Every finding on record at Austinburg NSG and Rehab CTR

Based on observation, interview, record review and review of facility policy the facility did not ensure menu spreadsheets were followed to provide appropriate portion sizes to Resident #26, #40, #43, #55 and #57 who the facility identified as receiving pureed diets. In addition, the facility did not ensure all other residents receiving meals from the kitchen received appropriate portions sizes at meals excluding Resident #441 who received a full liquid diet and Resident #64 who the facility identified as receiving nothing by mouth (NPO). The facility census was 82. Findings include: 1. Review of the facility menu Atrium Living Center Fall/Winter 2024/2025 Menus for week three revealed for dinner on 01/28/25 chicken pot pie, buttered broccoli, pineapple cup, two percent milk and coffee/tea were to be served. Review of the facility week three dinner (01/28/25) spread sheet (expanded menu) revealed for the pureed chicken pot pie no specific scoop size listed, but one #16 (two ounce) scoop was to be used for the pureed broccoli. The spreadsheet did not indicate mashed potato was to be served for the puree diets at this meal. Review of Chicken Pot Pie Pureed recipe, with a report date of 09/05/24, revealed the chicken pot pie would be prepared as directed in the recipe. Remove portions required from the prepared recipe and add to food processor and process until fine in consistency. Gradually add hot broth while processing and scrape down sides of processor with a rubber spatula and process for 30 seconds. The serving size would be two number eight (four ounce) scoops. Review of the facility document titled Resident Listing Report, dated 01/27/24, revealed a list of of all residents in the facility and their diet order. Resident #26, #40, #43, #55 and #57 had diet orders including pureed texture. Observations during tray line on 01/28/25 from 4:20 P.M. to 5:24 P.M. revealed the puree entree/meat being served on the dinner tray line was pureed chicken and not chicken pot pie. The serving scoop sizes being provided on the pureed resident meals was one number six (5.3 ounces) scoop of puree chicken, one number eight scoop (four ounces) of mashed potatoes, and one number ten (3.2 ounces) scoop of puree broccoli. During the observation on 01/28/25 from 4:20 P.M. to 5:24 P.M. Dietary [NAME] (DC) #700 confirmed the puree meat was pureed chicken with gravy and not chicken pot pie, and the puree diets were receiving one number six scoop of puree chicken, one number eight scoop of mashed potatoes, and one number ten scoop of puree broccoli. An interview and record review of the week three dinner spread sheet (01/28/25) was conducted on 01/29/25 at 2:35 P.M. with Registered Dietitian (RD) #826 who verified the spread sheet for the dinner meal on 01/28/25 meal did not clearly specify what the serving size should have been for the pureed chicken pot pie, and she didn't know what the serving size should have been for the pureed chicken pot pie. She confirmed the puree diet should have received a pureed chicken pot pie and broccoli instead of puree chicken, mashed potatoes, and broccoli. 2. Review of the facility menu Atrium Living Center Fall/Winter 2024-2025 Menus for week three revealed for dinner on 01/28/25 chicken pot pie, buttered broccoli, pineapple cup, two percent milk and coffee/tea were to be served. Observations during tray line on 01/28/25 from 4:20 P.M. to 5:24 P.M. revealed residents on a regular diet were being served one number six scoop (5.3 ounces) of chicken pot pie and residents on a mechanical soft diet were being served one number six scoop (5.3 ounces) of chicken pot pie with ground meat. Interview on 01/28/25 at 4:49 P.M. with Dietary Supervisor #702 confirmed one number six scoop was being used for both the chicken pot pie and chicken pot pie with ground meat. Review of week three dinner (01/28/25) spread sheet (expanded menu) revealed the residents on a regular diet were to receive one eight-ounce ladle of chicken pot pie and residents on a mechanical soft diet were to receive one eight-ounce ladle of chicken pot pie with ground meat. An interview and record review of the week three dinner spread sheet (01/28/25) was conducted on 01/29/25 at 2:35 P.M. with RD #826 who verified one eight-ounce ladle was the serving for the chicken pot pie for regular diets and mechanical soft diets and the residents on those diets had received less than what would have been provided with the eight ounce ladle when facility used one number six (5.3 ounces) scoop. Review of facility policy Tray and Dining Room Meal Service, revised August 2023, revealed each employee should review the expanded menu at the beginning of their shift. The dietary manager or cook would go over the expanded menu with tray line personnel before starting to serve.

Based on observations, interviews, and review of facility policy, the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all residents receiving meals from the kitchen excluding Resident #64 who the facility identified as receiving nothing by mouth (NPO). The facility census was 82. Findings include: 1. Observation of the kitchen on 01/27/25 from 8:11 A.M. to 8:45 A.M. with Dietary Supervisor (DS) #702 revealed the following concerns: The large industrial fan located in the corner of the kitchen revealed a build up of dust and debris on the blades and metal guard. On the inside top of the microwave used for resident fooods was an accumulation of food particles and dried food splatters. In the walk in cooler on the right hand side of the floor under the crates of milk was a moderate amount of a white dried substance resembling milk that had spilled onto the floor. There was one five pound container of cottage cheese which was unopened but had a best by date of 01/06/25. There was half of a factory bag of diced chicken on a shelf and it had been opened and resealed with no date. The large industrial food mixer that was sitting on a two-tiered base had dried food splatters and visible build-up of dust and particles of debris on both tiers of the base. At the time of observation, DS #702 confirmed the areas of concern. Review of facility policy Dietary Sanitary Procedures for Infection Control, revised August 2023, revealed all equipment and counters would be sanitized per department guidelines and refrigerated items opened would be labeled with a use by date. 2. Observation of the unit refrigerators on 01/27/25 from 8:45 A.M. to 9:00 A.M. with Dietary Supervisor (DS) #702 revealed the following concerns: In the refrigerator part of the refrigerator/freezer unit in the unit three nourishment room there was one carton of med pass supplement opened with no lid, one bacon and cheese sandwich wrapped in plastic with no name or date, one gallon pitcher of lemonade dated 01/18/25 with a throw out date of 01/24/25, one eight-ounce factory bag of shredded [NAME] jack cheese one fourth full with a best by date of 01/15/25, one small circular clear storage container with a lid with what looked like mayonnaise with no date or label, and one fast food restaurant bag with a breakfast sandwich with no name or date. There was a buildup of debris on the inside top of the microwave sitting on the counter in the unit three nourishment room. In the freezer part of the refrigerator/freezer unit in the unit one nourishment room there was one pint of Almost Heaven ice cream with no date or name and one pink colored fast-food drink with whip cream frozen solid with no name or date with a lid which had a circular opening in the lid leaving it open to air. In the refrigerator part of the refrigerator/freezer unit in the unit one nourishment room there was one gallon pitcher half full of orange juice with a date of 01/18/25 and a throw out date of 01/24/25, one gallon pitcher full of cranberry juice with a date of 01/19/25 and a throw out date of 01/25/25 and one grocery plastic bag with a storage container with a piece of meat and sweet potatoes with no name or date. Interview with DS #702 at the time of observations confirmed areas of concern and stated dietary was responsible for cleaning, stocking, and ensuring nothing was outdated or unlabeled in the unit nourishment rooms. DS #702 confirmed these were storage areas for resident foods on the unit. Review of facility policy Foods Brought into Resident Education Material, revised August 2023, revealed food brought in must be stored in an airtight container; items would be labeled with the resident's name and date; and refrigerated cooked food items must be automatically disposed after three days. Review of facility policy Dry Goods Storage Guidelines, undated, revealed the storage length for refrigerated juice was five days, and storage length must be followed. Review of facility policy Dietary Sanitary Procedures for Infection Control, revised August 2023, revealed all equipment would be sanitized per department guidelines. 3. Observation on 01/27/25 at 12:29 P.M. revealed Certified Nursing Assistant (CNA) #607 took a meal tray, which had cake uncovered on the tray, out of the covered delivery cart and placed one eight ounce of glass of water uncovered on the tray and walked down the hallway on unit three to a common area to deliver Resident #4's meal tray. At the time of observation, CNA #607 confirmed the cake and beverage were uncovered, and she stated she complained about it all the time. Observation on 01/27/25 at 12:34 P.M. revealed CNA #620 took a meal tray, which had cake uncovered on the tray, out of the covered delivery cart and placed one cup of coffee uncovered on the meal tray and walked halfway down the hallway to Resident #22's room. At the time of observation, Resident #22 revealed she always received desserts and beverages in cups uncovered. At the time of observation, CNA #620 confirmed the cake and beverage were uncovered. Observation on 01/27/25 at 12:36 P.M. revealed CNA #620 took a meal tray, which had a piece of cake uncovered on the tray, out of the covered delivery cart and placed a cup of coffee and a glass of apple mango juice uncovered on the meal tray and walked halfway down the hallway to deliver the meal to Resident #8. At the time of observation, CNA #620 confirmed cake and beverages were uncovered. Observation on 01/27/25 at 12:40 P.M. revealed CNA #608 took a meal tray, which had a piece of cake uncovered, out of the covered delivery cart and placed one cup of coffee and a glass of grape juice uncovered onto the meal tray and walked the full hallway and into the unit three common area to deliver Resident #51's meal tray. At the time of observation, CNA #608 confirmed the cake and beverages were uncovered. Interview on 01/29/25 at 2:35 P.M. with Dietitian #826 revealed when delivering room trays, the aides were supposed to walk the meal delivery and beverage carts with them so they could stay close to the rooms, and when they delivered the meal trays, they were not supposed to walk extended distances with items uncovered.

Based on observations, interviews, record reviews, and review of facility policy, the failed to ensure palatable meals were served to Resident #16, #17, #21, #24, #27, #31, #32, #56 and #73. This affected nine residents (#16, #17, #21, #24, #27, #31, #32, #56 and #73) of 21 residents reviewed for food. The facility census was 82. Findings include: 1.Review of facility menu Atrium Living Center Fall/Winter 2024/2025 Menus for week three dinner on 01/28/25 revealed chicken pot pie, buttered broccoli, pineapple cup, two percent milk and coffee/tea was to be served. Observation on 01/28/25 at 4:20 P.M. of Dietary [NAME] (DC) #700 taking the temperature of the tray line items using a facility thermometer revealed all items were at a safe temperature with the chicken pot pie at 206 degrees Fahrenheit (F), the broccoli at 179 degrees F, the pineapple at 42 degrees F and an eight-ounce carton of milk at 38.8 degrees F. Observations throughout the tray line process on 01/28/25 from 4:20 P.M. to 5:24 P.M. revealed the chicken pot pie for the regular diets had a very thin layer of biscuit on top and some servings of the pot pie for the regular diets had very little biscuit in the portion which was served to the residents. The facility utilized a heat retention system for the food which included a heating unit that heated both the plates and metal pellets. On the stainless steel table next to the range oven behind the steam table was a stack of metal pellets sitting at room temperature instead of being in the heating unit. When the tray line was three fourths of the way completed, Dietary Supervisor (DS) #702 was observed loading the metal pellets into the heating unit leaving a minimal amount of time for the metal pellets to heat up prior to being placed in the thermal plate base on the meal tray to keep the food hot. On 01/28/25 at 5:12 P.M. as the last cart for unit three was starting to be loaded a test tray was requested by the state surveyor. The test tray was plated at 5:24 P.M. and placed on the food cart. Also at 5:24 P.M. the state surveyor touched the metal pellets in the heating unit and the pellets were not warm to the touch. At 5:26 P.M. DS #702 wheeled the cart out of the kitchen and the cart arrived on unit three at 5:29 P.M. The first meal tray was passed at 5:30 P.M. and by 5:46 P.M. all the meal trays had been passed. The test tray was then taken off the meal cart at 5:46 P.M. by DS #702 and taken to an overbed table in the hallway. Using a facility thermometer DS #702 took temperatures of the food and beverage items. As DS #702 was taking the temperatures the state surveyor was tasting the items. The coffee was 166 degrees F and tasted warm. The milk was 37 degrees F and tasted cold and not spoiled. The pineapple was 52 degrees F but still tasted cold and was palatable. The chicken pot pie was 124 degrees F and tasted warm and bland. The broccoli was 113 degrees and didn't taste warm and tasted very bland. On 01/28/25 at 5:49 P.M. DS #702 tasted the chicken pot pie and broccoli and stated the pot pie tasted a little bland and the broccoli was not hot and had no flavor. DS #702 confirmed she had added the room temperature metal pellets part way through tray line to the heating unit since there was not enough room in the unit to house all the metal pellets for tray line. 2. Review of the medical record for Resident #32 revealed an admitted d of 06/22/19. Medical diagnoses included chronic pulmonary (lung) disease, major depression, chronic kidney disease and dysphagia. Review of Resident #32's physician orders revealed an order dated 01/21/25 for a regular diet with extra gravy on meats and thin liquids. Review of the Minimum Data Set (MDS) 3.0 annual assessment, dated 01/10/25, revealed Resident #32's cognition was intact. Interview on 01/28/25 at 5:52 P.M. with Resident #32 revealed she didn't think the chicken pot pie tasted good the last time it was served, and she didn't think it tasted good this time 3. Review of medical record for Resident #21 revealed an admitted [DATE]. Medical diagnoses included chronic pulmonary (lung) disease, hyperlipidemia, hypertension, and vascular dementia. Review of Resident #21's physician orders revealed an order dated 12/20/24 for a regular diet thin liquids. Review of the MDS 3.0 quarterly assessment, dated 01/28/25, revealed Resident #21's cognition was moderately impaired. Interview on 01/28/25 at 5:54 P.M. with Resident #21 revealed the chicken pot pie didn't taste like chicken pot pie, and she got very little biscuit with her serving of pot pie 4. Review of medical record for Resident #16 revealed an admitted d of 01/24/20. Medical diagnoses included cerebral infarction (stroke), anxiety disorder, major depression, and prediabetes. Review of Resident #16's physician order revealed an order dated 08/01/23 for a regular diet thin liquids. Review of the MDS 3.0 annual assessment, dated 01/01/25, revealed Resident #16 had mild cognitive impairment. Interview on 01/28/25 at 5:59 P.M. with Resident #16 revealed she got very little biscuit with her serving of chicken pot pie, and the pot pie had no flavor 5. Review of medical record for Resident #73 revealed an admitted [DATE]. Medical diagnoses included atherosclerosis, type two diabetes, hallucinations, and chronic kidney disease. Review of a physician order dated 10/01/24 revealed Resident #73 had an order for a regular diet with sugar substitute and thin liquids. Review of MDS 3.0 quarterly assessment, dated 12/13/24, revealed Resident #73's cognition was intact. Resident #73 needed supervision while eating and had a significant weight loss that was not physician prescribed. Interview on 01/28/25 at 6:01 P.M. with Resident #73 revealed if that was chicken pot pie, they left out the biscuit and Resident #73 stated the pot pie didn't have much flavor. 6. Review of medical record for Resident #27 revealed an admitted [DATE]. Medical diagnoses included pneumonia, congestive heart failure (CHF), cerebrovascular disease, and hypertension. Review of a physician order dated 01/05/25 revealed Resident #27 had an order for a regular diet with thin liquids. Review of the MDS 3.0 admission assessment, dated 01/10/25, revealed Resident #27's cognition was intact. Interview on 01/28/25 at 6:02 P.M. with Resident #27 revealed the chicken pot pie was bland. 7. Observation on 01/28/25 from 10:55 A.M. to 11:10 A.M. revealed DS #702 placed ten portions of green beans into a robo coupe (commercial food processor) to blend until a portion between pudding and mashed potatoes was achieved for a puree consistency. The final product, which was ready to be placed into a square serving pan for tray line for lunch on 01/28/25, had the appropriate puree consistency but was very salty when tasted. DS #702 at the time of observation tasted the final product and stated it was salty because they added salt. Registered Dietitian #826 who was also in the kitchen at the time of observation, also tasted the puree green beans and confirmed the pureed green beans were very salty. Review of the green beans pureed recipe, with a report date of 09/05/24, revealed the recipe called for green beans, margarine, and food thickener. The staff were to remove portions from the regular prepared vegetable (drain liquid), add drained vegetables with melted margarine to the food processor and process until smooth in texture; add a food thickener briefly until mixed while scraping sides of bowl; pour into the steamtable pan. There was nothing documented in the recipe indicating salt should have been added. 8. Interviews conducted with four residents (#17, #24, #31, and #56) during a resident council meeting held with the state surveyors on 01/29/25 at 11:05 A.M. revealed the residents voiced concerns about hot foods not being hot and describing the hot food as served cold and stated food was served bland and at times was too salty.

Based on observations, interviews, medical record review, and review of facility policy, the facility failed to ensure meal intakes were recorded for Residents #13, #18, #65, and #66, failed to ensure weights were obtained and recorded into the medical record for residents #13 and #41 and failed to ensure therapeutic diets were implemented as ordered for Residents #65 and #66 to allow for accurate nutritional assessment and monitoring of nutritional status. This affected five residents (#13, #18, #41, #65, and #66) out of five reviewed for nutrition. The facility census was 82. Findings include: 1. Review of Resident #66's medical record revealed an admitted [DATE]. Diagnoses included non-displaced fracture of greater trochanter of right femur, Alzheimer's disease, dementia, major depressive disorder, type two diabetes, and dysphagia. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 01/15/25, revealed Resident #66 was severely impaired cognitively, dependent on staff for eating, had no significant weight loss over one and six months, and was on a therapeutic diet. Review of Resident #66's care plan, initiated on 01/15/24, revealed the resident was at risk for malnutrition. Interventions included assistance with meals as needed, diet per doctor's order, medication as ordered and monitor labs as needed. Review of Resident #66's labs revealed on 08/02/24 potassium (normal range 3.5 to 5.1 millimoles per liter) was low at 3.1 millimoles per liter (mmol/L), on 08/06/24 potassium level was low at 3.3 mmol/L, on 08/09/24 potassium level was low at 3.3 mmol/L, and on 9/03/24 potassium level was 3.7 mmol/L which was within the normal range but was at the lower end of the normal reference range which was 3.5 to 5.1 mmol/L. Review of physician orders for Resident #66 revealed an order dated 10/03/24 to push high potassium foods, regular diet with extra gravy on tray, sugar substitute, thin liquids with two glasses of punch/juice with meals. Review of the annual nutritional assessment dated [DATE] and authored by Registered Dietitian (RD) #826 revealed Resident #66 was on a regular diet, extra gravies, high potassium, sugar substitute diet and was consuming 75-100% of meals and ate in her room. Resident #66's weight had triggered a significant weight increase over three months, but weight had been fairly stable over the past month. Resident #66 had recently tested positive for Covid-19 on 01/06/25 and the dietitian indicated she would monitor intakes and make adjustments as needed. Review of meal intake records in Resident #66's medical record from 01/01/25 to 01/29/25 revealed there were no meal intakes recorded. Review of Resident #66's lunch meal tray ticket for 01/28/25 revealed Resident #66 was on a regular diet with sugar substitute. Listed under the section titled beverage/equipment on the tray ticket was two glasses of juice, ginger ale and juice water Observation on 01/28/25 at 12:57 P.M. revealed on Resident #66's lunch meal tray was ginger ale, iced tea, milk, sloppy joes, green beans, and rice crispy treat. At the time of observation, Certified Nursing Assistant (CNA) #513 confirmed there was no juice or juice water on the tray served to the resident. Observation on 01/28/25 at 5:40 P.M. of Resident #66's dinner tray revealed one can of ginger ale, one glass of water, one cup of coffee, one bowl of crushed pineapple, and one plate with chicken pot pie and broccoli. At the time of observation, CNA #616 confirmed what was on the meal tray. Interview on 01/29/25 at 10:01 A.M. with CNA #513 revealed meal intakes were supposed to be put into the resident's electronic medical record (EMR) but confirmed meal intakes hadn't been put into the EMR due to lack of time. She stated she had most of the intakes in her brain and would tell the nurse if a resident hadn't eaten a meal. Interview on 01/29/25 at 10:05 A.M. with CNA #511 confirmed meal intakes were not being documented into the EMR and the reason she hadn't documented meal intakes was she lost track of time. Interview on 01/29/25 at 2:31 P.M. with RD #826 revealed for residents on high potassium diet the facility would push high potassium foods by offering banana at breakfast and orange juice at all meals. RD #826 confirmed Resident #66 was to receive high potassium foods and beverages. After RD #826 reviewed Resident #66's meal tray ticket, she confirmed the meal tray ticket did not state to give orange juice at all meals. RD #826 also confirmed there were no meal intake records in the medical record for Resident #66 for the month of January 2025 so for purposes of nutritional assessments and monitoring of the therapeutic diet she would get her information from nursing on how much the resident was eating. RD #826 verified she was not aware Resident #66 was not getting orange juice at all meals. Review of facility policy Nutrition Assessment, revised August 2023, revealed nurse aides were to complete food intake and record daily. 2. Review of Resident #65's medical record revealed a readmitted [DATE]. Diagnoses included displaced interochanteric fracture of left femur, fracture of right forearm, essential hypertension, anxiety disorder, and localized edema. Review of the 01/06/25 admission MDS 3.0 assessment, dated 01/06/25, revealed Resident #65 was cognitively intact, required setup or clean up assistance for eating, had no significant weight changes and was on a therapeutic diet. Review of the care plan, initiated on 01/06/25, revealed Resident #65 was at nutritional/hydration risk. Interventions included 2000 cubic centimeter (cc) fluid restriction (1080 dietary/920 nursing), diet per doctor's orders, monitor for signs and symptoms of fluid imbalance, monitor labs as needed, and monitor meal intake/record. Further review of Resident #65's medical record revealed an admission nursing note dated 12/31/24 indicating the resident was to be on a 2,000 cc fluid restriction due to low sodium levels. Review of physician orders revealed an order dated 01/01/25 for a regular, thin liquids diet and an order dated 01/06/25 for 2000 cc/24 hr (hour) fluid restriction (1080 cc dietary and 920 cc nursing) Review of Resident #65's recorded meal intakes from 01/01/25 to 01/30/25 revealed there were no recorded meal intakes. Review of 01/06/24 initial nutritional assessment authored by RD #826 revealed Resident #65 was on a regular diet, and was consuming 75 to 100 percent of meals. The resident was receiving a 2000 cc fluid restriction due to low sodium levels. Review of labs in Resident #65's medical record revealed the last sodium lab level was drawn on 10/21/24 and it was 137 millimoles per liter (mmol/L), which was at the lower end of the normal reference range of 137 to 147 mmol/L. Observation on 01/27/25 at 12:46 P.M. revealed on Resident #65's lunch meal tray there was one full bowl of chicken noodle soup which consisted of broth, chicken, and noodles, one eight ounce (240cc) full glass of lemonade, one eight ounce (240 cc) carton of two percent milk and one eight ounce (240 cc) cup of hot chocolate. At the time of observation Certified Nursing Assistant (CNA) #620 confirmed the soup and beverages on the meal tray. Observation on 01/28/25 at 1:02 P.M. revealed on Resident #65's lunch tray was one eight ounce (240 cc) cup of hot chocolate, one full eight ounce (240 cc) glass of lemonade, and one eight ounce (240 cc) carton of two percent milk. Sitting on top of her overbed table was a full pitcher of water. At the time of observation, CNA # 511 confirmed the beverages on the meal tray and the full water pitcher. Observation on 01/28/25 at 5:44 P.M. revealed on Resident #65's dinner tray was one eight ounce cup (240 cc) of hot chocolate, and one full eight ounce (240 cc) cup of lemonade. There was a full water pitcher on the overbed table. At the time of observation CNA #620 confirmed the beverages on the meal tray and the water pitcher. Interview on 01/29/25 at 10:01 A.M. with CNA #513 revealed meal intakes were supposed to be put into the resident's electronic medical record (EMR) but confirmed meal intakes hadn't been put into the EMR due to lack of time. She stated she had most of the intakes in her brain and would tell the nurse if a resident hadn't eaten a meal. Interview on 01/29/25 at 10:05 A.M. with CNA #511 confirmed meal intakes were not being documented into the EMR and the reason she hadn't documented meal intakes was she lost track of time. CNA # 511 indicated she normally worked the unit where Resident #65 resided and was unaware of Resident #65 being on a fluid restriction and stated every resident had a water pitcher. Interview on 01/29/25 at 2:25 P.M. with RD # 826 confirmed Resident #65 was on a fluid restriction due to history of having low sodium lab levels. She stated Resident #65 was to receive one eight ounce (240cc) hot beverage and a half of an eight ounce (120cc) glass of juice for each meal for a total of 1080cc/day. She stated the aides should be reading the tray ticket and should be providing what is on the tray ticket. She also indicated that a resident on a fluid restriction was not supposed to have a water pitcher at bedside. She also stated if a resident received soup it would need to be strained. She went on to confirm there were no meal intakes recorded in the medical record for Resident #65 and stated she would get her information from nursing on how much the resident was eating for a meal. Review of facility policy Fluid Restrictions/Hydration, revised August 2023, revealed physician orders for fluid restrictions would be followed, and dietary and nursing would determine the amount of fluids to be given with meals and between meals. Review of facility policy Nutrition Assessment, revised August 2023, revealed nurse aides were to complete food intake and record daily. 3. Review of Resident #13's medical record revealed an admitted [DATE]. Diagnoses included fracture of right humerus, depression, anxiety, fracture of part of scapula, other fracture of second lumbar vertebra, essential hypertension, acute on chronic diastolic (congestive) heart failure, and hyperlipidemia. Review of Resident #13's quarterly MDS 3.0 assessment, dated 01/25/25, revealed the resident was cognitively intact, required partial/moderate assistance from staff for eating, had no significant weight changes, and received a therapeutic diet. Review of Resident #13's care plan, initiated on 10/25/24 revealed the resident was at nutritional risk related to being status post fracture of femoral head. Interventions included monitor meal intake and record, monitor tolerance of diet texture, make adjustments as needed, offer substitutes if consumes less than 50 percent of meals, and weight every month and or as needed and notify physician of significant change. Review of physician orders revealed an order dated 10/19/24 for weekly weights for four weeks following admission once a day on Monday, an order dated 12/09/24 for weekly weights for four weeks once a day on Monday, and an order dated 12/11/24 for Regular No Added Salt thin liquids diet. Review of the 10/25/24 initial assessment authored by RD #826 revealed at the time of the assessment the resident was on a regular diet, was eating her meals in her room, and was consuming 50 to 100 percent of meals with setup from staff. The facility diet was providing 2000 to 2200 calories, 85 to 100 grams protein, and greater than 1400 cubic centimeters of fluid (cc) a day, and Resident #13's estimated needs were 1301 to 1550 calories, 57 to 68 grams protein, and 1425 to 1710 cc fluid. Further review of Resident #13's medical record revealed a progress note dated 12/09/24 and authored by RD #826 indicatng the resident's monthly weight taken on 12/04/24 of 129.6 pounds had shown a significant weight loss for one month and the previous weight may have been in error with the resident reporting her usual weight was 125 pounds. In the progress note it was documented intakes had been good for Resident #13 with 50 to 100 percent of most meals being consumed; however, it was noted later in the progress note that therapy had reported resident was not eating much recently and the resident stated her appetite was fair. The dietitian was going to request a reweight and weekly weights for verification and stabilization to determine the need for further interventions and was going to try adding a mighty shake (nutritional supplement) to increase intakes and stabilize weights. Review of meal intakes for November 2024 revealed the only meal intake which was recorded was on 11/19/24 when Resident #13 consumed 51 to 75 percent of the dinner. In December 2024 the only meal intakes recorded was on 12/09/24 when Resident consumed 51 to 75 percent of breakfast and on 12/14/24 when Resident #13 consumed 76 to 100 percent of breakfast. In January 2025 there were no recorded meal intakes. Review of weights recorded in Resident #13's medical record revealed a weight of 137.8 pounds (lbs) on 11/14/24, a weight of 129.6 lbs on 12/04/24, a weight of 128.4 lbs on 12/31/24, and a weight of 128.6 lbs on 01/06/25 were the only weights recorded in the medical record. There were no weights recorded on 10/21/24, 10/28/24, 11/04/24, and 11/11/24 for the weekly weights for the order dated 10/19/24 for four weekly weights. Resident #13 had a 5.9 percent weight loss from 137.8 pounds on 11/14/24 to 129.6 pounds on 12/04/24. There were only two weekly weights on 12/16/24 and 12/23/24 out of four ordered for the order dated 12/09/24 for weekly weights for four weeks . Interview on 01/29/25 at 10:01 A.M. with CNA #513 revealed meal intakes were supposed to be put into the residents electronic medical record (EMR) but confirmed meal intakes hadn't been put into the EMR due to lack of time. She stated she had most of the intakes in her brain and would tell the nurse if a resident hadn't eaten a meal. Interview on 01/29/25 at 10:05 A.M. with CNA #511 confirmed meal intakes were not being documented into the EMR and the reason she hadn't documented meal intakes was she lost track of time. Interview on 01/29/25 at 2:51 P.M. with RD #826 revealed weekly weights were put into the medication administration record (MAR) and would auto populate so the nurses would know when a weight was needed. The nurses would then let the aides know who needed weighed and the nurses were to put the weight into the MAR. She confirmed there was no reweight obtained and the Resident #13 was missing weekly weights. Dietitian #826 went on to state no one told her she refused to be weighed. She confirmed the missing meal intakes and stated she got her information on how much a resident ate from nursing. 51073 4. Review of the medical record revealed Resident #18 was admitted on [DATE] with diagnoses including cognitive communication deficit, schizoaffective disorder, obsessive-compulsive disorder, generalized anxiety disorder, major depressive disorder, and constipation. Review of the MDS 3.0 assessment dated [DATE] revealed the resident was alert with minimal recall of current events, a weight of 177 pounds, no known swallowing disorder, and no known weight loss in the last month. Review of physician orders dated 12/11/24 revealed Resident #18 was ordered a regular diet with thin liquids, Prostat AWC (protein supplement) 30 cc twice a day, and a Mighty Shake (nutritional supplement) daily at lunch. Review of Resident #18's care plan initiated on 12/16/24 identified Resident #18 as a nutrition/hydration risk. Interventions included monitoring meals intake/records and weigh every month and as needed. Review of a dietary admission note dated 12/16/24 identified Resident #18 as at risk for malnutrition. Review of meal consumption records for December 2025 revealed Resident #18 was eating between 51 to 75 percent of her meals, however, the meal intakes were only recorded on eight of 20 meals reviewed. No meal consumption records were completed from 01/01/25 to 01/27/25. An interview on 01/27/25 at 1:10 P.M. with Resident #18's husband revealed Resident #18 required someone to feed her since she was unable to use regular cups or silverware, and she required special equipment if trying to eat by herself. The husband stated he visited her each day to assist her with eating. He stated he did not know if Resident #18 had lost weight. Observation of Resident #18 during the interview revealed she was alert with confusion and unable to answer simple or open-ended questions, so she was not a reliable source of information. An interview with Registered Dietician (RD) #826 on 01/28/25 at 11:08 A.M. revealed Resident #18 required adaptive equipment for eating that included built up silverware, scoop late and handled cup. RD #826 stated the resident was at risk of impaired nutritional status due to depression, weakness and constipation, and was consuming between 50 to 75 percent of her meals and supplements. An interview on 01/29/25 at 10:56 A.M. with Licensed Practical Nurse (LPN) #804 verified meal intake records for Resident #18 were partially documented during the month of December 2024 and not documented at all from 01/01/25 to 01/29/25. A follow up interview on 01/29/25 at 2:59 P.M. with RD #826 revealed there were meal intakes not being recorded for residents by nursing staff, so she got her information on how much a resident ate from nursing. 51067 5. Review of the medical record review for Resident #41 revealed an admitted [DATE]. Diagnoses included acute respiratory failure with hypoxia, severe sepsis without septic shock, hypertension, solitary pulmonary nodule, cerebrovascular disease, type two diabetes mellitus without complications, hyperlipidemia, shortness of breath, constipation, obesity, and chronic atrial fibrillation. Review of the MDS 3.0 assessment, dated 12/12/24, revealed Resident #41 was cognitively impaired. Review of Resident #41's physician orders revealed an order dated 01/09/2025 for weekly weights once a day on Mondays to start on 01/13/25 for one month. Review of Resident #41's weights for January 2025 revealed no weekly weight was recorded for 01/13/25 and 01/27/25 per the physician order to be weighed weekly on Mondays. Observation on 01/29/25 at 11:05 A.M. with RD #826 revealed RD #826 presented a list of weekly weights for January 2025 for residents requiring weekly weights and Resident #41 was not on the weekly weight list. RD #826 stated the list was how the nursing staff identified which residents required weekly weights, in addition to the physician order. Interview on 01/29/25 at 11:05 A.M. with RD #826 verified Resident #41 had an order to be weighed weekly on Mondays to start on 01/13/25 and no weekly weights were obtained on 01/13/25 and 01/27/25. Review of the facility policy titled Weight and Height Records Policy, revised August 2023, revealed residents would have their weight obtained by certified and licensed staff at monthly intervals unless more frequent monitoring was needed as determined by resident weight record, medical condition, or clinical staff. Weight orders would be placed in the electronic medical record (EMR) if more frequent monitoring was needed than stated in facility policy. Weights would be recorded in EMR when obtained and residents have the right to decline weights and would document refusals of weights not obtained in the EMR as refused, combative, deferred due to condition, or unavailable. Review of facility policy Nutrition Assessment, revised August 2023, revealed nurse aides were to complete food intake and record daily.

Based on record review and interview, the facility failed to ensure timely notification of Resident #74's fall to the resident representative. This affected one resident (#74) of one resident reviewed for notification of change. The facility census was 82. Findings include: Review of the medical record for Resident #74 revealed an admitted [DATE]. Diagnoses included metabolic encephalopathy, cognitive communication deficit, and vascular dementia, moderate, with agitation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #74 had severely impaired cognition. Review of the interdisciplinary team (IDT) progress note dated 01/22/25 at 3:45 P.M. revealed a fall on 01/13/25 was discussed. Resident #74 noted to be confused with agitation and was wandering into other residents' rooms. He was last seen sitting on his bed at 4:00 A.M. As an aide was answering another resident's call light, she heard a male voice coming from a resident room, and upon opening the door Resident #74 was laying on his right side behind the door. He was assisted up and placed in wheelchair and brought to the common area. The physician was notified regarding increased behaviors and medication adjustment made. Medication adjustment effective at this time. Review of the progress note dated 01/23/25 at 10:56 A.M. revealed a nurse attempted to contact emergency contact list on Resident #74's face sheet to inform Resident #74's resident representative of resident's fall on 01/13/25, but there was no answer, so a message was left to contact facility. Review of the progress note dated 01/23/25 at 11:11 A.M. revealed Resident #74's resident representative returned the call at 11:09 A.M., the fall was reviewed with her and advised of the medication adjustment made after the fall due to his wandering and agitation. She indicated that she was in contact with Resident #74's son who resided in another state and would update him as well. Review of the fall investigation dated 01/13/25 revealed the resident representative was notified on 01/23/25 at 11:09 A.M. noted under time of notification. Interview on 01/29/25 at 3:44 P.M. with Assistant Director of Nursing (ADON) #720 stated the internet was down on 01/13/25 so that was why the fall wasn't documented on that day. ADON #720 verified Resident #74's resident representative was notified on 01/23/25 and stated she was not sure why it took 10 days. ADON #74 stated the expectation for notifications were to be immediately if able. Reviewed policy Notification of Change, dated 07/2017 revealed the resident's physician and responsible party must be notified when an event involving the resident occurs or when the resident experiences a change in condition, potential discharge, room transfer, or death. Under notification, item number eight revealed the resident legal representative or interested family member is notified of a significant change in the resident condition unless the resident has specified otherwise. The legal representative or family member may indicate to the facility specific notification parameters. Should this occur, document and place behind the face sheet in the chart and care plan their preferences.

Based on observation, record review, and interview the facility failed to give medications with an error rate of under five percent. This affected one resident (Resident #435) of two residents reviewed for medication administration. The total census was 82. Findings include: Record review of Resident #435 revealed he was admitted [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD), acute peptic ulcer with hemorrhage, and hypoxemia. He had active orders dated 01/17/25 for one pill of coenzyme Q10 30 milligrams (mg), one pill of vitamin E 268 mg, and one puff of Trelegy Ellipta (a combination inhalation medication for COPD) 200-62.5-25 micrograms. All of these medications were ordered to be given once daily between 7:00 A.M. and 11:00 A.M. Observation of medication administration for Resident #435 by Licensed Practical Nurse (LPN) #802 on 01/28/25 at 8:25 A.M. revealed she did not have the correct doses of coenzyme Q10 and vitamin E in the medication cart and held the medications. The Trelegy Ellipta container included specific instructions to swish and spit after administration. When the nurse administered the Trelegy Ellipta, she then exited the room without instructing the resident to swish and spit and the resident was not observed to do so before the nurse left the room. Interview with LPN #802 on 01/28/25 at 8:57 A.M. confirmed the above findings. Follow-up interview with LPN #802 on 01/28/25 at 11:18 A.M. revealed the coenzyme Q10 and correct vitamin E medications had to be ordered from pharmacy and were expected to arrive the next day, so she marked both medications as held due to not being available. The above findings identified three errors out of 28 observed opportunities for medication error, creating a total error rate of 10.7%.

Based on record review, interview and review of facility policy, the facility failed to ensure the interdisciplinary team was present as required when care plan conferences were conducted for Resident #24 and Resident #75. This affected two residents (Resident #24 and #75) of two residents reviewed for care planing. The facility census was 82. Findings include: 1. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including cellulitis of right lower limb, acute respiratory failure with hypoxia, sepsis, hypertensive chronic kidney disease, cognitive communication deficit, methicillin resistant staphylococcus aureus infection, type two diabetes mellitus with diabetic neuropathy, and hypertension. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he was cognitively intact. Review of the facility documents titled Care Conference, dated 10/30/24 and 01/13/25 revealed only Resident #24, Social Services (SS) #823, MDS Registered Nurse (RN) #811 and a therapist were present for the care conference on 10/30/24 and only Resident #24, SS #823 and MDS RN #811 were present for the care conference on 01/13/25 There was no additional information on the form to indicate any other members of the facility interdisciplinary care team took part in the care conferences. Interview with Resident #24 on 01/27/25 at 8:59 AM revealed he believed he had not had a care conference with members of the facility care team. Interview with SS #823 on 01/29/25 at 3:43 PM verified all members of the health care team at the facility do not attend care conferences for Resident #24 as required. SS #823 stated she sent a schedule out each Friday to the care team and before the scheduled care conferences to inform staff of the upcoming meetings the following week however not all required staff members attend. SS #823 stated her care conference with the residents last approximately 10 minutes and are very informal so the residents possibly misunderstand their care conferences as a general discussion. 2. Review of the medical record for Resident #75 revealed an admitted [DATE] with diagnoses including acquired absence of right leg below knee, hereditary and idiopathic neuropathy, major depressive disorder and hypertension. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #75 had intact cognition. Review of the facility documents titled Care Conference, dated 11/21/24 revealed only Resident #75, Social Services (SS) #823, MDS Registered Nurse (RN) #811, a therapist and another nurse were present for the care conference on 11/21/24. There was no additional information on the form to indicate any other members of the facility interdisciplinary care team took part in the care conferences. Interview with SS #823 on 01/29/25 at 3:43 PM verified all members of the health care team at the facility do not attend care conferences for Resident #75 as required. SS #823 stated she sent a schedule out each Friday to the care team and before the scheduled care conferences to inform staff of the upcoming meetings the following week however not all required staff members attend. SS #823 stated her care conference with the residents last approximately 10 minutes and are very informal so the residents possibly misunderstand their care conferences as a general discussion. Review of Resident Assessment Comprehensive Care Plans policy (updated 05/24/2022, reviewed 01/01/25) revealed, an interdisciplinary team, in conjunction with the resident, resident's family, surrogate, or representative, as appropriate, should develop quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on the comprehensive assessment.

Based on interview, observation, record review, and facility policy review the facility failed to ensure insulin was dated when opened. This affected two residents (#9 and #28) out of three residents observed during the medication storage review. This had the potential to affect eight residents (#6, #9, #10, #28, #38, #62, #174, and #219) that received insulin. The facility census was 74. Findings included: 1. Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses including diabetes with unspecified diabetic retinopathy without macular edema, and long-term insulin use. Review of the January 2023 Physician Orders revealed Resident #28 had an order for Novolin Regular U-100 solution (insulin) inject 10 units twice a day. Observation on 01/11/23 at 12:11 P.M. with Licensed Practical Nurse (LPN) #474 of 200-Back Hall medication cart revealed Resident #28's Novolin Regular U-100 insulin vial was opened and undated in the cart. Interview on 01/11/23 at 12:13 P.M. with LPN #474 verified Resident #28's insulin was not dated when it was opened. She revealed the insulin was dispensed from the pharmacy on 08/20/22 and she stated, I have no idea when it was opened. 2. Review of the medical record for Resident #9 revealed an admitted d of 11/14/19 with diagnoses including diabetes, dementia, and acute respiratory failure. Review of the January 2023 Physician Orders revealed Resident #9 had an order for Humalog U-100 insulin per sliding scale before meals and at bedtime. Observation on 01/11/23 at 12:18 P.M. with LPN #460 of the 300-Long Hall medication cart revealed Resident #9's insulin was opened and undated. Interview on 01/11/23 at 12:18 P.M. with LPN #460 verified Resident #9's insulin was opened and undated in the medication cart. Interview on 01/12/23 at 11:26 A.M. with the Director of Nursing verified all insulins were to be dated upon opening. Review of the facility policy labeled Maintenance of Medication Storage Areas, dated May 2019, revealed insulins, eye drops, saline solution multi-dose were to be dated when opened.

Based on interview, record review, and facility policy review the facility did not ensure pharmacy recommendations were addressed. This affected two residents (#11 and #61) out of six residents reviewed for unnecessary medications. The facility census was 74. Findings included: 1. Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses including dementia, psychotic disturbance, heart failure, hypertension, and acute kidney failure. Review of the pharmacy Consultation Report dated 04/07/22 revealed Pharmacist #901 recommended to consider changing the immediate release formulation of Metoprolol (medication to treat high blood pressure, chest pain, and heart failure) to the extended-release formulation. The pharmacy recommendation was not addressed. Review of the pharmacy Consultation Report dated 08/13/22 revealed Pharmacist #901 recommended discontinuing acetaminophen- hydrocodone (opioid pain medication) as she had not used the medication since 11/14/21. The pharmacy recommendation was not addressed. Review of the pharmacy Consultation Report dated 12/06/22 revealed Pharmacist #901 reviewed the medical record due to Resident #11 had a fall on 11/30/22 and identified medications that contributed to falls that included: Lorazepam (antianxiety), Remeron (antidepressant), Zoloft (antidepressant), tolterodine extended release (antispasmodic), metoprolol and acetaminophen-hydrocodone. Pharmacist #901 recommended the physician evaluate the medications as they possibly contributed to the fall and look at decreasing the lorazepam to 0.5 milligram (mg) in the morning and 1 mg at night. She also recommended to discontinue the acetaminophen-hydrocodone due to non-use. The pharmacy recommendation was not addressed. Review of the January 2022 physician orders for Resident #11 revealed she continued to have an order for acetaminophen-hydrocodone 5-325 mg given by mouth every six hours as needed for pain and lorazepam 1 mg twice a day. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had impaired cognition. Interview on 01/11/23 at 10:10 A.M. with the Director of Nursing revealed the Former Director of Nursing #511 had not followed up on the pharmacy recommendations as she verified the recommendations dated 04/07/22, 08/13/22, and 12/06/22 were not addressed for Resident #11. 2. Review of the medical record for Resident #61 revealed an admitted [DATE] with diagnoses including cerebral infarction, dementia, dysphagia, and diabetes. Review of the care plan dated 07/13/22 revealed Resident #61 was at risk for complications related to diabetes. Interventions included administer medications as ordered, monitor blood glucose levels as ordered, and monitor for signs of hypoglycemia and hyperglycemia. Review of the pharmacy Consultation Report dated 11/04/22 revealed Pharmacist #901 recommended to discontinue Glimepiride (diabetic medication) 1 mg daily and after reevaluation of blood glucose levels initiate alternative therapy with glipizide (diabetic medication) as long- acting sulfonylureas are not recommended in older adults due to prolonged hypoglycemia. The pharmacy recommendation was not addressed. Review of the pharmacy Consultation Report dated 01/06/23 revealed Pharmacist #901 noted on the report Repeated Recommendation from 11/04/22 and to respond promptly to assure facility compliance with federal regulation as Resident #61 continued to receive Glimepiride 1 mg daily. The pharmacy recommendation was not addressed. Review of the Medication Administration Record (MAR) for January 2022 revealed Resident #61 continued to have an order for Glimepiride 1 mg once a day from 01/01/23 to 01/11/23. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #61 was cognitively impaired. Interview on 01/09/23 at 11:29 A.M. with Resident #61's responsible party revealed he was concerned that Resident #61 took too many medications that were not necessary and at times he felt Resident #61 appeared overmedicated. Interview on 01/11/23 at 10:10 A.M. with the Director of Nursing revealed the Former Director of Nursing #511 had not followed up on the pharmacy recommendations as she verified the recommendations dated 11/04/22 was not addressed for Resident #61 and that she continued to receive Glimepiride. Review of the facility policy labeled; Medication Regimen Review, dated 12/01/07, revealed the facility should ensure that the facility physicians/ prescribers were provided with copies of the medication regimen reviews. The policy revealed the facility should then encourage the physician receiving the medication regimen review to act upon the recommendations or reject with an explanation as to why the recommendation was rejected. The facility should maintain copies of medical regimen reviews.

Based on record review, interview, and facility policy review the facility failed to ensure accurate and timely weights were obtained for Residents #52 and #171, who were both on feeding tubes. This affected two residents (#52 and #171) of three residents reviewed for weights. The facility census was 74. Findings include: 1. Review of the medical record revealed Resident #171 was admitted to the facility on [DATE] with diagnoses including diseases of intestine, atrial fibrillation, dysphasia, bacterial pneumonia, non-Hodgkin's lymphoma, iron deficiency anemia secondary to blood loss (chronic), and unspecified protein-calorie malnutrition. Review of the Medicare 5-Day Minimum Data Summary (MDS) 3.0 assessment of 12/28/22 revealed Resident #171 was cognitively intact, required extensive assist of two for most activities of daily living (ADL), was totally dependent for eating and received 51 percent (%) or more of his total calories through a feeding tube. Review of Resident #171's care plan of 12 23/22 identified a care area for treatment of a urinary tract infections and the need for ADL assistance. Review of the census revealed Resident #171 was discharged to the hospital on 12/28/22 and readmitted on [DATE]. The care plan was revised on 01/11/23 to include a care area for increased nutrient needs (related to weight loss in the last year and compared to hospital weight, a 6.6 % loss in nine days though unclear of weighing technique used during hospitalization with a history of brain cancer status post (s/p) chemotherapy, aspiration pneumonia, s/p nasogastric (NG) tube, underweight and triggering for malnutrition based on a mini nutritional assessment as evidenced by a body mass index (BMI) of 18.23. Review of the weights for Resident #171 revealed the only entries were on 01/06/23 with a weight of 152 pounds (lbs.) and a weight of 142 lbs. on 01/11/23. There were no weights recorded from 12/23/22 through 12/28/22 when the resident was at the facility. Interview on 01/12/23 at 11:20 A.M. with the Director of Nursing (DON) verified Resident #171 was not weighed after his admission on 12/23/22 and that residents were usually weighed within 24 hours of admission and monitored, usually with weekly weights upon admission for four weeks and monthly weights after that. Review of the April 2021 policy for Residents at Nutritional Risk revealed nutritionally at-risk residents included tube feed residents and those with below acceptable body weight range. Timely assessment and implementation of a plan, including monitoring, were essential for proper care of a resident at risk. 2. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including cerebral infarction weakness, unspecified dementia, dysphasia, encephalopathy, and alcohol abuse. Diet orders included a mechanical soft diet with honey thick liquids, enteral nutrition via feeding tube three times a day, and supplemental Magic Cups twice a day. Review of the quarterly MDS 3.0 assessment of 10/03/22 revealed Resident #52 was moderately cognitively impaired, required total dependence of one for eating and received at least 51% of his nutrition from tube feeding. Review of Resident #52's care plan of 10/12/22 revealed care areas included risks of complications due to use of feeding tube, and nutrition/hydration risks. Review of the weights for Resident #52 revealed an invalid weight on 12/19/22 of 145.6 lbs., invalidated by the DON on 01/09/23 and a weight by Registered Dietitian/Licensed Dietitian (RDLD) #513 on 12/19/22 of 116 lbs. A second invalidated weight on 01/09/23 of 153.4 lbs. was reviewed with Assistant Director of Nursing (ADON) #473 on 01/09/23 and a reweigh on 01/09/23 indicated Resident #52 weighed 119 lbs. Interview on 01/11/23 at 10:41 A.M. with RDLD #513 revealed she reviewed all residents identified on the weight variance report as having a significant change. Sometimes she would request a reweigh if a weight seemed inaccurate. Accurate weights were important for those individuals at higher nutritional risk. She was reviewing Resident #52 monthly due to his low BMI/weight, refusal of eating, and tube feedings. Interview on 01/12/23 at 11:58 A. M with ADON #473 revealed the aides weighed the residents and the nurses entered them into the medical record. She verified inaccurate weights were entered for Resident #52 on 12/19/22 and 01/09/23 and the nurse should have questioned the accuracy in comparison with the other weights. She stated the weight on 01/09/23 of 153.4 lbs. included the weight of the resident's wheelchair. Review of the April 2021 policy for Residents at Nutritional Risk revealed nutritionally at-risk residents included tube feed residents and those with below acceptable body weight range. Timely assessment and implementation of a plan, including monitoring, were essential for proper care of a resident at risk.

Based on interview, record review, and facility policy review the facility failed to ensure the physician and/or resident responsible party was notified of change in condition. This affected three residents (#15, #52, and #61) out of seven residents reviewed for change in condition. The facility census was 74. Findings include: 1. Review of the medical record for Resident #15 revealed an admitted [DATE] with diagnoses including congestive heart failure, diabetes, dementia, altered mental status, and hypertension. Resident #15's medical record revealed she had a power of attorney (POA) for medical decisions. Review of the care plan dated 05/10/20 revealed Resident #15 was at nutritional risk due to congestive heart failure and confusion. The care plan revealed on 12/16/22 she triggered for weight loss of 7.8 percent in 30-days due to inadequate oral intake. Interventions included diet as ordered, monitor intake, weight every month, and notify physician of a significant change. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 had impaired cognition. She was independent with eating. Her weight was 154 pounds, and she had no weight loss. Review of the weight record revealed Resident #15 had a significant weight loss as on 11/04/22 her weight was 161.8 pounds and on 12/01/22 her weight was 149.2 pounds (7.8 percent weight loss). Review of the nursing notes dated 11/04/22 to 01/11/23 for Resident #15 revealed no documentation her physician and/ or her POA were notified of her significant weight loss. Review of the Nutrition Follow Up for Significant Weight Change assessment dated [DATE] and completed by Dietitian #415 revealed on 11/04/22 Resident #15's weight was 161.8 pounds and on 12/01/22 her weight was 149.2 pounds. The assessment revealed Resident #15 had a 7.8 percent weight loss in 30 days. The assessment revealed Dietitian #415 recommended Boost Breeze (supplement) every day at breakfast. The assessment revealed no documented evidence Resident #15's Primary Care Physician #900 and/ or Resident #15's POA were notified regarding her significant weight loss. Interview on 01/09/23 at 10:23 A.M. with Resident #15's POA revealed she did not feel the facility notified her regarding Resident #15's change in condition and/ or significant changes. Interview on 01/11/23 at 10:42 A.M. with Dietitian #415 verified Resident #15 had a significant weight loss of 7.8 pounds in 30 days on 12/01/22 and that she recommended a supplement to be provided at breakfast. She revealed she did not notify Primary Care Physician #900 and/ or Resident #15's POA regarding the significant weight loss. She revealed she was unsure of who notified the physician and/ or responsible party regarding significant weight loss. Interview on 01/11/23 at 11:33 A.M. with the Director of Nursing and Assistant Director of Nursing (ADON)/ Licensed Practical Nurse (LPN) #473 revealed the Former Dietitian #512 used to complete the notifications to the physician and/ or responsible party regarding significant weight loss and did not know the current Dietitian #415 was not doing the same. They verified there was no documented evidence Primary Care Physician #900 and/ or Resident #15's POA were notified regarding her significant weight loss on 12/01/22. 2. Review of the medical record for Resident #61 revealed an admitted [DATE] with diagnoses including cerebral infarction, dementia, dysphasia, and diabetes. Resident #61 had a responsible party listed in her medical record. Review of the care plan dated 07/01/22 revealed Resident #61 was at nutritional risk due to difficulty swallowing and chewing due to recent stroke. Interventions included diet as ordered, monitor meal intake, and weight every month. Review of the weight record for Resident #61 revealed on 08/31/22 Resident #61's weight was 129 pounds and on 09/06/22 her weight was 121.2 pounds (5.9 percent weight loss). Review of the nursing notes dated 09/06/22 to 01/11/23 revealed there was no documented evidence Primary Care Physician #900 was notified regarding Dietitian #415's recommendation on 09/26/22 for a multivitamin with minerals and of her significant weight loss and on 12/14/22 again with the recommendation for a multivitamin with minerals. Review of the quarterly Dietary Review dated 09/26/22 and completed by Dietitian #415 revealed Resident #61 had a 30-day weight loss of 5.9 percent. The review revealed Dietitian #415 recommended to add a multivitamin with minerals. There was no documented evidence the physician and/ or responsible party were notified regarding her weight loss and recommendation. Review of the Nutritional assessment dated [DATE] and completed by Dietitian #415 revealed Resident #61 had a moderate decrease in food intake. The assessment revealed to have the physician consider multivitamin with minerals every day. There was no documented evidence the physician and/ or responsible party were notified regarding the recommendation. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #61 was cognitively impaired. She required extensive assist of one staff with eating. She had no weight loss. Interview on 01/11/23 at 10:42 A.M. with Dietitian #415's verified she recommended Resident #61 receive a multivitamin with minerals on 09/26/22 and on 12/14/22 per her assessments. She revealed she sends the Administrator and Director of Nursing her recommendations and that she thought nursing then notified the physician of her recommendations which would have included for Resident #61 to receive a multivitamin with mineral. She verified Resident #61 did not have an order for a multivitamin with minerals and was unsure if the physician was notified of her recommendations and/ or significant weight loss as she did not notify Primary Care Physician #900. Interview on 01/11/23 at 11:33 A.M. with the Director of Nursing and Assistant ADON/ LPN #473 revealed Former Dietitian #512 used to complete the notifications to the physician of any dietary recommendations and received the order from the physician. They verified there was no documented evidence the physician was notified regarding Resident #61's dietary recommendation on 09/26/22 and 12/14/22 for a multivitamin with minerals and/ or her significant weight loss. They revealed they were not aware Dietitian #415 was not contacting Primary Care Physician #900 regarding her recommendations and obtaining her own orders and/ or notifying the physician and/ or responsible party of significant weight loss. Review of the facility policy labeled Nutritional Plan for Weight Loss, dated January 2022, revealed the dietitian would be responsible for reviewing the weight variance report and making additional recommendations, documenting in the medical records, and discussing weight changes with the weight committee. The policy did not have any information regarding the notification to the physician and/ or responsible party of recommendations and/ or significant weight changes. 38094 3. Review of the medical record for Resident #52 revealed the resident was admitted on [DATE] with diagnoses including cerebral infarction weakness, unspecified dementia, dysphasia, encephalopathy, and alcohol abuse. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #52 was moderately cognitively impaired and required extensive assist of two for activities of daily living (ADL). Review of the care plan dated 10/12/22 revealed care areas for impaired cognition and a risk of falls. Review of the face sheet revealed the resident's mother was listed as his POA and first emergency contact. Review of the 10/28/22 Event Report for Resident #52 revealed the resident had a fall at 10:20 P.M. during a transfer to bed when the resident became spastic. The fall resulted in a small red area under the resident's right shoulder. Review of the 10/28/22 progress note regarding the fall reported the Director of Nursing and physician were notified of the fall, and the resident's family would be notified in the morning. Interview on 01/12/23 at 12:20 P.M. with Resident #52's mother revealed she did not receive notification of the fall and was not aware the resident had fallen. She stated if her daughter, who was Emergency Contact #2, was contacted she would have told her of the fall. She reported communication was an ongoing problem with the facility. Interview on 01/12/23 at 11:58 A.M. with ADON /LPN #473 verified a resident's POA should be notified when a resident has a fall. The facility failed to provide documented evidence of notification of the Resident #52's family. Review of the January 2022 Notification of Change Policy revealed the resident's responsible party must be notified when an event involving the resident occurs.

Based on interview, record review, and policy review the facility failed to ensure Primary Care Physician #900 and Resident #53's responsible party were notified in a timely manner after Resident #53 fell requiring her to be sent to the emergency room . This affected one resident (Resident #53) of three residents (Resident's #39, #53 and #71) reviewed for change in condition requiring hospitalization . This had the potential to affect 68 residents residing at the facility. Findings include: Review of the medical record for Resident #53 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record revealed Resident #53's daughter was listed as Resident #53's emergency contact. Review of the care plan dated 07/02/19 revealed Resident #53 had impaired cognition as her Brief interview for Mental Status (BIMS) score ranged from an eight to a twelve indicating moderate impairment. Interventions included assess contributing factors including diagnoses, medications, infection and explain all procedures and treatments. There was nothing in the care plan regarding notifying Resident #53's responsible party of change in condition. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 had intact cognition. Review of the facility form labeled Event Report with an event date of 01/17/22 at 4:30 P.M., a completion date of the report as 01/18/22 at 12:55 P.M. and authored by the Director of Nursing revealed the Director of Nursing was called to Resident #53's room by State tested Nursing Assistant (STNA) #606 and observed Resident #53 lying in a fetal position on the floor next to her bed. The Director of Nursing revealed Resident #53 was holding her left side of her head and copious amount of bright red blood was noted. The Director of Nursing applied pressure to Resident #53's wound to control the bleeding and assessed head to toe for further injury. She revealed Resident #53 had a skin tear to her right shin. Resident #53 was asked what had happened and she was responding nonsensical by saying, Who is that? The Director of Nursing called the emergency rescue squad and sent Resident #53 to the hospital for evaluation. There was no documented evidence Resident #53's responsible party or Resident #53's Primary Care Physician #900 was notified of the incident and of Resident #53 sent to the hospital. Review of the facility form labeled Fall Investigation and Root- Cause Analysis dated 01/18/22 and authored by the Director of Nursing revealed Resident #53 was found on the floor next to her bed. The fall investigation revealed Primary Care Physician #900 and Resident #53's responsible party was notified on 01/18/22 with no time recorded. The fall investigation revealed the Director of Nursing had a phone conversation with the family as they were upset, they were not notified regarding Resident #53 being sent to the hospital without being notified and the Director of Nursing apologized for not notifying Resident #53's responsible party. Review of the nursing note dated 01/17/22 at 9:13 P.M. and authored by Licensed Practical Nurse (LPN) #607 revealed Resident #53 returned to the facility from the emergency room and she had received five staples to the top of her head. She had complained of no discomfort and her vital signs were stable. The nursing notes revealed neurological checks were initiated as well as alarms were placed to the bed and wheelchair for safety. LPN #607 contacted Primary Care Physician #900 but there was no documented evidence Resident #53's responsible party was notified regarding Resident #53's return from the hospital. Interview on 02/18/22 at 10:48 A.M. with the Director of Nursing revealed she was the nurse on the floor on 01/17/22 when Resident #53 fell and hit her head resulting in a copious amount of blood from a laceration to her head. She revealed she contacted the emergency rescue squad to transport Resident #53 to the emergency room for evaluation. She verified she did not notify Resident #53's Primary Care Physician #900 or Resident #53's responsible party as she had forgotten and had not remembered until the next day on 01/18/22. She revealed when Resident #53 had returned from the hospital LPN #607 had contacted Primary Care Physician #900 but had not contacted Resident #53's responsible party of her return. The Director of Nursing verified she contacted Resident #53's responsible party on 01/18/22 and Resident #53's responsible party was upset that she had not been contacted. She verified Resident #53 fluctuated in her cognitive status as at times she felt Resident #53 was alert and oriented, but she revealed at the time of the incident on 01/17/22 Resident #53 had a urinary tract infection and had not been eating well. The Director of Nursing verified Resident #53 was confused at the time of the incident on 01/17/22 and was not alert and oriented times three as she just looked at her face during the assessment and repeated, Who is this? in a nonsensical manner. The Director of Nursing verified Resident #53's responsible party and Primary Care Physician #900 should have been notified on 01/17/22 regarding Resident #53's change in condition requiring her to be sent to the emergency room . Review of facility policy labeled Notification of Change in Condition, dated January 2022, revealed the resident's physician and responsible party must be notified when an event involving the resident occurred or when the resident experienced a change in condition. This deficiency substantiates Complaint Number OH 957.

Based on observation, interview, record review, facility policy review, review of guidelines from the Centers for Disease Control and Prevention, and review of guidelines from the Department of Health & Human Services, Centers for Medicare & Medicaid Services, the facility failed to maintain infection control practices for the spread of infectious diseases and for the prevention of COVID-19 by not ensuring the appropriate screening of visitors to the facility, by not ensuring the appropriate storing of clean linen, by not ensuring staff properly donned and maintained the wearing of facemasks while in resident care areas, by not clearly identifying transmission-based precautions for Resident #18, and by not appropriately maintaining soiled linen and trash containers used for Resident #18 who required transmission-based precautions. This affected Resident #18 and had the potential to affect all the residents who reside in the facility. The census was 71. Findings include: 1) Observation on 01/08/22 at 8:50 A.M. during entrance to the facility allowed through the 100-hall entry door which led into an enclosed entryway revealed signs announcing personal protective equipment (PPE) and screening process which required filling out of a questionnaire and temperature checks. There was no thermometer available for use, and no staff in the entry way to monitor visitors for screening. However, hand sanitizer was available for use. There was a doorbell which alerted staff to allow entry through the second door, which Licensed Practical Nurse (LPN) #201 provided entrance into the 100-hall area. After entrance, at 8:52 A.M. this surveyor requested LPN #201 to complete a temperature check for appropriate screening, which LPN #201 obtained, then did not return to the entryway outside of the locked entryway door to record on the screening sheet. Review of screening log for visitors/vendors from 01/03/22 to 01/08/22 revealed on 01/03/22, four visitors entered the facility without temperatures documented and hand hygiene documented as completed; on 01/04/22, one visitor entered the facility without a temperature documented and hand hygiene documented as completed; on 01/05/22, one visitor entered the facility without a temperature documented and hand hygiene documented as completed; on 01/06/22, three visitors entered the facility without temperature checks and hand hygiene documented as completed; on 01/08/22, one visitor entered the facility without temperature checks and hand hygiene documented as completed. Interview on 01/08/22 at 4:10 P.M. with the Administrator verified visitor screening required temperature checks, completion of screening questions, donning of PPE, and use of hand sanitizer. Administrator confirmed the screening log for visitors/vendors from 01/03/22 to 01/08/22 did not have completed screening which included temperature checks and documented hand hygiene. 2) Observation on 01/08/22 at 8:57 A.M. during initial tour revealed on 100-hall was a clean linen cart filled with items including towels, washcloths, bed linens, and heel protectors which was uncovered with the cover draped over the top of the cart and was positioned between rooms [ROOM NUMBERS]. A second clean linen cart was observed filled with items including towels, washcloths and bed linens which was uncovered with the cover draped over the top of the cart and was positioned between resident rooms [ROOM NUMBERS]. Interview at the time of the observation with LPN #201 confirmed the two linen carts observed on 100-hall were not covered as required. 3) Observation on 01/08/22 at 9:05 A.M. during initial tour revealed on 300-hall was State tested Nursing Assistant (STNA) #202 standing in the entrance of the clean utility room across from the 300-hall nurses station talking to LPN #203 who was standing at a medication cart. STNA #202's N95 face mask was positioned underneath the chin. LPN #203's N95 face mask was not properly donned with the upper strap in place and the lower strap not applied, dangling underneath the chin. Interview at the time of the observation with STNA #202 confirmed the N95 facemask was positioned underneath the chin and stated it should be positioned properly over the mouth and nose while in a resident care area. Interview at the time of the observation with LPN #203 confirmed the N95 facemask was not donned properly as required. 4) Review of the medical record for Resident #18 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress note dated 01/04/22 at 11:27 P.M. revealed Resident #18 was placed on isolation and droplet precautions with full PPE worn with episodes of hands-on care. Review of Resident #18's progress notes dated 01/07/22 at 1:38 P.M. revealed droplet precautions remained in place. Review of Resident #18's baseline care plan dated 01/05/22 revealed a private room, required staff assistance with activities of daily living, and was at risk for falls. Observation on 01/08/22 at 9:48 A.M. revealed Resident #18's room had a container with drawers containing PPE positioned outside of Resident #18's room to the right of the room's entrance. Also, outside Resident #18's room to the left of the room's entrance was positioned a covered yellow barrel identified for soiled linen and next to the barrel was an uncovered cardboard box lined with plastic. There was no identification on or near Resident #18's door to identify the room as a room that required transmission-based precautions (TBP's). Interview at the time of the observation with LPN #201 and Administrator verified Resident #18 was admitted a few days prior and was required to be on TBP's. LPN #201 and Administrator confirmed there were no signs posted on Resident #18's room to identify the requirement for TBP's and verified the two containers positioned outside Resident #18's room as isolation containers used for soiled linen and garbage for Resident #18, stating the containers should be inside the room. Observation on 01/08/22 at 12:34 P.M. revealed Resident #18's room had two signs posted to the right of the room's entrance which indicated droplet precautions and contact precautions. The covered yellow barrel identified for soiled linen and the uncovered cardboard box lined with plastic were observed inside Resident #18's room. Review of facility policy titled 2019 Novel Coronavirus (COVID-19), updated September 2021, revealed wear a facemask at all times while in the facility; all visitors will be screened for fever and symptoms of COVID-19 prior to entry into the facility at the screening station and will not be permitted to visit if a fever, symptoms of COVID-19 or exposure to a person(s) with known COVID-19 infection; and attention should be paid to proper donning, doffing and disposal of PPE. Review of Nursing Home Visitation - COVID-19, revised 11/12/21, from the Department of Health & Human Services, Centers for Medicare & Medicaid Services, QSO-20-39-NH Memorandum, located at https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/nursing-home-visitation-covid-19-revised revealed facilities should screen all who enter for symptoms of COVID-19 and the core principles of COVID-19 infection prevention should be adhered to at all times which include appropriate staff use of PPE and hand hygiene with use of alcohol-based hand rub preferred. Review of Best Practices for Management of Clean Linen, last reviewed on 03/27/20, from the Centers for Disease Control and Prevention's Healthcare-Associated Infections (HAIs) Appendix D: Linen and Laundry Management, located at https://www.cdc.gov/hai/prevent/resource-limited/laundry.html#anchor 204 revealed to store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items.

Based on observation, interview and record review, the facility failed to ensure all resident medications were recorded in the medication administration record (MAR) when administered. This affected two residents (Residents #36 and #65) of three residents reviewed for medication documentation. Findings include: 1. Review of the medical record for Resident #36 revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #36's Minimum Data Set (MDS) assessment 3.0 of 07/07/21, revealed the resident was cognitively intact, and required extensive assist of two for activities of daily living, and used a wheelchair for mobility. Resident #36's care plan of 06/15/21, revealed care areas for risk of complications related to high blood pressure and risk of complications related to diabetes, history of urinary tract infections ([CONDITION(S)]), and risk of nutrition/hydration complications. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Other orders included an order dated 04/02/21 for [MEDICATION(S)] (for diabetes) 5 mg qam, an order dated 04/29/21 for [MEDICATION(S)] 17 gm, qam, an order dated 05/14/21 for [MEDICATION(S)] (for diabetes) 500 mg twice a day, [MEDICATION(S)] 25 mg twice a day, an order dated 05/23/21 for Vitamin B-12 1000 mcg qam, an order dated 06/26/21 for [MEDICATION(S)] (a blood thinner) 5 mg twice a day, an order dated Rosurvastatin Calcium 40 mg qhs, and an order dated 08/01/21 for [MEDICATION(S)] (for pain) 10 mg, four times a day . Review of the MAR for Resident #36 from 06/01/21 to 09/09/21 revealed no entry the medications were administered or the medications were refused for the following: -Aspirin 81 mg at 7:00 A.M. to 11:00 A.M. on 06/08/21, 07/06/21, 08/15/21 -[MEDICATION(S)] 10 mg at 6:00 A.M. on 08/15/21 -[MEDICATION(S)] 10 mg at 2: 00 P.M. on 06/08/21, 06/16/21, 06/28/21, 07/04/21, 07/06/21, 07/2621, and 08/05/21 -[MEDICATION(S)] 10 mg at 12:00 P.M. on 08/05/21 and 08/15/21 -[MEDICATION(S)] 5 mg at 7:00 A.M. to 11:00 A.M. on 07/06/21 and 08/15/21 -[MEDICATION(S)] 5 mg at 7:00 P.M. to 11:00 P.M. on 07/26/21 -[MEDICATION(S)] 20 mg at 7:00 A.M. to 11:00 A.M. on 06/0821, 07/06/21, and 08/15/21 -[MEDICATION(S)] 1 mg at 7:00 A.M. to 11:00 A.M. on 06/08,/21, 07/06/21, and 08/15/21 -[MEDICATION(S)] 500 mg at 7:00 A.M. to 11:00 A.M. on 06/08/21, 07/06/21, and 08/15/21 -[MEDICATION(S)] 500 mg at 4:00 P.M. to 6:00 P.M. on 06/02/21, 06/08/21, 06/10/21, 06/16/21, 06/19/21, and 07/04/21 -[MEDICATION(S)] 25 mg at 7:00 A.M. to 11:00 A.M. on 06/08/21, 07/04/21, 07/06/21, 08/05/21, 08/10/21, and 08/15/21 -[MEDICATION(S)] 25 mg at 7:00 P.M. to 11:00 P.M. on 07//26/21 -[MEDICATION(S)] 17 grams at 7:00 A.M. to 11:00 A.M. on 06/08/21, 06/16/21, 07/04/21, 07/06/21, and 08/15/21 -[MEDICATION(S)] 40 mg at 4:00 P.M. on 06/02/21, 06/08/21, 06/10/21, 06/16/21, 06/19/21, 07/04/21, and 07/06/21 -Prosight 5,000-60-30 unit-mg-unit 1 tablet at 7:00 A.M. to 11:00 A.M. on 06/08/21, 06/16/21, 07/06/21, and 08/15/21 -Rosurvastatin Calcium at 7:00 P.M. to 11:00 P.M. on 07/26/21 -[MEDICATION(S)] 1 gram at 7:00 A.M. to 11:00 A.M. on 06/08/21, 06/16/21, 07/06/21, and 08/15.21 -[MEDICATION(S)] 1 gram at 7:00 P.M. to 11:00 P.M. on 07/26/21 -[MEDICATION(S)] 5 mg at 7:00 A.M. to 11:00 A.M. on 06/08/21, 06/16/21, 07/06/21, and 08/15/21 -Vitamin B-12 1,000 micrograms (mcg) at 7:00 A.M. to 11:00 A.M. on 06/08/21, 07/06/21, and 08/15/21 -Vitamin D 3 125 mcg at 7:00 A.M. to 11:00 A.M. on 06/08/21, 06/16/21, 07/06/21, and 08/15/21 Observation and interview on 09/08/21 at 8:40 A.M. with Registered Nurse (RN) #251 verified there was a problem with the wireless Internet network (wi-fi) reaching to the end of some of the hallways in the building. The nurse demonstrated how the medication cart could be parked in an area with wi-fi, the medications prepped in the electronic medical record (EMR), taken to the resident's room, and then recorded as administered when the nurse returned to the cart. Interviews on 09/07/21 at 8:47 A.M. with Resident #36 verified that she received all her medications as prescribed. Interview on 09/09/21 at 4:08 P.M. with Administrator verified the missing MAR entries were due to the poor wi-fi situation and nurses stated all medications were given as prescribed. Review of the investigation of the the incomplete MAR documentation, completed by the Administrator on 09/10/21, revealed statements from Licensed Practical Nurses (LPN) #200, #201, #203, #204, #205 verified they had administered the medications not recorded on the MAR. LPN #205 reported she was unable to enter the medications due to the wi-fi not working from 06/01/21 to 08/15/21. 2. Review of the medical record for Resident #65 revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident #65's Minimum Data Set (MDS) assessment 3.0 of 07/07/21, revealed the resident was cognitively intact, required extensive assist of two for ADL's, and used a walker and wheelchair for mobility. Review of Resident #65's care plan of 06/14/21, revealed care areas included rejection of care, bathing per resident choice, urinary catheter, nutrition/hydration, risk of skin breakdown, pain, and bleeding/bruising. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for Resident #65 from 04/01/21 to 09/09/21 revealed no entry the medications were administered or the medications were refused for the following: -[MEDICATION(S)] HCl 60 mg at 12:00 A.M. on 04/27/21 and 05/01/21 -[MEDICATION(S)] HCl 60 mg at 6:00 A.M. on 05/01/21, 05/20/21, 05/24/21, 06/17/21, 06/26/21, 06/28/21, 07/27/21, and 08/21/21 -[MEDICATION(S)] HCl 60 mg at 6:00 P.M. on 05/24/21, 07/13/21, 07/27/21, 08/09/21, 08/15/21, 08/19/21, 08/23/21, and 08/27/21 -[MEDICATION(S)] 5 mg at 7:00 P.M. to 11:00 P.M. on 05/15/21 and 08/25/21 - Melatin 3 mg at 7:00 P.M. to 11:00 P.M. on 04/15/21 and 08/25/21 -[MEDICATION(S)] 20 mg at 4:00 A.M. to 6:00 A.M. on 05/0/21, 05/20/21, 06/17/21, 06/21/21, 06/28/21, 07/27/21, and 08/21/21 -[MEDICATION(S)] 20 mg at 4:00 P.M. to 6:00 P.M. on 05/15/21 and 08/25/21 -[MEDICATION(S)] 1 mg at 7:00 P.M. to 11:00 P.M. on 05/15/21 and 08/25/21 -Trazadone 50 mg at 7:00 P.M. to 11:00 P.M. on 05/15/21 -[MEDICATION(S)] drops 1 qtts at 7:00 P.M. to 11:00 P.M. on 08/25/21 -[MEDICATION(S)] 500 mg at 6:00 A.M. on 08/21/21 -[MEDICATION(S)] 500 mg at 10:00 P.M. on 08/25/21 -[MEDICATION(S)] 1 qtts at 7:00 P.M. to 11:00 P.M. on 08/25/21 Interviews on 09/07/21 at 8:40 A.M. with Resident #65 verified that she received all her medications as prescribed. Observation and interview on 09/08/21 at 8:40 A.M. with Registered Nurse (RN) #251 verified there was a problem with the wireless Internet network (wi-fi) reaching to the end of some of the hallways in the building. The nurse demonstrated how the medication cart could be parked in an area with wi-fi, the medications prepped in the electronic medical record (EMR), taken to the resident's room, and then recorded as administered when the nurse returned to the cart. Interview on 09/09/21 at 4:08 P.M. with the administrator verified the missing MAR entries were due to the poor wi-fi situation and nurses stated all medications were given as prescribed. Interview on 09/14/21 at 8:17 A.M. with LPN #200 verified she had given the medications to Resident #65 on 07/27/21, 08/21/21 and 08/25/21, entered them into the MAR but due to the issue with the wi-fi, they showed up as not given. Review of the investigation of the the incomplete MAR documentation, completed by the Administrator on 09/10/21, revealed statements from Licensed Practical Nurses (LPN) #200, #201, #203, #204, #205 verified they had administered the medications not recorded on the MAR. LPN #205 reported she was unable to enter the medications due to the wi-fi not working from 06/01/21 to 08/15/21. This deficiency substantiates Complaint Number OH 381.

Based on interview, record review, and facility policy review, the facility did not ensure effective pest control for the resident areas of 100, 200 and 300 halls between 03/31/21 and 05/26/21. This specifically affected 10 Resident's (#1, #3, #5 #11, #19, #27, #35, #48, #55 and #76) and had the potential to affect all 70 residents residing in the facility. Findings include: Review of Pest Control Service Agreement dated 09/27/17 revealed monthly services to begin September 2017 and to continue until canceled by facility or pest control company. The agreement included services for pavement ants, spiders, millipedes, centipedes, silverfish, earwigs, meal moths, roaches, and rodents. Interview on 06/02/21 at 12:04 P.M. with Housekeeping #201 confirmed ants were a problem during the past three months. Interview on 06/02/21 at 12:14 P.M. with Maintenance #202 verified the maintenance department received complaints in written form about ants and indicated the facility already had scheduled monthly pest control treatments. Review of documentation for pest control services revealed pest control visits to the facility were completed on 02/24/21, 03/24/21, 04/28/21 and on 05/26/21. There was no documentation pests or ants were treated in resident rooms for pest control visits on 02/24/21, 03/24/21 and on 04/28/21. Review of pest control services on 05/26/21 revealed flying ants were treated in resident rooms #330, #331, #332 and #336. Interview on 06/02/21 at 12:47 P.M. with Housekeeping #203 and Housekeeping #204 confirmed in the last three months ants were a problem, especially around windows, walls, and floors. Multiple written complaint forms were submitted to the maintenance department, and the ants were swept up or cleaned away as needed for the residents. Interview on 06/02/21 at 2:04 P.M. with Resident #19 verified ants were a problem for a while in the room. Interview on 06/02/21 at 2:24 P.M. with Resident #48 verified there were a lot of ants in the room and indicated it took a long time for them to go away over a few weeks, stating staff would sweep them up. Interview on 06/02/21 at 2:28 P.M. with Resident #11 confirmed there were a lot of ants in the room just last week, stating it looked like a black sea, and indicated staff would clean them up. Review of facility maintenance documents, Maintenance Repair Requisition: (all work orders should be completed within 24 hours) unless parts need to be ordered, dated from 03/31/21 to 05/21/21 revealed 22 complaints of multiple and repetitive pest sightings. On 03/31/21, a complaint submitted for Resident #55 indicated, Resident has bugs in bathroom, needs immediate attention, work completed 04/02/21. On 04/06/21, a complaint submitted for Room 115 indicated, Ants, needs immediate attention, no work completed date was documented. On 04/07/21, a complaint submitted for Room 116 indicated Ants, needs immediate attention, no work completed date was documented. On 04/12/21, another complaint submitted for Room 116 indicated Ants all over, needs immediate attention, no work completed date was documented. On 04/12/21, a complaint submitted for isolation wing (100 hall) indicated, Ants have invaded all of the rooms on isolation end, the residents are really complaining, no work completed date was documented and a note on the complaint form indicated, For pest guy. On 04/22/21, a complaint submitted for Resident #35 indicated, Excessive ant problem, ants crawling on resident in his bed, needs immediate attention, no work completed date was documented. On 04/23/21, another complaint submitted for Resident #55 indicated, Ants in room, no work completed date was documented. On 05/05/21, a complaint submitted for Room 211 indicated, Ants are really bad by window all the way to bed, needs immediate attention, no work completed date was documented. On 05/10/12, another complaint submitted for Room 104 indicated, Patient says there are still ants in his room. Thank you! Needs immediate attention, no work completed date was documented. On 05/11/21, a complaint submitted for Resident #1 indicated, Ants under window, needs immediate attention, no work completed date was documented. On 05/12/21, a complaint submitted for Resident #76 indicated, There are ants and flying ants on the wall and floor by window, needs immediate attention, no work completed date was documented. On 05/13/12, another complaint submitted for Resident #76 indicated, Ants tons, needs immediate attention, no work completed date was documented. On 05/13/12, another complaint submitted for Resident #76 indicated Ants everywhere by register and window, no work completed date was documented. On 05/19/21, a complaint submitted for Resident #48 indicated, Ants and flying ants by window and under heater, needs immediate attention, no work completed date was documented. On 05/19/21, a complaint submitted for Resident #19 indicated, Ants under heater and near window, needs immediate attention, no work completed date was documented. On 05/19/21, another complaint submitted for Resident #76 indicated, Ants by window, no work completed date was documented. On 05/19/21, a complaint submitted for Resident #27 indicated, pest sighting at window and bathroom heater, no work completed date was documented. On 05/19/21, a complaint submitted for Resident #3 indicated, Flying ants, needs immediate attention, no work completed date was documented. On 05/20/21, another complaint submitted for Residents #19 and #76 indicated, Ants in bathrooms, no work completed date was documented. On 05/20/21, a complaint submitted for 300 hall area indicated, Ants in hall, no work completed date was documented. On 05/20/21, a complaint submitted for Resident #5 indicated, Flying ants in middle of hallway, needs immediate attention, no work completed date was documented. On 05/21/21, a complaint submitted for Resident #11 indicated, Ants covering floor next to bed by window, crawling up wall also, needs immediate attention, no work completed date was documented. Of the 22 complaints reviewed, one complaint had a documented completed date, and there was no documentation on the 22 complaints reviewed of an indoor insecticide or other alternative intervention, in addition to the once monthly scheduled facility pest control treatment, to resolve the complaints. Interview on 06/02/21 at 2:58 P.M. with Maintenance #202 verified the pest control company provided monthly scheduled pest treatments on 03/24/21, 04/28/21 and on 05/26/21. Maintenance #202 confirmed the maintenance department received seven ant complaints after the pest treatment on 03/24/21, beginning on 03/31/21 and ending on 04/23/21, and received 15 additional complaints after the pest treatment on 04/28/21, beginning on 05/05/21 and ending on 05/21/21. Maintenance #202 verified knowledge the ant complaints were multiple on some days and repetitive for some residents. Maintenance #202 indicated the Administrator was aware of the ant problem and did permit the pest company to make additional visits for treatment, yet further stated he decided to wait for each scheduled monthly visit to inform the pest company about the persisting problem. Maintenance #202 indicated interventions for pest complaints between the scheduled pest company visits was to sweep the ants up, use disinfectant to the area, and the maintenance assistant would spot spray the ants. Interview on 06/02/21 at 3:03 P.M. with State tested Nursing Assistant (STNA) #205 verified ants were a problem over the last two months on 100 hall, which was the isolation wing, by the windows, walls, floors and in resident rooms, and confirmed the written complaints were submitted to the maintenance department. Interview on 06/02/21 at 3:12 P.M. with Nursing Assistant (NA) #206 verified ants were a problem on the 300 hall over the last month and indicated there were a lot more than usual specifically on the floors and by trash cans. NA #206 confirmed written complaints were submitted to the maintenance department, and indicated towels were used to kill the ants when maintenance was not available, but the ants seemed to come back. Interview on 06/02/21 at 3:31 P.M. with Licensed Practical Nurse (LPN) #207 verified ants were a problem on the 300 hall over the last month which caused several residents and family complaints. LPN #207 confirmed on the weekends, when maintenance was not available, soap and water was used to spray the ants, the ant concern was passed along in oral report, and written complaints were submitted to the maintenance department. Interview on 06/02/21 at 3:36 P.M. with Maintenance #208 verified attendance with the pest control treatment company during each treatment visit and indicated the pest control treatments were made around exterior doors of the building, the kitchen and dining room areas. Maintenance #208 indicated a personal preference not to provide the pest control treatment company with resident room numbers for pest treatment due to concerns about aggravating residents' breathing problems. Maintenance #208 stated an odorless water-based indoor insecticide was used to spot treat the ants when necessary but only for ants by windows, and further indicated only spraying on the outside of the facility windows due to concerns of residents' breathing problems. Maintenance #208 confirmed not remembering which resident rooms the indoor insecticide was used to treat the ant complaints and stated if the indoor insecticide was used, it would be documented on the maintenance complaint forms. Interview on 06/02/21 at 3:45 P.M. with Administrator verified knowledge of the facility ant complaints and confirmed permitting maintenance to allow additional pest control visits if needed. Administrator indicated not receiving notification of a persisting problem and believed the problem was resolved. Review of facility policy, Pest Control, dated undated, revealed the facility will maintain an effective pest control program to eradicate and contain common household pest (roaches, ants, mosquitoes, flies, mice, rate, etc.); the Director of Maintenance will monitor contract service provider to assure that regular service is performed; and the Director of Maintenance will contact the provider if additional services are needed. This deficiency substantiates Complaint Number OH 579.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff used appropriate infection control practices, including hand washing and use of gloves, during wound care for Resident #19. The facility reported five Resident's (#8, #14, #19, #33 and #35) with wounds. The census was 70. Findings include: Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 06/02/21 at 2:04 P.M. during wound care with Registered Nurse (RN) #200 revealed Resident #19's right lateral ankle dressing was removed with gloved hands and discarded. RN #200 removed the soiled gloves and without performing handwashing, donned clean gloves and cleansed the right lateral ankle wound with normal saline solution, applied collagen, applied [MEDICATION(S)], and then applied a clean dry dressing. RN #200 then reached into her right uniform pocket while still wearing the soiled gloves and obtained a marking pen, dated the right lateral ankle dressing, and then removed the soiled gloves. RN #200 exited Resident #19's room to the treatment cart without performing handwashing, opened the treatment cart, obtained a tube of triple antibiotic ointment, opened the tube of ointment and expelled a small amount into a medication administration cup, closed the tube of ointment, returned it to the treatment cart, closed the treatment cart, and re-entered Resident #19's room with the prepared triple antibiotic ointment. RN #200 then performed hand hygiene using hand sanitizer, donned clean gloves, removed a soiled dressing from Resident #19's right hand wound, removed the soiled gloves, performed hand hygiene with hand sanitizer, donned clean gloves, and measured and cleansed the right hand wound with normal saline. RN #200 then removed the soiled gloves, donned a clean pair of gloves without performing hand washing, indicated a need for an applicator to apply the triple antibiotic ointment, removed the gloves and without performing handwashing, exited Resident #19's room to the treatment cart, opened the treatment cart, obtained an applicator, closed the treatment cart, re-entered Resident #19's room, and placed the applicator into the prepared triple antibiotic ointment in the medication administration cup. RN #200 performed handwashing, donned gloves, applied triple antibiotic ointment to the right hand wound, applied a dry dressing, and then reached into her right uniform pocket while still wearing the soiled gloves and obtained a marking pen, dated the right hand wound dressing, and then removed the soiled gloves. Interview at the time of the observation with RN #200 confirmed the above observation and verified handwashing was not performed as required. Review of facility policy, Hand Washing/Hand Hygiene, reviewed 01/2021, revealed wash hands and other skin surfaces after removing gloves or other personal protective equipment. Review of facility policy, Wearing Gloves, undated, revealed decontaminate your hands after removing gloves; wear gloves once; discard.

The following deficiency represents an incident of past noncompliance that was subsequently corrected prior to the survey. Based on closed record review, review of facility policy and procedures related to notification of change in condition and fall prevention and management, facility investigation, interviews with facility staff, and Primary Care Physician/ Medical Director #610 the facility failed to seek timely and appropriate care and treatment for one resident (Resident #83), who received anticoagulant therapy, fell out of bed sustaining a head injury. This resulted in Immediate Jeopardy that presented actual harm on [DATE] at 3:00 A.M. when the facility failed to notify the physician when Resident #83 fell out of bed hitting her head, was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Emergency Medical Services pronounced Resident #83 deceased on [DATE] at 5:25 A.M. This affected one resident (Resident #83) of three residents reviewed for change in condition/quality of care. On [DATE] at 2:28 P.M. the Administrator and the Director of Nursing (DON) were notified that Immediate Jeopardy began on [DATE] at 3:00 P.M. when Resident #83 fell resulting in head injury while on anti-coagulants and antiplatelets, and Licensed Practical Nurse (LPN) #600 failed to notify Resident #83's Primary Care Physician/ Medical Director #610. The Immediate Jeopardy was removed and the deficiency was corrected on [DATE] when the facility implemented the following corrective action: · The DON educated LPN #600 on proper notification to the physician, family, and DON, of any fall with injury (including an unwitnessed fall). The DON completed the education on [DATE] at 10:20 A.M. Verification on [DATE] at 10:20 A.M. that Regional Director #627 and the DON educated LPN #600. · All licensed nurses were educated on [DATE] on notification to physician, DON, and resident representatives of any fall with injuries (including an unwitnessed fall). The DON completed the education on [DATE] from 10:20 A.M. to 7:00 P.M. of all 21 floor nurses. The facility does not utilize agency staff. Verification revealed all 21 nurses were educated on [DATE]. On [DATE] from 11:22 A.M. to 2:20 P.M. seven of the 21 nurses were interviewed, Registered Nurses (RN's) #616, #617, #622, and LPN ' s #605, #623, #624 and #625, and were knowledgeable regarding proper notification to the physician, DON and resident representative of any fall with injuries including unwitnessed fall. · Education to licensed staff to ensure alarms were in place and functioning properly was completed by the DON on [DATE] from 10:20 A.M. until 7:00 P.M. Verification revealed all 21 nurses were educated on [DATE]. On [DATE] from 11:22 A.M. to 2:20 P.M. seven of the 21 nurses were interviewed (RN's #616, #617, #622, and LPN's #605, #623, #624 and #625) and were knowledgeable regarding ensuring proper placement of alarms and ensuring they were functioning. Observation on [DATE] from 11:22 A.M. to 11:35 A.M. revealed ten residents had orders for chair or bed alarms including Resident ' s #31, #34, #56, #52, #10, #63, #22, #24, #54 and #3, and observation revealed all resident ' s had their bed or chair alarms in place as ordered. · The Administrator or Designee will present to the Quality Assurance and Performance Improvement (QAPI) meeting monthly for two months then will present randomly. The facility has not had a QAPI since the event on [DATE]. The next scheduled QAPI is [DATE]. · All new hire nurses will be educated to call the Physician and DON immediately of listed events that included any unwitnessed fall or fall with injury verbally and with written education during orientation per the DON or Designee. The facility has not hired any new nurses since the incident on [DATE]. · Review of residents that have fallen in the morning clinical meeting daily to ensure notification to family, physician and resident representative was done timely starting [DATE]. The facility DON or Designee will conduct daily audits of falls starting [DATE] Monday through Friday for three months and then three times weekly. Verification revealed daily audits Monday through Friday were completed since [DATE]. · Review of resident falls to ensure current interventions were in place and the interventions were appropriate when reviewing the falls began on [DATE]. The facility DON or Designee will conduct a daily audit of falls to ensure interventions were in place and interventions were appropriate starting [DATE] Monday through Friday for three months and then three times weekly. Verification revealed daily audits were completed Monday through Friday since [DATE]. · LPN #600 was suspended pending investigation. She's currently on Family Medical Leave of Absence (FMLA) for medical reasons. · Review of the residents with orders for bed alarms and ensure the alarms function and placement was completed on [DATE] by the DON. The DON or Designee will audit alarms for placement and function and orders for every shift were signed off starting [DATE] daily for five days and then three times a week for four weeks. Verification of audits was completed. Findings included: Review of the closed medical record for Resident #83 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #83 expired at the facility on [DATE]. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #83 had a Brief Interview for Mental Status (BIMS) score of a 14, indicating she was cognitively intact, and required extensive assist of one person with bed mobility, ambulation, transfers, toileting, and locomotion. Review of the form titled Critical Admission assessment dated [DATE] completed by RN #616 revealed Resident #83 required one person assist with transfers and ambulation. The fall risk assessment was combined in this assessment and revealed Resident #83 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated [DATE] revealed the resident was at risk for falls due to a history of falls at home, weakness, impaired balance, and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included evaluate need for bed and chair alarms, increased staff supervision with intensity based on the resident ' s need and provide individualized toileting interventions based on needs and patterns. Review of the care plan dated [DATE] revealed Resident #83 was at risk for injury and bleeding due to use of anticoagulant medication related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included observe for signs of active bleeding such as nosebleeds, hematoma, and abdominal pain, and protect the resident from injury and trauma. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing notes dated [DATE] at 3:00 A.M. authored by LPN #600 revealed the nurse was walking down the hallway and observed Resident #83 on the floor on the side of her bed on her left side. Resident #83 was alert to her name but confused to time and place. Resident #83 was asked how she fell , and she stated she was looking for her stroller and pointed to her wheelchair on the other side of the room. LPN #600 completed a range of motion assessment, and range of motion was within normal limits. Two staff assisted Resident #83 into her wheelchair and observed a scrape to her left lower back. LPN #600 cleansed the scrape with normal saline and added ointment. LPN #600 palpated two bumps to the back of Resident #83's head that were purplish reddish in color with no drainage. Resident #83 denied pain or discomfort and neurological monitoring was started. The nursing note stated the power of attorney, DON, and physician were to be notified in the morning. There was no documented evidence in the nursing notes Resident #83's bed alarm was sounding at the time of the fall. Review of the facility form labeled Neurological Monitoring, dated [DATE], revealed LPN #600 completed neurological monitoring for Resident #83 after her fall. On [DATE] at 3:00 A.M. Resident #83 ' s blood pressure was ,d+[DATE], pulse 63, respirations 18, temperature 97.5 degrees Fahrenheit, she was fully conscious, she had movement of all extremities, her hand grasp was equal and strong, her speech was clear, and her pupil reaction was brisk. On [DATE] at 3:15 A.M., 3:30 A.M., and 3:45 A.M. Resident #83 ' s neurological monitoring remained relatively the same. Review of the monitoring documentation revealed on [DATE] at 4:00 A.M. Resident #83 ' s blood pressure dropped to ,d+[DATE], at 4:15 A.M. her blood pressure dropped to ,d+[DATE], at 4:30 A.M. her blood pressure dropped to ,d+[DATE]. Review of Neurological Monitoring form revealed on [DATE] at 4:45 A.M. Resident #83 ' s level of consciousness changed to lethargic and responding slowly to verbal stimuli, she had no movement to the extremities, had no hand grasp, her pupils were sluggish, her speech was aphasic, blood pressure had dropped to ,d+[DATE], and her respirations were 12. Review of the nursing notes dated [DATE] at 10:18 A.M. authored by LPN #608 revealed Resident #83 was sitting at the nursing station and at 4:55 A.M. was noted to be unresponsive and staff assisted her to her room. Emergency Medical Services (EMS) was called, and Resident #83 was assisted to the floor. The resident had no pulse or breath sounds. CPR was initiated at 5:00 A.M. and continued until EMS arrived at the facility at 5:20 A.M. EMS pronounced Resident #83 deceased at 5:25 A.M. Resident #83 ' s daughter was notified on [DATE] at 5:30 A.M. Resident #83 ' s Primary Care Physician #610 was notified on [DATE] at 5:35 A.M. and the Coroner ' s office was notified on [DATE] at 6:00 A.M. Review of the facility investigation labeled Fall Investigation dated [DATE] revealed on [DATE] at approximately 2:00 A.M. rounds were completed by the state tested nurse aides (STNAs), and Resident #83 was in bed resting at that time. On [DATE] at approximately 3:00 A.M., LPN #600 was walking towards the nursing station and observed Resident #83 on the floor on her left side. LPN #600 performed range of motion without difficulties and there were no abnormalities to the front of Resident #83 ' s face. LPN #600 with the assistance of STNA ' s transferred the resident to her wheelchair and took the resident to the nursing station and initiated neurological monitoring. LPN #600 indicated she observed two bumps to the back of Resident #83 ' s head with no drainage and an abrasion to her back while observed at the nursing station. Resident #83 was placed back in bed by the STNA ' s. The investigation indicated Resident #83 was attempting to get out of bed, so LPN #608 indicated Resident #83 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . While the STNA ' s were taking Resident #83 to get her weight, Resident #83 became unresponsive at approximately 4:55 A.M. LPN ' s #600 and #608 immediately took Resident #83 to her room, lowered to her to the floor, and CPR was initiated. 911 was contacted at 4:55 A.M. and CPR continued with LPN #626 arriving to assist. LPN #600 exited the room to assist with paperwork. CPR continued until EMS arrived at 5:20 A.M. and took over CPR and pronounced the resident expired at 5:25 A.M. Findings of the investigation revealed Resident #83 ' s alarm was not turned on at the time of the fall, and LPN #600 failed to notify the physician, DON and family at time of fall. Review of the facility investigation labeled Fall Action Plan/ PNC dated [DATE] and completed by the Administrator revealed the purpose of the action plan was because the nurse failed to notify the physician with change in neurologic condition. The investigation revealed there was a concern leading to the action plan development due to the fall occurred at the facility for Resident #83, and LPN #600 failed to notify the family and the physician when the fall occurred and failed to notify the physician when a change in condition with the change in neurological checks was identified. Review of untitled form with interview questions dated [DATE] revealed the DON asked LPN #600 what Resident #83 hit to cause the scrape and bump to her head, and LPN #600 revealed she did not know. LPN #600 was asked when Resident #83 fell if she followed the fall protocol, and LPN #600 revealed she did not complete the Fall Situation-Background-Assessment-Recommendation (SBAR) report. LPN #600 was asked if during neurological checks Resident #83 ' s blood pressure had a significant drop, and LPN #600 stated yes. LPN #600 was asked if she notified the physician, and LPN #600 stated no. LPN #600 was asked if during the neurological checks if Resident #83 ' s level of consciousness changed, and she stated yes, after two hours. Review of the Witness Statement dated [DATE] completed by LPN #600 revealed she was walking down the hallway and glanced into Resident #83 ' s room and saw her lying on the floor beside her bed. LPN #600 performed range of motion and it was within normal limits. LPN #600 took Resident #83 down to the nursing station in a wheelchair and asked the resident if she was having any pain or discomfort, and she stated no. LPN #600 began neurological checks, and Resident #83 continued to talk with staff. LPN #600 stated she rubbed the resident ' s head, and she noticed two bumps to her head. She revealed staff took her to her room because she stated she was tired and placed her into bed. LPN #600 revealed LPN #608 stated Resident #83 needed a weight because she had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #600 revealed Resident #83 became unresponsive and was taken back to her room and placed on the floor for CPR. Review of the Witness Statement dated [DATE] completed by STNA #606 revealed she last saw Resident #83 on [DATE] at 2:00 A.M., and she was sleeping in her bed. STNA #606 revealed Resident #83 was trying to get to her wheelchair and did not ring for help. She revealed her alarm was disarmed. Review of the Witness Statement dated [DATE] completed by STNA #607 revealed Resident #83 was last seen on [DATE] at 2:00 A.M., and she was sleeping in bed. She revealed Resident #83 was going to her wheelchair and did not call for help. She revealed Resident #83 ' s bed alarm was not connected, and she had no chair alarm in place. Interview on [DATE] at 4:08 P.M. with the Administrator and DON revealed LPN #600 failed to notify the physician at the time of Resident #83 ' s fall with head injury and after Resident #83 ' s change in neurological status when her blood pressure significantly dropped. LPN #600 continued to fail to contact the physician regarding Resident #83 ' s change in condition. The DON and Administrator indicated they interviewed and investigated the incident, and LPN #600 admitted at the time of the incident she was having memory problems. They suspended LPN #600, and she was going to contact her physician to seek a medical evaluation. They verified she should have notified the physician at the time of Resident #83 ' s fall as she had two bumps to her head and was on blood thinning medications, and they verified she should have contacted the physician when Resident #83 ' s blood pressure dropped significantly. The DON and Administrator stated LPN #600 did not follow their policy regarding change in condition. They revealed they implemented an immediate corrective action plan to prevent a reoccurrence. Attempted interview on [DATE] at 4:59 P.M. and on [DATE] at 12:10 P.M. with STNA #607 who was the other STNA assigned on [DATE] to Resident 83 ' s unit and there was no answer and unable to leave a message. STNA #607 no longer worked at the facility. Interview on [DATE] at 4:50 P.M. with STNA #606 revealed LPN #600 found Resident #83 on the floor and assessed her while on the floor. STNA #606 revealed they then got her up and put her in her wheelchair. She revealed Resident #83 appeared to have dry heaves and complained of not feeling well at approximately 4:00 A.M. She revealed they assisted her back in bed at 4:15 A.M. and after placing her back in bed at 4:15 A.M., Resident #83 stated she continued to not feel well. She revealed LPN #600 was aware of Resident #83 not feeling well as she continued to check on her and do her vitals. She revealed LPN #608 came in and was the nurse on the floor for Resident #83, and at approximately 5:00 A.M. LPN #608 had asked her to get a weight on Resident #83. STNA #606 revealed she brought it up to LPN #608 that she did not think it was right to weigh Resident #83 as she was not feeling well, and she had fallen. STNA #606 stated LPN #608 still requested the weight be obtained. STNA #606 stated she and STNA #607 obtained Resident #83 ' s weight, and she was weaker than usual. She usually required only one-person assist to transfer out of bed, and she required two person assist and was having difficulty. She revealed she notified LPN #608, and she left Resident #83 at the nursing station while she started performing rounds on other residents. A short time later, LPN #600 came and got her and stated Resident #83 was coding, and they needed assistance to get her out of the chair onto the floor. STNA #606 revealed she did not notice any memory impairment or concerns with LPN #600 as she seemed to be acting per her usual self. STNA #606 revealed LPN #608 initiated CPR. Interview on [DATE] at 5:36 P.M. with LPN #608 revealed she came in early on [DATE] at approximately 4:30 A.M. and started to get report from LPN #600. She revealed she did remind the STNA ' s on the floor Resident #83 was a daily weight prior to getting report. LPN #608 revealed STNA #606 and #607 never reported to her that Resident #83 was not feeling well, any concerns about getting her weight or any concerns that she required more assistance with transferring. She revealed Resident #83 was at the nursing station while she was getting report and was having more trouble focusing, had decreased alertness, and rapidly declined. They took her back to her room and lowered her to the floor as she did not have a pulse, and she started CPR. A second interview on [DATE] at 2:50 P.M. with LPN #608 revealed she did not notice any memory impairments with LPN #600 as she seemed her usual baseline while giving her report. She revealed she did not notice any delay with LPN #600 reacting when Resident #83 coded, but she was only focused on initiating CPR. Interview on [DATE] at 11:49 A.M. with LPN #600 revealed she found Resident #83 on the floor and assessed Resident #83, but she revealed she only checked the front of her head. She revealed Resident #83 did not have a bed alarm in place as it was not sounding, and she was not aware Resident #83 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #600 revealed she brought Resident #83 to the nursing station and about an hour later, it came to her to check the back of Resident #83 ' s head. LPN #600 stated she felt the back of Resident #83 ' s head and noticed two bumps on the back of her head. LPN #600 stated again something seemed to go wrong with her memory as she could not remember what to do next such as call the physician. She revealed her thought process just continued to leave her during the event on [DATE] as she did not call the physician at the time of the fall or after she assessed and found the bumps on the back of Resident 83 ' s head. She revealed she continued to complete the neurological checks including vital signs, and she stated at the time it did not register that Resident #83 ' s blood pressure significantly declined until after the DON educated her and asked why she did not call the physician earlier. That was when she realized Resident #83 ' s blood pressure had significantly decreased. She revealed it felt like she was in shock that evening after Resident #83 ' s fall and she verified she did not follow the facility procedure in calling the physician after Resident #83 ' s fall with head injury or after Resident #83 ' s change in condition with her blood pressure decreasing. LPN #600 revealed when Resident #83 coded LPN #608 took over, and she completed the CPR. LPN #600 stated she again froze and could not assist with CPR as she forgot the steps of CPR. She revealed she contacted her primary care physician to get checked out as she was having memory problems and currently remains off duty due to medical issues. Interview on [DATE] at 3:51 P.M. with Primary Care Physician/ Medical Director #610 revealed she had a discussion with the coroner and felt Resident #83 had multiple comorbidities. She stated she signed the death certificate but could not remember exactly what she wrote as the cause of death but stated she thought she included cardiac death, [CONDITION(S)], [CONDITION(S)], and from the recent fall. She revealed she had reviewed Resident #83 ' s fall that occurred on [DATE] at 3:00 A.M. and stated the facility should have notified her right away of the fall especially because Resident #83 had hit her head and was on blood thinners. She revealed she would have ordered Resident #83 immediately sent to the hospital for evaluation after the fall. Primary Care Physician/ Medical Director #610 then reviewed the neurological monitoring form and stated Resident #83 ' s blood pressure significantly declined which is indicative of head trauma, and she stated the facility should have notified her of the decrease in blood pressure as she would have ordered her to be sent to the hospital. Primary Care Physician/ Medical Director #610 verified the facility did not notify her of Resident #83 ' s fall or change in condition as the facility notified her after Resident #83 expired on [DATE] at 5:35 A.M. Interview on [DATE] at 6:13 P.M. with LPN #626 revealed she was working on a different unit on [DATE] and heard them announce the need for assistance due to code blue in Resident #83 ' s room. LPN #626 revealed she went to Resident #83 ' s room and found her on the floor with LPN #608 performing CPR. She revealed she then assisted LPN #608 with the CPR until EMS arrived and took over. She revealed she had not seen Resident #83 prior to this event on [DATE], and she had only briefly seen LPN #600 when they were punching in for the evening and then while assisting with CPR. She stated she appeared per her usual baseline without signs of memory impairment. Review of facility policy labeled Notification Of Change, dated [DATE], revealed the facility failed to implement their policy as the residents physician and responsible party were to be notified when an event involving the resident occurred or when the resident experienced a change in condition. The policy revealed to notify the physician immediately if the resident required immediate action and call 911 in emergency which included fall with head or neck injury. Review of facility policy labeled Fall Prevention and Management Program Policy, dated [DATE], revealed the facility failed to implement their policy as after a fall the nurse would complete a series of post fall assessments, interviews, and investigative reports to gather information that would be used to determine contributing factors and root causes to the fall event. The documents were to include Fall SBAR and Neurological Checklist Tool (if indicated). The policy revealed prior to notification to the physician and DON, a Post Fall SBAR tool would be initiated with completion following communications in which physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy revealed if the resident had sustained injuries that required transfer to acute care setting then a interact hospitalization form would be completed. This deficiency substantiates Complaint Number OH 039.

The following deficiency represents an incident of past noncompliance that was subsequently corrected prior to the survey. Based on closed record review, review of facility policy and procedures related to notification of change in condition and fall prevention and management, facility investigation, interviews with facility staff, and Primary Care Physician/ Medical Director #610 the facility failed to notify the physician for one resident (Resident #83), who received anticoagulant therapy, fell out of bed sustaining a head injury. This resulted in Immediate Jeopardy that presented actual harm on [DATE] at 3:00 A.M. when the facility failed to notify the physician when Resident #83 fell out of bed hitting her head, was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Emergency Medical Services pronounced Resident #83 deceased on [DATE] at 5:25 A.M. This affected one resident (Resident #83) of three residents reviewed for change in condition/quality of care. On [DATE] at 2:28 P.M. the Administrator and the Director of Nursing (DON) were notified that Immediate Jeopardy began on [DATE] at 3:00 P.M. when Resident #83 fell resulting in head injury while on anti-coagulants and antiplatelets, and Licensed Practical Nurse (LPN) #600 failed to notify Resident #83 ' s Primary Care Physician/ Medical Director #610. The Immediate Jeopardy was removed and the deficiency was corrected on [DATE] when the facility implemented the following corrective action: · The DON educated LPN #600 on proper notification to the physician, family, and DON of any fall with injury (including an unwitnessed fall). The DON completed the education on [DATE] at 10:20 A.M. Verification on [DATE] at 10:20 A.M. that Regional Director #627 and the DON educated LPN #600. · All licensed nurses were educated on [DATE] on notification to physician, DON, and resident representatives of any fall with injuries (including an unwitnessed fall). The DON completed the education on [DATE] from 10:20 A.M. to 7:00 P.M. of all 21 floor nurses. The facility does not utilize agency staff. Verification revealed all 21 nurses were educated on [DATE]. On [DATE] from 11:22 A.M. to 2:20 P.M. seven of the 21 nurses were interviewed, Registered Nurses (RN ' s) #616, #617, #622, and LPN ' s #605, #623, #624 and #625, and were knowledgeable regarding proper notification to the physician, DON and resident representative of any fall with injuries including unwitnessed fall. · The Administrator or Designee will present to the Quality Assurance and Performance Improvement (QAPI) meeting monthly for two months then will present randomly. The facility has not had a QAPI since the event on [DATE]. The next scheduled QAPI is [DATE]. · All new hire nurses will be educated to call the Physician and DON immediately of listed events that included any unwitnessed fall or fall with injury verbally and with written education during orientation per the DON or Designee. The facility has not hired any new nurses since the incident on [DATE]. · Review of residents that have fallen in the morning clinical meeting daily to ensure notification to family, physician and resident representative was done timely starting [DATE]. The facility DON or Designee will conduct daily audits of falls starting [DATE] Monday through Friday for three months and then three times weekly. Verification revealed daily audits Monday through Friday were completed since [DATE]. · LPN #600 was suspended pending investigation. She currently on Family Medical Leave of Absence (FMLA) for medical reasons. Findings included: Review of the closed medical record for Resident #83 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #83 expired at the facility on [DATE]. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #83 had a Brief Interview for Mental Status (BIMS) score of a 14, indicating she was cognitively intact, and required extensive assist of one person with bed mobility, ambulation, transfers, toileting, and locomotion. Review of the form titled Critical Admission assessment dated [DATE] completed by RN #616 revealed Resident #83 required one person assist with transfers and ambulation. The fall risk assessment was combined in this assessment and revealed Resident #83 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated [DATE] revealed the resident was at risk for falls due to a history of falls at home, weakness, impaired balance, and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included evaluate need for bed and chair alarms, increased staff supervision with intensity based on the resident ' s need and provide individualized toileting interventions based on needs and patterns. Review of the care plan dated [DATE] revealed Resident #83 was at risk for injury and bleeding due to use of anticoagulant medication related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included observe for signs of active bleeding such as nosebleeds, hematoma, and abdominal pain, and protect the resident from injury and trauma. Review of the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing notes dated [DATE] at 3:00 A.M. authored by LPN #600 revealed the nurse was walking down the hallway and observed Resident #83 on the floor on the side of her bed on her left side. Resident #83 was alert to her name but confused to time and place. Resident #83 was asked how she fell , and she stated she was looking for her stroller and pointed to her wheelchair on the other side of the room. LPN #600 completed a range of motion assessment, and range of motion was within normal limits. Two staff assisted Resident #83 into her wheelchair and observed a scrape to her left lower back. LPN #600 cleansed the scrape with normal saline and added ointment. LPN #600 palpated two bumps to the back of Resident #83 ' s head that were purplish reddish in color with no drainage. Resident #83 denied pain or discomfort and neurological monitoring was started. The nursing note stated the power of attorney, DON, and physician were to be notified in the morning. Review of the facility form labeled Neurological Monitoring, dated [DATE], revealed LPN #600 completed neurological monitoring for Resident #83 after her fall. On [DATE] at 3:00 A.M. Resident #83 ' s blood pressure was ,d+[DATE], pulse 63, respirations 18, temperature 97.5 degrees Fahrenheit, she was fully conscious, she had movement of all extremities, her hand grasp was equal and strong, her speech was clear, and her pupil reaction was brisk. On [DATE] at 3:15 A.M., 3:30 A.M., and 3:45 A.M. Resident #83 ' s neurological monitoring remained relatively the same. Review of the monitoring documentation revealed on [DATE] at 4:00 A.M. Resident #83 ' s blood pressure dropped to ,d+[DATE], at 4:15 A.M. her blood pressure dropped to ,d+[DATE], at 4:30 A.M. her blood pressure dropped to ,d+[DATE]. Review of Neurological Monitoring form revealed on [DATE] at 4:45 A.M. Resident #83 ' s level of consciousness changed to lethargic and responding slowly to verbal stimuli, she had no movement to the extremities, had no hand grasp, her pupils were sluggish, her speech was aphasic, blood pressure had dropped to ,d+[DATE], and her respirations were 12. Review of the nursing notes dated [DATE] at 10:18 A.M. authored by LPN #608 revealed Resident #83 was sitting at the nursing station and at 4:55 A.M. was noted to be unresponsive and staff assisted her to her room. Emergency Medical Services (EMS) was called, and Resident #83 was assisted to the floor. The resident had no pulse or breath sounds. CPR was initiated at 5:00 A.M. and continued until EMS arrived at the facility at 5:20 A.M. EMS pronounced Resident #83 deceased at 5:25 A.M. Resident #83 ' s daughter was notified on [DATE] at 5:30 A.M. Resident #83 ' s Primary Care Physician #610 was notified on [DATE] at 5:35 A.M. and the Coroner ' s office was notified on [DATE] at 6:00 A.M. Review of the facility investigation labeled Fall Investigation dated [DATE] revealed on [DATE] at approximately 2:00 A.M. rounds were completed by the state tested nurse aides (STNAs), and Resident #83 was in bed resting at that time. On [DATE] at approximately 3:00 A.M., LPN #600 was walking towards the nursing station and observed Resident #83 on the floor on her left side. LPN #600 performed range of motion without difficulties and there were no abnormalities to the front of Resident #83 ' s face. LPN #600 with the assistance of STNA ' s transferred the resident to her wheelchair and took the resident to the nursing station and initiated neurological monitoring. LPN #600 indicated she observed two bumps to the back of Resident #83 ' s head with no drainage and an abrasion to her back while observed at the nursing station. Resident #83 was placed back in bed by the STNA ' s. The investigation indicated Resident #83 was attempting to get out of bed, so LPN #608 indicated Resident #83 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . While the STNA ' s were taking Resident #83 to get her weight, Resident #83 became unresponsive at approximately 4:55 A.M. LPN ' s #600 and #608 immediately took Resident #83 to her room, lowered to her to the floor, and CPR was initiated. 911 was contacted at 4:55 A.M. and CPR continued with LPN #626 arriving to assist. LPN #600 exited the room to assist with paperwork. CPR continued until EMS arrived at 5:20 A.M. and took over CPR and pronounced the resident expired at 5:25 A.M. Findings of the investigation revealed LPN #600 failed to notify the physician, DON and family at time of fall. Review of the facility investigation labeled Fall Action Plan/ PNC dated [DATE] and completed by the Administrator revealed the purpose of the action plan was because the nurse failed to notify the physician with change in neurologic condition. The investigation revealed there was a concern leading to the action plan development due to the fall occurred at the facility for Resident #83, and LPN #600 failed to notify the family and the physician when the fall occurred and failed to notify the physician when a change in condition with the change in neurological checks was identified. Review of untitled form with interview questions dated [DATE] revealed the DON asked LPN #600 what Resident #83 hit to cause the scrape and bump to her head, and LPN #600 revealed she did not know. LPN #600 was asked when Resident #83 fell if she followed the fall protocol, and LPN #600 revealed she did not complete the Fall Situation-Background-Assessment-Recommendation (SBAR) report. LPN #600 was asked if during neurological checks Resident #83 ' s blood pressure had a significant drop, and LPN #600 stated yes. LPN #600 was asked if she notified the physician, and LPN #600 stated no. LPN #600 was asked if during the neurological checks if Resident #83 ' s level of consciousness changed, and she stated yes, after two hours. Review of the Witness Statement dated [DATE] completed by LPN #600 revealed she was walking down the hallway and glanced into Resident #83 ' s room and saw her lying on the floor beside her bed. LPN #600 performed range of motion and it was within normal limits. LPN #600 took Resident #83 down to the nursing station in a wheelchair and asked the resident if she was having any pain or discomfort, and she stated no. LPN #600 began neurological checks, and Resident #83 continued to talk with staff. LPN #600 stated she rubbed the resident ' s head, and she noticed two bumps to her head. She revealed staff took her to her room because she stated she was tired and placed her into bed. LPN #600 revealed LPN #608 stated Resident #83 needed a weight because she had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #600 revealed Resident #83 became unresponsive and was taken back to her room and placed on the floor for CPR. Interview on [DATE] at 4:08 P.M. with the Administrator and DON revealed LPN #600 failed to notify the physician at the time of Resident #83 ' s fall with head injury and after Resident #83 ' s change in neurological status when her blood pressure significantly dropped. LPN #600 continued to fail to contact the physician regarding Resident #83 ' s change in condition. The DON and Administrator indicated they interviewed and investigated the incident, and LPN #600 admitted at the time of the incident she was having memory problems. They suspended LPN #600, and she was going to contact her physician to seek a medical evaluation. They verified she should have notified the physician at the time of Resident #83 ' s fall as she had two bumps to her head and was on blood thinning medications, and they verified she should have contacted the physician when Resident #83 ' s blood pressure dropped significantly. The DON and Administrator stated LPN #600 did not follow their policy regarding change in condition. They revealed they implemented an immediate corrective action plan to prevent a reoccurrence. Interview on [DATE] at 4:50 P.M. with STNA #606 revealed LPN #600 found Resident #83 on the floor and assessed her while on the floor. STNA #606 revealed they then got her up and put her in her wheelchair. She revealed Resident #83 appeared to have dry heaves and complained of not feeling well at approximately 4:00 A.M. She revealed they assisted her back in bed at 4:15 A.M. and after placing her back in bed at 4:15 A.M., Resident #83 stated she continued to not feel well. She revealed LPN #600 was aware of Resident #83 not feeling well as she continued to check on her and do her vitals. She revealed LPN #608 came in and was the nurse on the floor for Resident #83, and at approximately 5:00 A.M. LPN #608 had asked her to get a weight on Resident #83. STNA #606 revealed she brought it up to LPN #608 that she did not think it was right to weigh Resident #83 as she was not feeling well, and she had fallen. STNA #606 stated LPN #608 still requested the weight be obtained. STNA #606 stated she and STNA #607 obtained Resident #83 ' s weight, and she was weaker than usual. She usually required only one-person assist to transfer out of bed, and she required twoperson assist and was having difficulty. She revealed she notified LPN #608, and she left Resident #83 at the nursing station while she started performing rounds on other residents. A short time later, LPN #600 came and got her and stated Resident #83 was coding, and they needed assistance to get her out of the chair onto the floor. Interview on [DATE] at 5:36 P.M. with LPN #608 revealed she came in early on [DATE] at approximately 4:30 A.M. and started to get report from LPN #600. She revealed she did remind the STNA ' s on the floor Resident #83 was a daily weight prior to getting report. LPN #608 revealed STNA #606 and #607 never reported to her that Resident #83 was not feeling well, any concerns about getting her weight or any concerns that she required more assistance with transferring. She revealed Resident #83 was at the nursing station while she was getting report and was having more trouble focusing, had decreased alertness, and rapidly declined. They took her back to her room and lowered her to the floor as she did not have a pulse, and she started CPR. Interview on [DATE] at 11:49 A.M. with LPN #600 revealed she found Resident #83 on the floor and assessed Resident #83, but she revealed she only checked the front of her head. She stated, it was like I forgot what to do as a nurse, I do not know what happened just forgot what steps to take. LPN #600 revealed she brought Resident #83 to the nursing station and about an hour later, it came to her to check the back of Resident #83 ' s head. LPN #600 stated she felt the back of Resident #83 ' s head and noticed two bumps on the back of her head. LPN #600 stated again something seemed to go wrong with her memory as she could not remember what to do next such as call the physician. She revealed her thought process just continued to leave her during the event on [DATE] as she did not call the physician at the time of the fall or after she assessed and found the bumps on the back of Resident 83 ' s head. She revealed she continued to complete the neurological checks including vital signs, and she stated at the time it did not register that Resident #83 ' s blood pressure significantly declined until after the DON educated her and asked why she did not call the physician earlier. That was when she realized Resident #83 ' s blood pressure had significantly decreased. She revealed it felt like she was in shock that evening after Resident #83 ' s fall and she verified she did not follow the facility procedure in calling the physician after Resident #83 ' s fall with head injury or after Resident #83 ' s change in condition with her blood pressure decreasing. LPN #600 revealed when Resident #83 coded LPN #608 took over, and she completed the CPR. LPN #600 stated she again froze and could not assist with CPR as she forgot the steps of CPR. She revealed she contacted her primary care physician to get checked out as she was having memory problems and currently remains off duty due to medical issues. Interview on [DATE] at 3:51 P.M. with Primary Care Physician/ Medical Director #610 revealed she had a discussion with the coroner and felt Resident #83 had multiple comorbidities. She stated she signed the death certificate but could not remember exactly what she wrote as the cause of death but stated she thought she included cardiac death, [CONDITION(S)], [CONDITION(S)], and from the recent fall. She revealed she had reviewed Resident #83 ' s fall that occurred on [DATE] at 3:00 A.M. and stated the facility should have notified her right away of the fall especially because Resident #83 had hit her head and was on blood thinners. She revealed she would have ordered Resident #83 immediately sent to the hospital for evaluation after the fall. Primary Care Physician/ Medical Director #610 then reviewed the neurological monitoring form and stated Resident #83 ' s blood pressure significantly declined which is indicative of head trauma, and she stated the facility should have notified her of the decrease in blood pressure as she would have ordered her to be sent to the hospital. Primary Care Physician/ Medical Director #610 verified the facility did not notify her of Resident #83 ' s fall or change in condition as the facility notified her after Resident #83 expired on [DATE] at 5:35 A.M. Review of facility policy labeled Notification Of Change, dated [DATE], revealed the facility failed to implement their policy as the residents physician and responsible party were to be notified when an event involving the resident occurred or when the resident experienced a change in condition. The policy revealed to notify the physician immediately if the resident required immediate action and call 911 in emergency which included fall with head or neck injury. Review of facility policy labeled Fall Prevention and Management Program Policy, dated [DATE], revealed the facility failed to implement their policy as after a fall the nurse would complete a series of post fall assessments, interviews, and investigative reports to gather information that would be used to determine contributing factors and root causes to the fall event. The documents were to include Fall SBAR and Neurological Checklist Tool (if indicated). The policy revealed prior to notification to the physician and DON, a Post Fall SBAR tool would be initiated with completion following communications in which physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy revealed if the resident had sustained injuries that required transfer to acute care setting then a interact hospitalization form would be completed. This deficiency substantiates Complaint Number OH 039.

Based on observation, interview, record review and policy review, the facility failed to ensure adequate interventions were implemented to prevent the development of a pressure ulcer to Resident #3's right hip area. Actual Harm occurred on 02/22/21 when Resident #3, who required one staff assist with bed mobility and transfers, was found to have an unstageable pressure ulcer (a wound caused by pressure that had full thickness tissue loss in which the base of the ulcer was covered by slough (nonviable dead tissue that is white or yellow in appearance) while getting ready for a shower and assessed by Registered Nurse (RN)/ Wound Nurse #604. This affected one resident (Resident #3) of three residents (Residents #3, #16, and #83) reviewed for pressure ulcers. The facility identified eight current residents with pressure ulcers (Residents #2, #3, #7, #11, #16, #22, #30 and #60). The facility census was 71. Finding include: Review of the medical record for Resident #3 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 11/06/20 revealed Resident #3 was at risk for skin breakdown related to impaired mobility and weakness. Interventions included assess resident for presence of risk factors, avoid shearing of resident's skin during positioning and turning, report any signs of skin breakdown, turn and reposition every two hours and as needed, and a pressure reducing mattress for pressure reduction. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had impaired cognition and required extensive assist of one staff for bed mobility, transfers, and ambulation. She was frequently incontinent of bowel and bladder. She was at risk for pressure ulcers but had no pressure ulcers. She had pressure reducing devices to her bed and chair. Review of the Braden Scale for predicting pressure ulcers dated 02/21/21 completed by Licensed Practical Nurse (LPN) #626 revealed Resident #3's sensory perception was slightly limited, she was occasionally moist, she was very limited with mobility, and probably had inadequate nutrition. She was at moderate risk for skin issues. Review of the facility form labeled, SBAR Communication Form dated 02/22/21 completed by RN/ Wound Nurse #604 revealed Resident #3 had a pressure injury with slough covering the ulceration to her right hip. Nurse Practitioner #628 was notified and ordered a treatment to the area. There were no measurements identified on this form. Review of the nursing notes dated 02/22/21 at 12:59 P.M. completed by RN/Wound Nurse #604 revealed Resident #3 had an ulceration to her right hip that was noted when she was getting ready for her shower. Nurse Practitioner #628 and Resident #3's daughter were notified. A new order for [MEDICATION(S)] (used for [MEDICATION(S)], moist wound healing and odor control) and alginate (used for heavily draining wounds) was received. Review of the care plan dated 02/22/21 revealed Resident #3 had an unstageable pressure ulcer to her right hip related to increased weakness and decreased mobility. Interventions included apply dressing as ordered, assess the pressure ulcer for stage, size, and condition weekly and as needed, supplements as ordered, turn, and reposition every two hours as tolerated and pressure reduction cushion when in chair. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Weekly Pressure Ulcer Progress Report dated 03/01/21 completed per RN/Wound Nurse #604 revealed Resident #3's date of initial discovery of her facility acquired pressure area to her right hip was on 02/22/21. The area was described as an unstageable with scant amount of serous exudate (fluid draining from the wound) that measured 2.2 centimeters (cm) in length, 2.5 cm in width and 0.1 cm in depth. The area had slough and was debrided by the nurse practitioner. Review of the nursing notes dated 03/01/21 at 8:54 A.M. completed by RN/Wound Nurse #604 revealed Wound Nurse Practitioner #629 was in to see Resident #3 and Resident #3's unstageable pressure area to her right hip was covered in slough and needed debrided by the nurse practitioner. There were no new orders at that time. Review of Wound Nurse Practitioner #629's progress note dated 03/01/21 revealed Resident #3 had a new in-house acquired pressure wound to her right trochanter area. She classified the wound as unstageable with 80 percent slough. Wound Nurse Practitioner #629 debrided the wound. She recommended pressure redistribution mattress, and cushion to wheelchair, float heels, and she would evaluate next on 03/08/21. Review of care plan dated 03/15/21 revealed Resident #3 wished to sleep in her recliner as she stated her bed was comfortable, but she had slept in her recliner at home and desired to continue with the same process. Interventions included allow Resident #3 to sleep in her recliner as she desired. Review of the last Weekly Pressure Ulcer Report dated 03/22/21 completed by RN/Wound Nurse #604 revealed Resident #3 continued to have an unstageable pressure ulcer to her right hip that measured one cm in length, 1.1 cm in width and 0.2 cm in depth and continued to have scant amount of serous exudate (thin and clear). Review of the nursing note dated 03/22/21 at 10:07 A.M. completed by RN/Wound Nurse #604 revealed Wound Nurse Practitioner #629 was in to see Resident #3. Resident #3's pressure ulcer continued to be an unstageable to her right hip and the area was covered with slough. There were no new orders. Interview on 03/25/21 at 1:54 P.M. and on 03/30/21 at 8:45 A.M. with RN/Wound Nurse #604 revealed Resident #3's pressure ulcer to her right hip was found at as unstageable and the wound contained slough to the center of the wound when they first observed the wound. She revealed Resident #3 liked to sleep on her right side which was most likely how she developed the pressure ulcer. She revealed unfortunately the wound was found on a Monday at an unstageable stage and she was not on the weekend but usually the nurses call her if they find a pressure area before it becomes an unstageable. She verified she did not have any documentation Resident #3 was noncompliant with turning and that she was to be turned every two hours. She verified it was only care planned on 03/15/21 several weeks after the pressure ulcer was found that she liked to sleep in her recliner. Observation of wound care for Resident #3 on 03/25/21 at 1:54 P.M. completed by RN/Wound Nurse #604 revealed she had an unstageable pressure ulcer to her right hip that contained 50 percent yellow slough and healthy granular tissue surrounded the wound. Resident #3's treatment was completed as ordered and no concerns were noted with the wound care. Interview on 03/25/21 at 2:03 P.M. with Resident #3 revealed she use to sleep on her right side and that was why she most likely developed the pressure ulcer. She revealed staff do not usually come into her room at night to turn or reposition her as when she goes to bed, she usually does not see any staff till around 5:00 A.M. when the nurse brings in her medication. She revealed now she slept on her left side and revealed staff still do not turn her at night but that was probably ok because she may have a hard time falling back to sleep. She shrugged her shoulders and revealed she was unsure if she would have trouble as they had never tried to turn her in the middle of the night. Review of facility policy labeled Pressure Wounds dated June 2016 revealed pressure wounds occur when tissue was compressed between bony prominences and external surfaces. The policy revealed it was important to recognize and evaluate all areas at risk for constant pressure. Critical steps revealed in pressure wound prevention and healing included identifying the individual at risk, identifying and evaluating risk factors ad changes in the resident's condition, identifying and evaluation factors that can be removed or modified, implementing individualized interventions to attempt to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions and modifying the interventions as appropriate. This deficiency substantiates Master Compliant Number OH 039.

Based on interview, record review, review of facility investigation and action plan, and review of facility abuse policy, the facility failed to report an allegation of neglect involving Resident #83 to the state agency and licensing board. The affected one resident (Resident #83) of three residents reviewed for abuse. This had the potential to affect all 71 residents residing at the facility. Findings include: Review of the closed medical record for Resident #83 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #83 expired at the facility on [DATE]. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #83 had a Brief Interview for Mental Status (BIMS) score of a 14, indicating she was cognitively intact, and required extensive assist of one staff with bed mobility, ambulation, transfers, toileting, and locomotion. Review of the form titled Critical Admission assessment dated [DATE] completed by Registered Nurse (RN) #616 revealed Resident #83 required one person assist with transfers and ambulation. The fall risk assessment was combined in this assessment and revealed Resident #83 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated [DATE] revealed Resident #83 was at risk for falls due to a history of falls at home, weakness, impaired balance, and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included evaluate need for bed and chair alarms, increased staff supervision with intensity based on the resident's need, and provide individualized toileting interventions based on needs and patterns. Review of the care plan dated [DATE] revealed Resident #83 was at risk for injury and bleeding due to use of anticoagulant medication related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included observe for signs of active bleeding such as nosebleeds, hematoma, and abdominal pain, and protect the resident from injury and trauma. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing notes dated [DATE] at 3:00 A.M. authored by Licensed Practical Nurse (LPN) #600 revealed the nurse was walking down the hallway and observed Resident #83 on the floor on the side of her bed on her left side. Resident #83 was alert to her name but confused to time and place. Resident #83 was asked how she fell , and she stated she was looking for her stroller and pointed to her wheelchair on the other side of the room. LPN #600 completed a range of motion assessment, and range of motion was within normal limits. Two staff assisted Resident #83 into her wheelchair and observed a scrape to her left lower back. LPN #600 cleansed the scrape with normal saline and added ointment. LPN #600 palpated two bumps to the back of Resident #83's head that were purplish reddish in color with no drainage. Resident #83 denied pain or discomfort and neurological monitoring was started. The nursing note stated the power of attorney, DON, and physician were to be notified in the morning. There was no documented evidence in the nursing notes Resident #83's bed alarm was sounding at the time of the fall. Review of the facility form labeled Neurological Monitoring, dated [DATE], revealed LPN #600 completed neurological monitoring for Resident #83 after her fall. On [DATE] at 3:00 A.M. Resident #83's blood pressure was ,d+[DATE], pulse 63, respirations 18, temperature 97.5 degrees Fahrenheit, she was fully conscious, she had movement of all extremities, her hand grasp was equal and strong, her speech was clear, and her pupil reaction was brisk. On [DATE] at 3:15 A.M., 3:30 A.M., and 3:45 A.M. Resident #83's neurological monitoring remained relatively the same. Review of the monitoring documentation revealed on [DATE] at 4:00 A.M. Resident #83's blood pressure dropped to ,d+[DATE], at 4:15 A.M. her blood pressure dropped to ,d+[DATE], at 4:30 A.M. her blood pressure dropped to ,d+[DATE]. Review of Neurological Monitoring form revealed on [DATE] at 4:45 A.M. Resident #83's level of consciousness changed to lethargic and responding slowly to verbal stimuli, she had no movement to the extremities, had no hand grasp, her pupils were sluggish, her speech was aphasic, blood pressure had dropped to ,d+[DATE], and her respirations were 12. Review of the nursing notes dated [DATE] at 10:18 A.M. authored by LPN #608 revealed Resident #83 was sitting at the nursing station and at 4:55 A.M. was noted to be unresponsive and staff assisted her to her room. Emergency Medical Services (EMS) was called, and Resident #83 was assisted to the floor. The resident had no pulse or breath sounds. Cardiopulmonary resuscitation (CPR) was initiated at 5:00 A.M. and continued until EMS arrived at the facility at 5:20 A.M. EMS pronounced Resident #83 deceased at 5:25 A.M. Resident #83's daughter was notified on [DATE] at 5:30 A.M. Resident #83's Primary Care Physician #610 was notified on [DATE] at 5:35 A.M., and the Coroner's office was notified on [DATE] at 6:00 A.M. Review of the facility investigation labeled Fall Investigation dated [DATE] revealed on [DATE] at approximately 2:00 A.M. rounds were completed by the state tested nurse aides (STNAs), and Resident #83 was in bed resting at that time. On [DATE] at approximately 3:00 A.M., LPN #600 was walking towards the nursing station and observed Resident #83 on the floor on her left side. LPN #600 performed range of motion without difficulties and there were no abnormalities to the front of Resident #83's face. LPN #600 with the assistance of STNA's transferred the resident to her wheelchair and took the resident to the nursing station and initiated neurological monitoring. LPN #600 indicated she observed two bumps to the back of Resident #83's head with no drainage and an abrasion to her back while observed at the nursing station. Resident #83 was placed back in bed by the STNA's. The investigation indicated Resident #83 was attempting to get out of bed, so LPN #608 indicated Resident #83 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . While the STNA's were taking Resident #83 to get her weight, Resident #83 became unresponsive at approximately 4:55 A.M. LPN's #600 and #608 immediately took Resident #83 to her room, lowered to her to the floor, and CPR was initiated. 911 was contacted at 4:55 A.M. and CPR continued with LPN #626 arriving to assist. LPN #600 exited the room to assist with paperwork. CPR continued until EMS arrived at 5:20 A.M. and took over CPR and pronounced the resident expired at 5:25 A.M. Findings of the investigation revealed Resident #83's alarm was not turned on at the time of the fall, and LPN #600 failed to notify the physician, Director of Nursing (DON) and family at time of fall. Review of the facility investigation labeled Fall Action Plan/ PNC dated [DATE] and completed by the Administrator revealed the purpose of the action plan was because the nurse failed to notify the physician with change in neurologic condition. The investigation revealed there was a concern leading to the action plan development due to the fall occurred at the facility for Resident #83, and LPN #600 failed to notify the family and the physician when the fall occurred and failed to notify the physician when a change in condition with the change in neurological checks was identified. Review of untitled form with interview questions dated [DATE] revealed the DON asked LPN #600 what Resident #83 hit to cause the scrape and bump to her head, and LPN #600 revealed she did not know. LPN #600 was asked when Resident #83 fell if she followed the fall protocol, and LPN #600 revealed she did not complete the Fall Situation-Background-Assessment-Recommendation (SBAR) report. LPN #600 was asked if during neurological checks Resident #83's blood pressure had a significant drop, and LPN #600 stated yes. LPN #600 was asked if she notified the physician, and LPN #600 stated no. LPN #600 was asked if during the neurological checks if Resident #83's level of consciousness changed, and she stated yes, after two hours. Review of the Witness Statement dated [DATE] completed by LPN #600 revealed she was walking down the hallway and glanced into Resident #83's room and saw her lying on the floor beside her bed. LPN #600 performed range of motion and it was within normal limits. LPN #600 took Resident #83 down to the nursing station in a wheelchair and asked the resident if she was having any pain or discomfort, and she stated no. LPN #600 began neurological checks, and Resident #83 continued to talk with staff. LPN #600 stated she rubbed the resident's head, and she noticed two bumps to her head. She revealed staff took her to her room because she stated she was tired and placed her into bed. LPN #600 revealed LPN #608 stated Resident #83 needed a weight because she had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #600 revealed Resident #83 became unresponsive and was taken back to her room and placed on the floor for CPR. Interview on [DATE] at 4:08 P.M. with the Administrator and DON revealed LPN #600 failed to notify the physician at the time of Resident #83's fall with head injury and after Resident #83's change in neurological status when her blood pressure significantly dropped. LPN #600 continued to fail to contact the physician regarding Resident #83's change in condition. The DON and Administrator indicated they interviewed and investigated the incident, and LPN #600 admitted at the time of the incident she was having memory problems. They suspended LPN #600, and she was going to contact her physician to seek a medical evaluation. They verified she should have notified the physician at the time of Resident #83's fall as she had two bumps to her head and was on blood thinning medications, and they verified she should have contacted the physician when Resident #83's blood pressure dropped significantly. The DON and Administrator stated LPN #600 did not follow their policy regarding change in condition. They revealed they implemented an immediate corrective action plan to prevent a reoccurrence. Interview on [DATE] at 4:50 P.M. with STNA #606 revealed LPN #600 found Resident #83 on the floor and assessed her while on the floor. STNA #606 revealed they then got her up and put her in her wheelchair. She revealed Resident #83 appeared to have dry heaves and complained of not feeling well at approximately 4:00 A.M. She revealed they assisted her back in bed at 4:15 A.M. and after placing her back in bed at 4:15 A.M., Resident #83 stated she continued to not feel well. She revealed LPN #600 was aware of Resident #83 not feeling well as she continued to check on her and do her vitals. She revealed LPN #608 came in and was the nurse on the floor for Resident #83, and at approximately 5:00 A.M. LPN #608 had asked her to get a weight on Resident #83. STNA #606 revealed she brought it up to LPN #608 that she did not think it was right to weigh Resident #83 as she was not feeling well, and she had fallen. STNA #606 stated LPN #608 still requested the weight be obtained. STNA #606 stated she and STNA #607 obtained Resident #83's weight, and she was weaker than usual. She usually required only one-person assist to transfer out of bed, and she required two-person assist and was having difficulty. She revealed she notified LPN #608, and she left Resident #83 at the nursing station while she started performing rounds on other residents. A short time later, LPN #600 came and got her and stated Resident #83 was coding, and they needed assistance to get her out of the chair onto the floor. STNA #606 revealed she did not notice any memory impairment or concerns with LPN #600 as she seemed to be acting per her usual self. STNA #606 revealed LPN #608 initiated CPR. Review of the facility self- reported incidents (SRI's) to the state agency dated from [DATE] to [DATE] revealed the facility had not filed a SRI for Resident #83's incident on [DATE]. Interview on [DATE] at 5:36 P.M. with LPN #608 revealed she came in early on [DATE] at approximately 4:30 A.M. and started to get report from LPN #600. She revealed she did remind the STNA's on the floor Resident #83 was a daily weight prior to getting report. LPN #608 revealed STNA #606 and #607 never reported to her that Resident #83 was not feeling well, any concerns about getting her weight or any concerns that she required more assistance with transferring. She revealed Resident #83 was at the nursing station while she was getting report and was having more trouble focusing, had decreased alertness, and rapidly declined. They took her back to her room and lowered her to the floor as she did not have a pulse, and she started CPR. A second interview on [DATE] at 2:50 P.M. with LPN #608 revealed she did not notice any memory impairments with LPN #600 as she seemed her usual baseline while giving her report. She revealed she did not notice any delay with LPN #600 reacting when Resident #83 coded, but she was only focused on initiating CPR. Interview on [DATE] at 11:49 A.M. with LPN #600 revealed she found Resident #83 on the floor and assessed Resident #83, but she revealed she only checked the front of her head. She revealed Resident #83 did not have a bed alarm in place as it was not sounding, and she was not aware Resident #83 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #600 revealed she brought Resident #83 to the nursing station and about an hour later, it came to her to check the back of Resident #83's head. LPN #600 stated she felt the back of Resident #83's head and noticed two bumps on the back of her head. LPN #600 stated again something seemed to go wrong with her memory as she could not remember what to do next such as call the physician. She revealed her thought process just continued to leave her during the event on [DATE] as she did not call the physician at the time of the fall or after she assessed and found the bumps on the back of Resident 83's head. She revealed she continued to complete the neurological checks including vital signs, and she stated at the time it did not register that Resident #83's blood pressure significantly declined until after the DON educated her and asked why she did not call the physician earlier. That was when she realized Resident #83's blood pressure had significantly decreased. She revealed it felt like she was in shock that evening after Resident #83's fall and she verified she did not follow the facility procedure in calling the physician after Resident #83's fall with head injury or after Resident #83's change in condition with her blood pressure decreasing. LPN #600 revealed when Resident #83 coded LPN #608 took over, and she completed the CPR. LPN #600 stated she again froze and could not assist with CPR as she forgot the steps of CPR. She revealed she contacted her primary care physician to get checked out as she was having memory problems and currently remains off duty due to medical issues. Interview on [DATE] at 2:36 P.M. with the Administrator revealed she did file a self-reporting incident to the State Agency regarding the incident that occurred on [DATE] with LPN #600 failing to notify the physician when Resident #83 fell with head injury. The Administrator revealed at the time she did not consider the event as neglect. The Administrator also verified she did not notify the board of nursing in regards to LPN #600. Interview on [DATE] at 3:51 P.M. with Primary Care Physician/ Medical Director #610 revealed she had a discussion with the coroner and felt Resident #83 had multiple comorbidities. She stated she signed the death certificate but could not remember exactly what she wrote as the cause of death but stated she thought she included cardiac death, [CONDITION(S)], [CONDITION(S)], and from the recent fall. She revealed she had reviewed Resident #83's fall that occurred on [DATE] at 3:00 A.M. and stated the facility should have notified her right away of the fall especially because Resident #83 had hit her head and was on blood thinners. She revealed she would have ordered Resident #83 immediately sent to the hospital for evaluation after the fall. Primary Care Physician/ Medical Director #610 then reviewed the neurological monitoring form and stated Resident #83's blood pressure significantly declined which is indicative of head trauma, and she stated the facility should have notified her of the decrease in blood pressure as she would have ordered her to be sent to the hospital. Primary Care Physician/ Medical Director #610 verified the facility did not notify her of Resident #83's fall or change in condition as the facility notified her after Resident #83 expired on [DATE] at 5:35 A.M. Review of self-reported incident (SRI) with tracking number # 3 was filed per the Administrator on [DATE] at 4:46 P.M. regarding Resident #83's incident on [DATE]. Review of form labeled, Supplemental Information Form for Employers dated [DATE] revealed the Administrator notified the board of nursing regarding the incident for Resident #83 that had occurred on [DATE] involving LPN #600. Review of facility policy labeled Notification Of Change, dated [DATE], revealed the facility failed to implement their policy as the residents physician and responsible party were to be notified when an event involving the resident occurred or when the resident experienced a change in condition. The policy revealed to notify the physician immediately if the resident required immediate action and call 911 in emergency which included fall with head or neck injury. Review of facility policy labeled Fall Prevention and Management Program Policy, dated [DATE], revealed the facility failed to implement their policy as after a fall the nurse would complete a series of post fall assessments, interviews, and investigative reports to gather information that would be used to determine contributing factors and root causes to the fall event. The documents were to include Fall SBAR and Neurological Checklist Tool (if indicated). The policy revealed prior to notification to the physician and DON, a Post Fall SBAR tool would be initiated with completion following communications in which physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy revealed if the resident had sustained injuries that required transfer to acute care setting then a interact hospitalization form would be completed. Review of facility policy labeled, Abuse Preventions program policy and Procedure dated [DATE] revealed neglect was defined in the policy as the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of facility policy labeled, Abuse Preventions and Program Seven Components dated [DATE] revealed the facility failed to implement their policy as all alleged or suspected violations were to be reported to the State Survey Agency, Adult protective Services, Local Public Health, Licensure Boards, and any other agencies in the accordance with the state law through established process. The facility was to report all alleged violations of abuse, neglect, exploitation, or mistreatment immediately no later than two hours after the allegation was made if the allegation involved abuse or result in serious bodily injury. The facility was to report no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily harm. This deficiency substantiates Master Complaint Number OH 039 and Complaint Number OH 949.