself understood and sometimes understands others with simple and direct communication. Further review of the MDS assessed her as requiring total assistance from staff for toileting and personal care needs. Review of an SRI dated 04/25/19 documented Resident #50 was emotionally abused by STNA #600 when it was discovered through investigation that STNA #600 posted a derogatory photograph of Resident #50 to her Facebook page. Further review documented Resident #50 was non-responsive and unaware of the situation. The abuse allegation was substantiated by the facility which documented the facility had determined the picture was taken at Friendship Village in one of the resident's rooms. This was based on the photograph containing the same room set up as Resident #50 by viewing the chair that was in the room, the type of bed the resident was in, the type of floor tile in the room and the blankets on the bed. The screenshot photograph did not contain Resident #50's face. STNA #600 denies taking the picture at Friendship Village but does not deny posting it. Further review of several staff statements obtained during the investigation confirmed staff were able to identify the resident in the photo as Resident #50. Upon review of the screenshot photograph posted to Facebook revealed STNA #600's Facebook posting was undated. Further review of the photograph documented the photograph was posted for approximately five hours previously to the screen shot of the photograph being taken. The screenshot photograph was of Resident #50 lying in bed with her lower body completely nude from the waist down. Resident #50 was also noted in the photograph to have feces coming from her rectum. A pattern of a chair was visualized with colored circles, a hand rail with controller, and the floor tile were observed which appeared cream with a speckled pattern and a purple night gown could be viewed. The resident's face was not in the photo. There was also a caption on the Facebook screenshot photograph reading Man (with two emoji faces) yea I'm ready to go it's[***]EVERYWHERE. Review of the employee time card report for STNA #600 documented she clocked in at 6:03 P.M. on 04/24/19 and clocked out at 04/25/19 at 6:05 A.M. On 05/01/19 at 1:45 P.M., interview with the DON verified she received a screenshot via text message of the photograph posted on STNA #600's Facebook the morning of 04/25/19. The DON indicated the photograph was sent to her by STNA #100. She revealed STNA #100's daughter was friends with STNA #600 and she had seen the photograph on her Facebook page and sent the screenshot to STNA #100 that morning. The DON revealed she notified the Administrator immediately and contacted STNA #600 to come in for an interview. She verified STNA #600 returned to the facility around 2:00 P.M. and was suspended immediately. According to the DON, STNA #600 revealed she removed the Facebook post the morning of 04/25/19. The DON stated STNA #600 told the facility the photograph was of her grandmother and adamantly denied it was Resident #50 in the photograph. She then revealed STNA #600 had no other evidence to prove it was her grandmother in the photograph. The DON verified the screenshot of the photo was not dated but had a time of being posted for approximately five hours which is the approximate time from when STNA #600's shift ended, and when she received the screen shot via text message. The DON verified she felt the photograph was of Resident #50 due to the bed rail with controller being the same one Resident #50 currently had, the circled chair pattern in the background, the floor tiles in the room and the purple night gown that could be seen in the Facebook screenshot photograph. On 05/01/19 at 2:54 P.M., interview with the Administrator verified he believed it was Resident #50 in the Facebook screenshot photograph due to the hand rail with the controller, the fabric of a chair in the background which had colored circles, and the floor tile in the room. He also verified he felt STNA #600 posted the photograph on 04/25/19 but confirmed the screen shot did not contain the date, only the approximate time of the photo, and that it had been posted for approximately five hours which was the approximate time STNA #600's shift ended. He verified STNA #600 adamantly denied the photo was of Resident #50 and told them it was of her grandmother but was unable to provide any further evidence of it being her grandmother. He confirmed STNA #600 was suspended immediately on 04/25/19 pending investigation. The Administrator verified STNA #600's termination will be set up since the investigation was substantiated on 04/30/19. The Administrator verified the substantiation of the facility's SRI was based on all the evidence and statements of other staff members which identified Resident #50 as the resident in the screenshot photograph of STNA #600's Facebook posting. On 05/01/19 at 3:08 P.M., an observation was made of Resident #50 and her room in comparison with the screenshot photograph posted to STNA #600's Facebook. The observation revealed Resident #50 was covered up with a blanket lying in bed. The hand rail with bed controller appeared to be the same in the screenshot photograph except in the screen shot it was cut in half. The observation also revealed the pattern of the chair beside Resident #50's bed had a circular pattern with different colors which was the same circular pattern with different colors observed in comparison with the screenshot photograph. Also, the floor in Resident #50's room was observed to be the same flooring in the screenshot photograph which was cream in color with a speckled pattern. Resident #50 was unable to communicate and was severely cognitively impaired as she was unable to answer when asked her name or how she was doing. On 05/01/19 at 3:32 P.M., interview with STNA #200 revealed she had seen the screenshot photograph of Resident #50. She verified she is not sure if STNA #600 took the photo or not because she did not see her take any photos on 04/25/19. STNA #200 verified she took over for STNA #600 the morning of 04/25/19 and had no concerns with Resident #50. STNA #200 revealed she was shown the screenshot photograph and thought it was a different resident at first, but they had different flooring. STNA #200 then verified she looked at the picture more and felt it was Resident #50 because of the room set up and she has had loose bowel movements recently. STNA #200 verified she could see Resident #50 had a purple night gown in the screenshot photograph. STNA #200 further verified Resident #50 was wearing the purple night gown on 04/25/19 when she worked because she took the night gown off the resident that morning. On 05/02/19 at 9:13 A.M., interview with STNA #100 verified she received a screenshot photograph from her daughter on 04/25/19 of Resident #50 who was nude from the waist down and had feces coming from her rectum. STNA #100 verified STNA #600 had it on her Facebook. STNA #100 revealed her daughter and STNA #600 are Facebook friends. STNA #100 further revealed once she received the screenshot of the photograph, she sent the screenshot photograph to the DON via text message on 04/25/19. STNA #100 verified Resident #50 was identified in the photograph because of the flooring, the pattern of the chair in the background and the hand rail with the controller were all the same as Resident #50 had in her room currently. STNA #100 verified she could see a purple night gown in the screenshot photograph which Resident #50 wore to bed frequently. On 05/02/17 at 9:20 A.M., an observation was made of Resident #50's light purple night gown hanging in her closet. This night gown was also observed in the Facebook screenshot photograph as identifiable evidence belonging to Resident #50. On 05/02/19 at 11:04 A.M., a call was made to the Police Department and a message was left for Police Detective #700 who was assigned to the investigation. Police Detective #700 did not return the call. On 05/02/19 at 4:04 P.M., interview with STNA #600 via the telephone revealed the resident in the screenshot photograph posted on her Facebook was her grandmother who lives in a nursing home in another state. STNA #600 provided no further information regarding the Facebook post or information to prove the photo was of her grandmother and not Resident #50. Review of the personnel file for STNA #600 documented a hire date of 03/15/19 for the facility's Assisted Living as a care provider. Further review documented she had abuse and resident rights training completed on 03/15/19 upon hire. It was also documented she completed the Nurse's Aide Training and Competency Evaluation Program on 04/08/19 at which time she started working as an STNA. Further review documented STNA #600 was suspended on 04/25/19 pending an abuse investigation regarding a photograph taken of Resident #50 that was posted to her Facebook page. Review of facility's policy and procedure titled Abuse, Neglect and Exploitation revised 04/23/18 documented a resident has a right to personal privacy including accommodations and personal care. Further review revealed taking photographs or recordings of a resident without the resident or residents' representative permission is a violation of the resident's right to privacy and confidentiality. The policy also documented keeping or distributing photographs or recordings through multimedia messages or on social media networks is a violation of the resident's rights to privacy and confidentiality. The policy also included a resident has the right to be free of mental abuse. Mental abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident humiliation, intimidation, fear, shame, or degradation. This included taking photographs or recordings that are demeaning and humiliating and keeping or distributing them on social media. Further review documented a lack of response by the resident does not mean that mental abuse did not occur; in this instance the facility would evaluate how the reasonable person would react under such circumstances. This deficiency substantiates Complaint Number OH 095.

Based on observation, staff and resident interview, and record review, the facility failed to ensure resident's assessed to need supervision and assistive devices for proper positioning received adequate supervision and assistance devices to prevent falls. This affected one sampled resident (#4) who sustained an ankle fracture after falling from her wheelchair while unsupervised and two other sampled residents (#12 and #28) who fell without injury when their assistance devices were not in use as directed by their individualized comprehensive care plans. The resident sample was 19 in a current resident census of 88. Findings include: 1. Review of the medical record of Resident #4 revealed the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident was admitted to the facility for specialized rehabilitation services including physical therapy, occupational therapy, and speech therapy per physician's orders [REDACTED]. The MDS also identified the resident required physical assistance of two or more staff to assist with bed mobility and transfers. Resident #4 was assessed as not able to stand without physical help and required partial physical support to sit. The resident was unable to walk at the time of the assessment resulting from her recent intracranial hemorrhage. Review of the comprehensive assessment of the resident's risk for falls, revealed she was identified at risk for falls related to hemiparesis. The comprehensive fall assessment documented the resident required assistance of two for all activities of daily living, as she had poor trunk control. Review of an initial physical therapy assessment completed by Physical Therapist (PT) #10 on 09/03/10, revealed the assessment identified the resident had left hemiparesis with no functional strength in the left lower extremity, decreased tone of lower left extremity, no functional balance, and decreased (poor) safety awareness due to weakness and impaired balance. Review of an occupational therapy initial assessment dated [DATE], revealed the occupational therapist identified the resident had left hemiparesis and no active motion in her left upper extremity. Review of nurse's notes by Licensed Practical Nurse (LPN) #55, dated 09/10/10 at 12:45 P.M., revealed Resident #4 was up in a wheelchair per therapy. The notes stated therapy asked the resident if she wanted to go to dining room for lunch and the resident stayed in her room per her request. Nurse's notes by LPN #55 dated 09/10/10 at 1:20 P.M. stated she heard Resident #4 yell for help and she found the resident on the floor by her wheelchair lying on her left side. No apparent injuries were noted. The resident stated she was trying to scratch her back and slid out of the wheelchair. The physician was notified of the fall and gave an order to sent the resident to the emergency room for evaluation. LPN #55 noted the resident complained of head and neck pain at the time of transport to the hospital but there was no documentation of the resident having any complaints of pain related to her legs, ankles, or feet. An x-ray of the resident's left ankle completed on 09/10/10 at 5:52 P.M. stated views of the left ankle showed a non-displaced fracture of the lateral malleolus and a transverse non-displaced fracture of the medical malleolus as well. The radiology exam report impression was a bimalleolar non-displace fracture of the ankle. Review of a physical therapy progress notes by PT #10 dated 09/10/10, revealed the resident was transferred to a wheelchair that day for the first time via a mechanical lift. The notes stated the resident was taken to the dining room to have a supervised lunch and that she fell out of the wheelchair after lunch when she was taken back to her room as per nursing information. The notes stated the resident was seen sidelying on her left side on the floor and unable to move her right upper extremity. PT #10 documented the resident's upper extremity (left) was positioned well with support on the left and that both feet were on foot rests while she was seated in the wheelchair. During interview on 10/14/10 at 11:10 A.M., PT #10 stated Resident #4 had left sided weakness, was able to move her left leg very little, and that she had no functional control related to sitting balance at the time of the 09/03/10 evaluation. PT #10 stated herself and a certified occupational therapy aide (COTA) placed the resident in a wheelchair using a mechanical lift on 09/10/10. PT #10 stated the wheelchair was equipped with a 1/2 lap tray and with foot rests/leg supports for both the resident's legs. She stated the resident was positioned in the wheelchair for proper positioning, balance, and comfort with the use of pads and bolsters. PT #10 stated the COTA took the resident to the unit after therapy services and to the best of her recollection, she was informed the COTA took the resident to the unit dining room. She stated she would not have recommended leaving the resident unsupervised in the wheelchair due to the resident's left sided weakness. On 10/12/10 at 11:44 A.M., Resident #4 was observed lying in bed asleep with four half bed rails up and the head of her bed slightly elevated. The resident's left lower leg was observed in a cast and propped up on a pillow. Interview with Resident #4 on 10/12/10 at 2:15 P.M. verified her ankle was broken and that she had fallen out of her wheelchair. The resident stated she could not recall specific details related to the fall and that she was a little "fuzzy" at the time of the incident as things were not real clear in her memory right after her stroke. She stated the fractured ankle was painful. Interview with LPN #55 on 10/14/10 at 9:10 A.M. revealed the resident returned to the floor in a wheelchair on 09/10/10 around lunch time after receiving therapy services. LPN #55 stated the therapy staff person took the resident back to the unit and stated the resident was not to be unsupervised while in the wheelchair. LPN #55 stated to the best of her recollection the resident was transported to the dining room to eat by a nurse aide, then returned to her room by a nurse aide. LPN #55 affirmed no staff was with Resident #4 when she was found on the floor in her room at approximately 1:20 P.M. During further interview on 10/15/10 at 11:45 A.M., LPN #55 reiterated that she was told by therapy the resident was in a wheelchair and needed to be supervised. She stated she believed the resident was initially left in her room. She stated the therapy staff person asked if the resident was to be taken to the dining room and she informed the therapy staff person the resident could choose if she wanted to go the the dining room or eat in her room. LPN #55 stated she was unsure if the resident was ever transported to the dining room or if she ate in her room. When asked what devices the wheelchair was equipped with when the resident was found, LPN #22 stated she remembered the leg/foot rests were present, but she could not recall if the 1/2 lap tray was in place. Interview with state tested nurse aide (STNA) #87 on 10/14/10 at 12:00 P.M., regarding Resident #4's fall on 09/10/10, revealed she was one of the first staff to respond to the fall and she saw the resident on the floor in her room. When asked if the resident had her leg rests and 1/2 lap tray for her left arm in place on the wheelchair, STNA #87 stated she recalled the wheelchair had leg rests in place. STNA #87 stated she did not remember if the 1/2 lap tray was affixed to the resident's wheelchair when she was found on the floor. Interview with LPN #34 revealed when the resident's room, she observed the resident lying on the floor on her right side. She stated she was concerned about the resident's position on the floor related to her right shoulder and that she and other nursing staff log rolled the resident onto her back to relieve the pressure to her right shoulder. She stated the resident complained of back and neck pain at that time, that she had no apparent injury, and no acute limitations in range of motion beyond her preexisting limitations related to her stroke. She stated the resident complained of generalized leg pain when she was in the process of being sent out to the emergency room for evaluation. LPN #34 denied the resident had any specific complaints related to left leg or ankle pain. LPN #34 stated she recalled the resident's leg rests were present on the wheelchair at the time of the fall but she could not confirm or deny the 1/2 lap tray for the resident's left arm was present on the wheelchair. 2. Review of the Resident #12's medical record, the Face Sheet stated the resident was admitted on [DATE] with diagnoses, from the Face Sheet, which included multiple sclerosis, symbolic dysfunction, major depression and anemia. Review of the Minimum Data Set (MDS), dated [DATE], assessed the resident to have problems with long and short term memory, moderately impaired for daily decisions, required extensive assistance of one person for toilet use. She was assessed to have a history of fall. Review of the Fall Risk Assessment, dated 08/30/10, assessed the resident to be a high fall risk. The Fall Care Plan, dated 02/20/10, updated 08/30/10, was reviewed. The care plan included interventions of Dycem to the wheelchair, dated 08/08/10, and a low bed with bolstered low air loss mattress. Review of the Physicians order, dated 10/10, included an order for [REDACTED]. Observations were made on 10/12/10 at 11:20 AM. , 12:55 P.M., 2:10 P.M., and at 2:20 P.M. of Resident #12 up in her wheelchair with no Dycem in the seat of the wheelchair. On 10/12/10 at 2:35 P.M. Resident #12 was observed in a low air loss bed with bolsters, when Stated tested Nursing Assistant (STNA) #32 provided personal care for Resident #12. The resident's low air loss bed with bolsters was place in the high position. STNA #32 left the resident's room and obtained gloves. The bed was left in the high position, with the resident in the bed, between 2:44 P.M. and 2:46 P.M. On 10/12/10 at 2:50 P.M. STNA #32 was interviewed. He affirmed there was no Dycem in Resident #12's wheelchair all day. He affirmed he left the resident's bed in the high position when he left the room to get gloves. 3. Review of the medical record of Resident #28 stated an admission date of [DATE], with diagnoses, from the Face Sheet, which included Alzheimer disease, hypertension, and depression. The Minimum Data Set (MDS), dated [DATE] assessed the resident to have problems with long and short term memory, moderately impaired for daily decisions, required supervision of one person for transfers, bed mobility, independent with ambulation with supervision for ambulation. She was assessed to have a history of falls. Review of the Fall Risk Assessment, dated 09/16/10, assessed the resident to be a high fall risk. The Fall Care Plan, dated 02/03/10, was reviewed. The care plan included an intervention of non-skid strips on the floor, with a date of 04/06/10. Review of the 10/10 physicians orders included non-skid strips to the floor. Observations were made on 10/12/10 at 11:38 A.M., 2:48 P.M., 3:10 P.M., on 10/13/10 at 2:30 P.M., and on 10/14/10 at 9:00 A.M. of Resident #28 in a bed by the wall on a parameter defining mattress. There were no non-skid strips on the floor. On 10/14/10 at 9:00 A.M. STNAs #96 and 97 were interviewed. They affirmed there were no non-skid strips on the floor by Resident #28's bed. On 10/14/10 at 10:05 Licensed Practical LPN #59 confirmed there were no non-skid strips by Resident #28's bed. She stated the resident was moved, where the non-skid strips were placed, on 07/29/10.