Every finding on record at Avalon by Otterbein at Perrysburg

Based on medical record review, observation, staff interviews, and review of facility policy, the facility failed to ensure infection control practices were maintained while performing wound care. This affected one (Resident #28) of one resident observed during wound care. The facility census was 54.Findings include:Review of the medical record for Resident #28 revealed she was admitted on [DATE] with diagnoses including chronic kidney disease, heart failure, and type two diabetes mellitus.Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #28 experienced moderate cognitive impairment and did not exhibit any behaviors nor refusals of care during the assessment period. Resident #28 had a diabetic foot ulcer.Review of the physician orders for Resident #28 revealed an order dated 08/27/26 to apply calcium alginate with silver to her right heel diabetic area and cover with bordered gauze every afternoon.Observation on 08/27/26 at 12:35 P.M. revealed Licensed Practical Nurse #103 was going to perform wound care for Resident #28. LPN #103 did not perform hand hygiene prior to donning gloves for wound care. LPN #103 changed her gloves four times while providing wound care and did not perform hand hygiene prior to applying new gloves.Interview on 08/27/26 at 12:45 P.M. with LPN #103 confirmed she did not perform hand hygiene between glove changes while providing wound care for Resident #28.Interview on 08/27/26 at 12:50 P.M. with the Director of Nursing confirmed hand hygiene should occur between glove changes while providing wound care.Review of the facility policy titled Hand Hygiene Procedure, dated 03/27/25, revealed facility staff would perform hand hygiene after removing personal protective equipment.This was an incidental finding discovered during the complaint investigation.

Based on review of the refrigerator temperature logs, staff interview, and review of facility policy, the facility failed to ensure the medication refrigerator temperature was monitored to ensure safe storage of medications. This had the potential to affect all residents at the facility. The facility census was 58. Findings include:Review of the medication refrigerator temperature logs for January 2025 through August 2025 revealed no evidence the facility monitored the temperature on nine days in January 2025, 13 days in February 2025, 18 days in March 2025, 15 days in April 2025, 26 days in May 2025, 14 days in June 2025, and 26 days in July 2025. Interview on 08/13/25 at 8:15 A.M. with Assistant Director of Nursing (ADON) #604 confirmed the facility did not have evidence the medication refrigerator temperatures were monitored as identified above, and it should have been monitored daily. ADON #604 stated the medication refrigerator could, at any time, contain medications for any resident in the facility. Review of facility policy dated 07/09/21 and titled Medication Storage revealed refrigerated medications would be stored at 36 to 46 degrees Fahrenheit (F).

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure insulin was administered per physician orders. This affected four (#13, #20, #08, #19) of four residents reviewed for insulin administration. The facility census was 58. Findings include:1. Review of Resident #13's medical record revealed an admission date of 04/02/25. Diagnoses included dementia, Type I diabetes mellitus, osteoarthritis, hyperlipidemia, depression, and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 07/09/25, revealed Resident #13 was moderately cognitively impaired, received insulin injections on seven of seven days of the look back period and exhibited no rejection of care. Review of the care plan, dated 04/02/25, revealed Resident #13 had diabetes, with an outcome goal to be free of signs and symptoms of hyperglycemia (high blood sugar). Interventions included to administer medications as ordered. Review of the physician orders revealed Resident #13 had an order dated 04/03/25 for Lantus (a slow acting insulin), inject 15 units subcutaneously (under the skin) one time a day in the morning. The order was discontinued on 06/17/25. Further review revealed an order dated 06/18/25 for Lantus, inject 25 units subcutaneously in the morning. The order was discontinued on 07/24/25. Additionally, Resident #13 had an order dated 07/29/25 for Lantus, inject 25 units subcutaneously twice a day, one time in the morning and one time at bedtime. Lastly, none of the three Lantus orders included parameters to withhold Lantus administration. Review of the Medication Administration Record (MAR) from 06/01/25 through 08/11/25 revealed Resident #13 was not administered her bedtime dose of Lantus due to her blood sugar (BS) being outside of order parameters on 06/03/25, 06/07/25, 06/08/25, 06/14/25, 06/17/25, 06/19/25, 06/21/25, 06/22/25, 06/25/25, 06/26/25, 07/01/25, 07/03/25, 07/05/25 in the morning, 07/05/25 at bedtime, 07/06/25 at bedtime, 07/08/25 at bedtime, 07/09/25 at bedtime, 07/17/25, 07/23/25, 07/24/25, 07/29/25, 07/31/25, 08/01/25, 08/02/25, 08/03/25, 08/06/25, 08/07/25, and 08/11/25. Additionally, Resident #13's Lantus was not administered for the morning doses on 07/05/25, 07/26/25, 07/30/25, and 08/10/25, with the documented reason being her BS was outside of order parameters. Interview on 08/14/25 at 3:12 P.M. with the Director of Nursing (DON) verified Lantus was not administer to Resident #13 on the above dates and further confirmed the physician orders did not include any parameters to withhold the administration of Lantus. The DON stated there was no reason Lantus was withheld. 2. Review of the medical record for Resident #20 revealed she was admitted on [DATE] with diagnoses that included Type two diabetes mellitus, hypertension, and stage four chronic kidney disease. Review of a physician order dated 04/16/25 revealed Resident #20 was ordered 30 units of Insulin Glargine (long-acting insulin) each evening, with no parameter exclusions included in the order. Further review revealed an order dated 04/17/25 for 35 units of Insulin Glargine each morning, with no parameter exclusions included in the order. Review of the MAR from 06/01/25 through 08/14/25 revealed for Resident #20 was not administered Insulin Glargine due to outside of parameters for administration on the mornings of 06/04/25, 06/05/25, 06/10/25, 06/14/25, 06/15/25, 06/16/25, 06/17/25, 06/19/25, 06/24/25, 06/30/25, 07/01/25, 07/03/25, 07/04/25, 07/06/25, 07/10/25, 07/11/25, 07/18/25, 07/21/25, 07/22/25, 07/23/25, 07/24/25, 07/26/25, 07/28/25, 07/29/25, 08/02/25, 08/03/25, 08/04/25, 08/05/25, 08/06/25, 08/07/25, 08/08/25, 08/11/25, 08/13/25 and 08/14/25. Additionally, Insulin Glargine was also held for the reason outside of parameters for administration on the evening of 07/28/25. Interview on 08/14/25 at 3:12 P.M. with the DON verified Resident #20's medication was documented as not administered on the above dates due to being outside of parameters . Further interview with the DON verified Resident #20's Insulin Glargine orders did not have parameters for administration and it should have been administered as ordered. 3. Review of the medical record for Resident #8 revealed and admission date of 01/06/21. Diagnoses included Type two diabetes mellitus, hypertension, and dementia. Review of the physician order dated 03/07/25 revealed Resident #8 was ordered 18 units of Lantus twice daily. The order did not include parameters for withholding the medication. Review of the MAR from 06/01/25 through 08/14/25 revealed Resident #8's Lantus was held for the reason outside of parameters for administration on the mornings of 06/19/25, 06/26/25, 07/10/25, 07/23/25, and 08/02/25. Further review revealed Lantus was also held for the reason outside of parameters for administration on the evening of 06/29/25. Interview on 08/14/25 at 3:12 P.M. with the DON confirmed Resident #8's Lantus was held on the above dates with the reason being documented as outside of parameters for administration. Further interview with the DON verified Resident #8's Lantus order did not include parameters for administration and should not have been held. 4. Review of Resident #19's medical record revealed an admission date of 07/18/25. Diagnoses included cellulitis of the lower limbs, back pain, and Type II diabetes. Review of Resident #19's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight, indicating Resident #19 was moderately cognitively impaired and received insulin injections. Review of Resident #19's care plan, revised 07/30/25, revealed supports and interventions for anticoagulant therapy, self-care deficit, impaired cognitive function, mood problem, risk for falls, and diabetes. Interventions for diabetes was to administer her medications as ordered. Review of Resident #19's physician orders revealed an order dated 07/18/25 for Insulin Glargine 100 units per milliliter (ml). Inject 10 units at bedtime for high glucose. Further review of the order revealed no parameters for withholding the medication. Review of Resident #19's MAR revealed on 07/28/25, Resident #19's Insulin Glargine was not administered at bedtime. The reason code indicated this was due to Resident #19 being out of parameters. Interview on 08/14/25 at 3:25 P.M. with the DON verified Resident #19's Insulin Glargine had been held on 07/28/25 and long-acting insulin should never be held unless ordered by the physician. Review of the facility policy titled, Medication Administration Policy, revised 07/09/21, revealed medications would be administered as prescribed.

Based on observation, staff interview, and review of facility policy the facility failed to ensure foods were properly stored and kitchens were maintained in a safe and sanitary manner. This affected 35 residents who resided in House 1 (#1, #3, #6, #7, #8, 10, #17, #27, #31, #35, #50 #58), House 2 (#4, #11, #14, #22, #25, #29, #36, #38, #42, #44, #53, #57) and House 5 (#2, #5, #12, #15, #40, #54, #61, #66, #67, #68, #69) who were identified by the facility as receiving food from the kitchen. The facility census was 58. Findings include: Observation on 08/11/25 at 8:34 A.M. of the kitchen in House 2 found the reach in freezer to have a frozen brown substance approximately two inches in length hanging between the bars of shelf. The freezer also had dust build-up along the bottom grating and debris and food build up in the bottom. A partially used bottle of Worcestershire sauce, with an opened date of 05/21/25 and and labeled refrigerate after opening, was stored on the dry storage shelf. Additionally, an open container of sanitization wipes was being stored in a lower cupboard next to an open bottle of vanilla. Interview on 08/11/25 at 8:42 A.M. with Admissions Staff (AS) #656 verified the reach in freezer had food and dust build-up, a frozen brown substance hanging on the shelf, the Worcestershire sauce was open on the dry storage shelf, and the open cleaning supplies were improperly stored next to food items. Observation on 08/11/25 at 8:49 A.M. of the kitchen of House 1 found a can of dented corn in line for use and an open and unsealed package of pecan cookies and an open and unsealed package of fudge stripe cookies on the shelf of the dry storage area. Interview on 08/11/25 at 8:58 A.M. with Certified Nursing Assistant (CNA) #607 verified the dented can in line for use and the cookies were open and had not been reclosed on the dry storage shelf. Observation on 08/11/25 at 9:08 A.M. of the House 5 kitchen preparation area found an open, partially use 1.5 liter bottle of coffee creamer on the counter. The bottle pump was broken off the top and there was spilled, dried creamer built up covering the majority of the exterior of the bottle. Interview on 08/11/25 at 9:15 A.M. with CNA #628 verified the coffee creamer bottle was broken, spilled, and should have been thrown away. CNA #628 then disposed of the coffee creamer. Review of the facility policy titled, Food Storage Policy and Procedure, revised May 2013 revealed the policy was to assure all food was stored, labeled, and dated to assure stock rotation and prevent food illnesses.

Based on medical record review, review of the pharmacy Monthly Medication Reviews (MMR), review of the pharmacy recommendations, staff interview and review of facility policy, the facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner. This affected two (#4 and #48) of five residents reviewed for unnecessary medications. The facility census was 58.Findings include: 1. Record review for Resident #4 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #4 included Parkinson's disease, diabetes Type two, heart disease, and brief psychotic disorder. Review of Resident #4's Minimum Data Set, (MDS), dated [DATE], revealed the resident had mildly impaired cognition. Review of the pharmacy MMRs revealed the pharmacist reviewed Resident #4's medications on 01/18/25, 02/08/25, and 03/09/25, and made recommendations to the physician. Further review of Resident #4's medical record and the pharmacy recommendations revealed no evidence of what the pharmacist's recommendations were on 01/18/25, 02/08/25, or 03/09/25 or that the physician reviewed and addressed the recommendations. Interview on 08/18/25 at 9:30 A.M. with the Director of Nursing, (DON), verified there was no documentation of the pharmacist's recommendations for 01/18/25, 02/08/25 or 03/09/25 or the physician's response to the recommendations. 2. Review of the medical record for Resident #48 revealed and admission date of 08/18/23. Diagnoses included parkinsonism, myasthenia gravis, multi-system degeneration of the autonomic nervous system, dystonia, and dysphagia. Review of the pharmacy recommendation dated 06/18/25 revealed the pharmacist recommended Resident #48's blood pressure (BP) readings be recorded on the Medication Administration Record (MAR) for the administration of midodrine (medication used to increase BP) and to have parameters for the medication to be held for a systolic (top number in BP) greater than 130 milliliters of mercury (mmHg). Further review revealed no physician response to the recommendation. A note on the document stated done and was signed by the DON on 07/29/25, 41 days after the recommendations was received. Review of a second pharmacy recommendation dated 06/18/25 revealed the pharmacist recommended midodrine not be given at bedtime, with the last dose being given four hours before bedtime and no later than 6:00 P.M. to prevent supine hypertension. Further review revealed no physician response to the recommendation. A note on the documented indicated the medication was changed to twice daily and was signed by the DON on 07/29/25, 41 days after the recommendation was received. Review of the progress notes from 06/18/25 through 07/29/25 revealed no evidence the physician was updated or provided verbal orders related to the pharmacy recommendations dated 06/18/25. Interview on 08/13/25 at 2:30 P.M. with the DON confirmed the pharmacy recommendations dated 06/18/25 were dated as completed on 07/29/25 and signed by her. Further interview with the DON revealed she was unable to state the timeframe for the physician's response to a pharmacy recommendation. A follow-up interview on 08/13/25 at 3:50 P.M. with the DON revealed the physician gave the pharmacy recommendations dated 06/18/25 for Resident #48 to her to complete. Review of the facility policy titled, Medication Regimen Review Policy, dated 11/13/17, revealed the pharmacist must report any irregularities to the attending physician and the physician's must act upon in a manner that meets the needs of the resident.

Based on observation, staff interview, and review of manufacturer instructions, the facility failed to ensure insulin pens were disinfected prior to attaching the needle. This affected one (#27) of one resident reviewed for insulin administration. The facility census was 58.Findings include:Observation on 08/13/25 at 7:55 A.M. revealed Licensed Practical Nurse (LPN) #611 prepared Insulin Glargine and insulin aspart for administration to Resident #27. LPN #611 attached a needle to each insulin pen, without disinfecting the rubber stoppers of the insulin pen tips prior to attaching the needed, and proceeded to administer the medications as ordered. Interview on 08/13/25 at 8:08 A.M. with LPN #611 confirmed she did not disinfect the rubber stoppers of the insulin pen tips prior to attaching the needles.Interview on 08/13/25 at 8:15 A.M. with Assistant Director of Nursing (ADON) #604 revealed the rubber stoppers of insulin pen tips should have been disinfected prior to attaching the needles.Review of the manufacturer instructions for the insulin aspart pen delivery system revealed the first step when preparing an insulin pen for administration was to disinfect the rubber stopper of the pen tip with alcohol prior to attaching the needle to the pen.

Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure active physician orders for the administration of oxygen therapy and further failed to ensure oxygen tubing was dated. This affected three (#1, #3, and #10) of three residents reviewed for oxygen use. The facility census was 58. Findings include:1. Review of the medical record for Resident #1 revealed an admission date of 04/15/25. Diagnoses included chronic obstructive pulmonary disease (COPD) and a history of COVID-19. Review of the Minimum Data Set (MDS) assessment, accepted date of 08/14/25, revealed Resident #1 was cognitively intact and received oxygen therapy. Observations on 08/12/25 at 8:25 A.M. and at 4:45 P.M. revealed Resident #1 had a nasal cannula on, delivering oxygen at three liters per minute (lpm). Further observations revealed the oxygen tubing was not dated. Interview on 08/12/25 at approximately 5:10 P.M. with Assistant Director of Nursing (ADON) #604 verified Resident #1's oxygen tubing was not dated and it should have been. 2. Review of the medical record for Resident #3 revealed an admission date of 02/03/24. Diagnoses included COPD, chronic respiratory failure with hypoxia (low oxygen levels), and a history of COVID-19. Review of the MDS assessment, dated of 07/09/25, revealed Resident #3 was cognitively intact and did not receive oxygen therapy. Review of the current physician orders revealed Resident #3 had no orders for the use of oxygen therapy. Observation on 08/12/25 at 7:35 A.M. revealed Resident #3 had a nasal cannula on, delivering oxygen at four lpm. Further observation revealed the oxygen tubing was not dated. Interview on 08/12/25 at approximately 5:10 P.M. with ADON #604 verified there were no active physician orders for the administration of oxygen therapy for Resident #3 and further confirmed the oxygen tubing was not dated. ADON #604 verified there should be active physician orders for oxygen administration and oxygen tubing should be dated. 3. Review of the medical record for Resident #10 revealed an admission date of 05/16/25. Diagnoses included COPD. Review of the current physician orders revealed Resident #10 had no orders for the use of oxygen therapy. Observation on 08/11/25 at 2:35 P.M. revealed Resident #10 had a nasal cannula on, delivering oxygen at two lpm. Further observation revealed the oxygen tubing was not dated. Interview on 08/12/25 at approximately 5:10 P.M. with ADON #604 verified there were no active physician orders for the administration of oxygen therapy for Resident #10 and further confirmed the oxygen tubing was not dated. ADON #604 verified there should be active physician orders for oxygen administration and oxygen tubing should be dated. Review of facility policy titled, Medication Administration Policy, dated 07/09/21, revealed medications would be administered as prescribed by persons lawfully authorized to do so.

Based on medical record review and staff interview, the facility failed to ensure nutritional needs were assessed and interventions were implemented timely for residents identified with nutritional problems. This affected one (#48) of four residents reviewed for nutrition. The facility census was 58.Findings include:Review of the medical record for Resident #48 revealed the resident was admitted on [DATE]. The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included parkinsonism, myasthenia gravis, multi-system degeneration of the autonomic nervous system, dystonia, dysphagia, and need for assistance with personal care. Review of the Minimum Data Set (MDS) assessment, dated 07/16/25, revealed Resident #48 was moderately cognitively impaired and had no significant weight loss.Review of the care plan, dated 07/17/25, revealed Resident #48 was at risk for altered nutritional status and needed nutritional supplements. Interventions included providing and serving the diet as ordered, honoring food preferences, and providing and serving supplements as ordered. Review of a Nutritional Screen, dated 07/22/25, revealed Resident #48 had no significant weight loss. The assessment noted the resident struggled to gain weight and was underweight. Further review revealed Resident #48 was placed on a weight gain program and received three nutritional supplements daily and an eight-ounce (oz) milkshake in the afternoon.Review of the physician orders for July 2025 and August 2025 revealed Resident #48's diet and nutritional supplement orders were discontinued on 07/25/25. Further review revealed a regular diet and nutritional supplements were not ordered until 08/12/25 (15 days after the resident's readmission to the facility). Review of Resident #48's weights, located in the medical record, revealed on 07/02/25, the resident weighed 97.4 pounds (lbs.) and on 08/01/25, the resident weighed 88.2 lbs., indicating a 9.45% weight loss in one month. Further review of Resident #48's medical record revealed no evidence the resident was assessed by the Registered Dietitian (RD) for her nutritional needs following her readmission to the facility on [DATE].Interview on 08/13/2025 at 8:30 A.M. with Licensed Practical Nurse (LPN) #613 revealed that Resident #48 had a decreased appetite and recently only ate small salads provided by her husband. LPN #613 further stated Resident #48 was previously on health shakes (nutritional supplement) for weight loss.Interview on 08/13/25 at 1:27 P.M. with RD #684 verified Resident #48's nutritional needs were not addressed when she readmitted to the facility on [DATE] and the resident was not assessed until 08/12/25, when a regular diet and nutritional supplements were ordered. RD #684 stated Resident #48 was reweighed and her current weight was 95.8 lbs., which was a 1.6% weight loss from her weight on 07/02/25. RD #684 stated the weight obtained on 08/01/25 of 88.2 lbs. was likely an error.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure used needles were properly disposed of. This affected one (#27) of one resident observed for insulin administration. The facility census was 58.Findings include:Observation on 08/13/25 at 7:55 A.M. of medication administration with Licensed Practical Nurse (LPN) #611 revealed LPN #611 prepared and administered insulin glargine and insulin aspart to Resident #27, as ordered. At the completion of administration, LPN #611 removed the needles from the insulin pens and disposed of them in Resident #27's bathroom trash can. Interview on 08/13/25 at 8:08 A.M. with LPN #611 confirmed she disposed of two insulin pen needles in Resident #27's bathroom trash can. Interview on 08/13/25 at 8:15 A.M. with Assistant Director of Nursing (ADON) #604 verified that insulin pen needles should be disposed of in a sharps container (one-way puncture resistant container) after use. Review of undated facility policy titled, Syringe and Needle Disposal, revealed needles would be placed in a one-way puncture resistant container immediately after use.

Based on medical record review, observation, family interview, and staff interview the facility failed to provide translation assistance or devices to aide in communication with residents. This affected one (#67) of three residents reviewed for communication. The facility census was 58.Findings include:Record review for Resident #67 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #67 included cholangitis, peripheral vascular disease, diabetes Type II, disease of the pancreas, pressure ulcer of sacrum stage two, and heart failure. Resident #67's Minimum Data Set (MDS) comprehensive admission assessment was in progress. Review of Resident #67's baseline care plan, dated 08/08/25, revealed a focus area for communication. Identified interventions included to provide a translator for communication and the translators would be the resident's family. Observation on 08/13/25 at 11:00 A.M. of Resident #67 revealed the resident was laying in her bed resting. No translation equipment or communication boards were observed in the room at the time of the observation. Observation on 08/13/25 at 2:30 P.M. of Resident #67 revealed the resident was sitting up in her wheelchair with her daughter in the room visiting. No communication boards or translation equipment was observed in the room. Interview on 08/13/25 at 2:30 P.M. with Resident #67's daughter revealed the resident only spoke Spanish. The daughter stated she and her brother were in the facility most of the day and sometimes at night and could provide translation to staff for Resident #67. The daughter stated there were times during the day and throughout the evening that family were not available to visit and provide translation services. Resident #67's daughter stated she was unaware of any translation interventions provided by the facility for the staff to be able to communicate with the resident when family were unavailable. Interview on 08/14/25 at 8:33 A.M. with Certified Nursing Assistant (CNA) #673 revealed she spoke a little Spanish and was able to communicate with Resident #67 on a very basic level. CNA #673 stated Resident #67 was able to say yes and no to some simple questions, but the aide was unaware of how much English the resident comprehended. CNA #673 stated she could use a translation application on her personal cell phone but she was uncertain of the accuracy of the translation. CNA #673 verified the facility did not provide any communication devices or other services to aide in communicating with Resident #67. Observation on 08/14/25 at 9:00 A.M. of wound and incontinence care for Resident #67, provided by CNA #619 and Licensed Practical Nurse (LPN) #631, revealed the staff spoke English throughout care and the resident did not respond to any of the questions asked. Concurrent interview with CNA #619 and LPN #631 verified the facility did not provide any translation services or communication devices to aid in communication with Resident #67.

Based on medical record review, resident interview, staff interview and review of facility policy, the facility failed to ensure comprehensive care plans were developed to include dental care needs. This affected one (#19) of three residents reviewed for ancillary services. The facility census was 58.Findings include:Review of Resident #19's medical record revealed an admission date of 07/18/25. Diagnoses included cellulitis of the lower limbs, back pain, osteoporosis, spinal stenosis, heart failure, chronic obstructive pulmonary disease (COPD), Type II diabetes, and glaucoma. Review of Resident #19's Minimum Data Set (MDS) assessment, dated 07/23/25, revealed a Brief Interview for Mental Status (BIMS) score of eight, indicating the resident was moderately cognitively impaired. Resident #19 required moderate assistance with toilet use, bathing, parts of dressing, and transfers. Resident #19 displayed no behaviors at the time of the review. The assessment noted Resident #19 had no mouth or facial pain, discomfort or difficulty chewing at the time of the review. Review of Resident #19's care plan, revised 07/30/25, revealed supports and interventions for self-care deficit, diabetes, actual skin breakdown, risk for decline in cognition, impaired cognitive function, mood problem, risk for falls, possible nutritional risk and had a swallowing problem. No supports or interventions for dental concerns were found. Further review of Resident #19's medical record revealed the resident was seen on 02/15/25 by the dentist. It was recommended Resident #19 have five teeth extracted. Contact information was provided for three provider options for completing the extractions. Resident #19's had five teeth extracted on 04/09/25. The resident had a follow up dental visit on 04/23/25 and additional extractions were completed 07/23/25. Interview on 08/11/25 at 4:06 P.M. with Resident #19 revealed she was alert and aware. Resident #19 reported her teeth were terrible and had been bad for a long time. Resident #19 reported she had to go to the hospital to have her teeth taken care of. She reported they were bothering her again and she was having trouble eating. Interview on 08/13/25 at 8:10 A.M. with Licensed Practical Nurse (LPN) #609 verified Resident #19 had oral surgery to remove a lot of her teeth. LPN #609 was not aware of Resident #19 having any additional pain but was aware her teeth had been an ongoing concern. Interview on 08/14/25 at 11:31 A.M. with the Director of Nursing (DON) verified Resident #19 had dental care needs and there were no care plan supports or interventions for dental care. Review of the facility policy titled, Comprehensive Care Planning Procedure, revised 11/13/17, revealed a comprehensive person-centered plan of care was developed for each resident within 21 days of admission and updated on a quarterly basis and with any significant change in resident status.

Based on open and closed medical record review, staff interview, and review of the facility policy, the facility failed to ensure transfer and/or discharge notices were provided to residents, resident representatives, receiving facilities, and the Ombudsman. This affected two (#63 and #3) of three residents reviewed for transfer and discharge. The facility census was 58.Findings include: 1. Review of Resident #63's closed medical record revealed an admission date of 04/07/25. Diagnoses included open wound on the left hip post-surgery, anxiety, heart disease, and hernia. The resident discharged to the hospital on [DATE]. Review of the Minimum Data Set (MDS) assessment, dated 04/14/25, revealed Resident #63 had intact cognition and was continent of bowel and bladder. Review of a nursing progress note dated 05/13/25 revealed Resident #63 was discharged to the hospital for a rectal prolapse. Further review of Resident #63's medical record, including notification communication documentation and discharge summaries, revealed no evidence the facility sent transfer/discharge there was no documentation in the records the receiving facility received a discharge summary and resident or family representative was notified of the transfer to the hospital prior to discharge. Additional there was no documentation of notification to the Ombudsman office noted in the records. Interview on 08/13/25 at 2:30 P.M. with the Director of Nursing, (DON) verified there was no documentation of a discharge/transfer summary sent to the receiving facility, provided to the resident or resident representative, or Ombudsman notification of Resident #63's transfer/discharge to the hospital. 2. Review of the medical record for Resident #3 revealed she was admitted to the facility on [DATE] with diagnoses that included hypertension, atrial fibrillation, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and history of COVID-19. Resident #3 was transferred to an acute care facility on 05/06/25. Further review of Resident #3's medical record revealed no evidence a report or transfer notification was given to the receiving acute care facility, and there was no evidence the Ombudsman was notified of the transfer. Interview on 08/14/25 at 12:00 P.M. with the DON verified there was no evidence report was given to the receiving acute care facility, and there was no evidence the Ombudsman was notified of the transfer. Further interview confirmed the receiving acute care facility should have been given report by the nurse on duty and the Ombudsman should have been notified of the transfer. Review of facility policy titled, Discharge/Transfer Policy and Procedure, dated 03/07/25, revealed the facility would provide notice to the resident's representative and the Ombudsman. Additionally, the policy indicated the facility would convey the following information to the receiving provider: contact information of the primary care provider, resident representative information, advance directives, all special instructions for ongoing care, comprehensive care plan information, and all other necessary information to ensure a safe and effective care transition.

Based on observation, resident interview, and staff interview, the facility failed to ensure the facility was maintained in good repair. This affected two (#9 and #16) of five residents reviewed for physical environment. The facility census was 58.Findings include:1. Observation on 08/11/25 at 10:22 A.M. of Resident #9's room revealed the door to the bathroom was split at the top and bottom at the hinges. Additionally, there was an approximately two inch hole with an about two foot long scrape along the wall leading from the entry door to the bedroom area with exposed drywall. Interview on 08/11/25 at 10:29 A.M. with Resident #9 confirmed the bathroom door was broken. Resident #9 stated she was not sure how long it had been in that condition and added that it did not look safe the way it was broken. Resident #9 was also unsure of how long the hole and scrape had been along the wall, stating she did not recall it ever not being there.Observation on 08/13/25 at 7:43 A.M. of Resident #9's room found the door continued to be broken and splitting at the hinges, and the hole and exposed drywall continued to be along the entry way wall. Coinciding interview with Maintenance Director (MD) #657 verified the door was broken at the hinges and the wall was in need of repair. MD #657 stated the door was a high priority and would be repaired today. 2. Observation on 08/11/25 at 11:12 A.M. of Resident #16 found her in bed with her bed in the low position. The wall behind the bed was observed to have large gouges with exposed drywall. Resident #16 was not able to be interviewed. Observation on 08/13/25 at 7:47 A.M. of Resident #16's room revealed the bed continued to be in the low position and the wall behind the bed continued to have large gouges with the drywall exposed. Coinciding interview with MD #657 verified the wall behind Resident #16's bed was in need of repair.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure advanced directives were clearly and accurately documented in the medical record. This affected one (#22) of 18 residents reviewed for code status. The facility census was 58. Findings include:Review of Resident #22's medical record revealed an admission date of [DATE]. Diagnoses included Alzheimer 's disease, hypertension, obstructive sleep apnea, hyperlipidemia, and heart failure.Review of the current physician orders revealed Resident #22 had a code status (advanced directive) order of Do Not Resuscitate - Comfort Care (DNRCC - do not provide cardiopulmonary resuscitation [CPR] in the event of cardiac or respiratory arrest). Further review of Resident #22's medical record revealed no evidence of a physician signed DNRCC advanced directive. Review of the care plan revealed Resident #22 had a focus area identifying his code status as full code (provide all possible life-saving measures in the event of a medical emergency).Interview on [DATE] at 10:55 A.M. with Assistant Director of Nursing (ADON) #604 confirmed Resident #22 had a physician order for a DNRCC code status, there was no physician signed DNRCC advanced directive, and the resident's care plan indicated the resident was a full code status. ADON #604 stated she was unable to determine the resident's correct code status. Review of the facility policy titled, Advance Directives Policy, dated [DATE], revealed the facility would, upon admission to the facility, identify if a resident would like a Do Not Resuscitate (DNR) code status ordered.

Based on record review, resident interview, staff interview, and review of the facility policy the facility failed to notify a resident and their representative of a room change. This affected one resident, Resident #2, out of three residents reviewed for rooms changes. The current census is 55. Findings include: Record review for Resident #2 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #2 include acute respiratory failure with hypoxia, heart failure, diabetes type two, and absence of right lower leg. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and had no behaviors during the assessment period. Further review of Resident #2's medical record including scanned documented, progress notes, and assessments revealed no evidence of any notification of a room change. Interview on 05/02/25 at 9:50 A.M. with Resident #2 revealed the resident was pleasantly confused. Resident #2 stated she was unsure of any notification of a room change and stated she did not know the day she was transferred to the new room. Resident #2 stated she was comfortable and denied any concerns with her care at the facility. Interview on 05/02/25 at 12:20 P.M. with Social Services Designee (SSD) #300 verified there was no documentation of notification of Resident#2 or the resident's Power of Attorney (POA) in the medical record regarding the room change in 03/2025. Per SSD #300 the other residents in house three, where Resident #2 was residing, had reported a concern to the SSD regarding Resident #2's yelling. Per SSD #300, the POA was contacted via telephone but there was no record of the call. SSD #300 stated she did text back and forth via the phone with the POA regarding the room change option, however SSD #300 stated she did not have any text messages to show as notification or the POA's agreement of the room transfer. SSD #300 verified there was no written documentation of the notification of the room change. SSD #300 stated on 03/07/25 Resident #2 was moved from house three to her current room in house one. Review of the facility policy titled, 'Discharge/Transfer Policy and Procedure', dated 03/07/25 revealed the facility will provide and document the preparation and orientation to the residents to ensure a safe and orderly transfer or discharge. Per the policy a transfer includes moving from one bed in the facility to another. Per the policy the facility will notify the resident or representative in writing. Review of the facility policy titled, 'Notification of Change' dated 11/2021 revealed the facility will notify the resident, resident's family or representative, and physician of the transfer to another room assignment 'promptly' and the facility will record the notification. This deficiency represents non-compliance discovered during the investigation of Complaint OH00163502.

Based on observation, staff interview, review of the temperature logs, and review of facility policies, the facility failed to ensure refrigerator and dishwasher temperatures were monitored and documented, failed to ensure safe food storage, and failed to sanitize thermometers between food items. This had the potential to affect all residents in House 2 (#6, #8, #20, #32, #33, #34, #40, #42, #43, #46, #47, and #59) , House 4 (#3, #9, #12, #17, #19, #21, #25, #39, #41, #52, #156, and #60), and House 5 (#2, #4, #13, #23, #35, #51, #157, #158, #159, #160, and #161). The facility identified all residents in these houses received food from the kitchen. The facility census was 58. Findings include: Interview on [DATE] at 8:34 A.M. with State tested Nurse Aide (STNA) #302 revealed she did not know the process for documenting refrigerator and freezer temperatures. Interview and observation on [DATE] at 8:42 A.M. with STNA #317, in House 2, confirmed two containers of food labeled for Resident #59 were undated. One container contained deviled eggs with liquid around the bottom of the container. Additional observation and interview confirmed a personal food item for Resident #47 with an illegible date. Additionally, STNA #317 confirmed the strawberries in the refrigerator were moldy. Concurrent observation revealed a sign posted on the refrigerator directing staff to date all food items. Further interview with STNA #317 revealed she could not find the refrigerator thermometer. Continued observation and interview with STNA #317 confirmed there were scoops in the flour, sugar, and cereal bins. STNA #317 said the scoops were washed periodically, but remained in the containers for convenience. Interview on [DATE] at 9:06 A.M. with STNA #338, in House 4, revealed she was not sure how to monitor the refrigerator temperature. Interview and observation of the refrigerator and dishwasher logs on [DATE] at 9:08 A.M. with STNA #306 confirmed no documentation of P.M. refrigerator and freezer temperatures since [DATE], and no temperatures were documented for any shift on [DATE] and [DATE]. Additionally, the dishwasher temperature log was blank from [DATE] through [DATE] for day shift, and no documentation was completed for night shift for the month of February 2024. Observation on [DATE] at 9:15 A.M. in House 5 revealed an opened gallon of milk dated [DATE] and a full gallon of milk dated [DATE] in the refrigerator. Interview on [DATE] at 9:16 A.M. with STNA #307 confirmed the milk was expired. Further interview revealed she did not serve any residents milk that morning. Further observation of the refrigerator and interview with STNA #307 on [DATE] beginning at 9:16 A.M. revealed two plastic bags of bacon were previously opened and undated and one plastic bag of sausage was previously opened and undated. Additionally, STNA #307 stated she did not know how to use the probe thermometer in the refrigerator to verify refrigerator temperatures. STNA #307 stated she used the temperature visible inside the refrigerator. Observation revealed the temperature she documented was a lighted read-out of the temperature setting for the refrigerator, not a thermometer. Observation and interview on [DATE] at 9:25 A.M. with STNA #364 confirmed the refrigerator/freezer temperature log for February 2024 was missing documentation for all entries on [DATE], [DATE], [DATE], and [DATE], and was missing P.M. temperatures for all days except [DATE]. Interview on [DATE] at 9:27 A.M. with Dietetic Technician (DT) #337 stated she was involved in oversight of food safety and temperatures logs. DT #337 stated the facility was attempting to improve their documentation on temperatures. Interview on [DATE] at 8:09 A.M. with DT #337 revealed scoops should not be left in food bins. Observations on [DATE] between 4:49 P.M. and 4:55 P.M. in House 2 revealed STNA #304 taking temperatures of chicken fried rice, egg rolls, and cauliflower. STNA #304 used a digital thermometer and wiped it on a paper towel between foods. Interview on [DATE] at 4:54 P.M. with STNA #304 confirmed she wiped the thermometer on the same paper towel between taking the temperature of the next food. Review of the policy Refrigerator and Freezer Temperatures Policy & Procedure, revised ,d+[DATE], revealed refrigerator and freezer temperatures should be checked twice daily and recorded on the log. Review of the policy Dishwashing, revised [DATE], revealed the dishwasher temperature should be recorded on the Dishwasher Monitoring Log. Review of the policy Food Handling and Preparation, revised [DATE], revealed clean, sanitized utensils should be used when preparing food. Review of the policy Food Storage Policy & Procedure, revised ,d+[DATE], revealed the purpose of the policy was to assure that all food was stored, labeled, and dated properly to assure stock rotation and prevent food illness. Review of the undated document Resource for Families revealed all foods in unmarked or unlabeled containers should be marked with the current date the food item was stored.

Based on observation, interview, record review, review of the facility recipes, and review of the facility menus, the facility failed to follow menus as planned by not following recipes, by not using portioned serving utensils, by not offering all menu items to each resident, and by not offering the main meal before offering a nutritionally unequal alternative. This affected Resident #5 and Resident #34 and had the potential to affect all residents in House 2 (#6, #8, #20, #32, #33, #40, #42, #43, #46, #47, and #59) and House 3 (#1, #16, #18, #22, #26, #27, #37, #38, #48, and #49). The facility census was 58. Findings include: 1. Review of the medical record for Resident #5 revealed an admitted [DATE] with diagnoses multiple sclerosis and type II diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5's level of cognition was not assessed. Resident #5 was on a therapeutic, mechanically altered diet and required maximal assistance with all activities of daily living. Resident #5 was on hospice at the time of the review. Review of the current physician order dated 01/08/24 revealed Resident #5 received regular diet with pureed texture and thin liquids. 2. Review of the medical record for Resident #34 revealed an admitted [DATE] with diagnoses of epilepsy, hemiplegia and hemiparesis affecting right dominant side. Review of the quarterly MDS assessment dated [DATE] revealed Resident #34 was rarely/never understood and required partial/moderate assistance for eating. Review of a physician order dated 10/25/23 revealed Resident #34 received a regular diet with mechanical soft textures and thin liquids. Review of the current care plan for Resident #34 revealed no meal preferences. Observation on 02/21/24 at 3:51 P.M. revealed State tested Nurse Aide (STNA) #304, in House 2, preparing chicken fried rice for the evening meal. Interview with STNA #304 on 02/21/24 at 3:51 P.M. revealed she did not follow a recipe to prepare the chicken fried rice, but felt comfortable making it from her basic knowledge of cooking. Further interview and observation revealed STNA #304 used a three-pound bag of chicken tenderloins. STNA #304 stated she made three cups of rice and expected to use three eggs when assembling the meal. STNA #304 stated she was preparing enough for approximately ten residents because Resident #43 usually ate waffles, and Resident #34, on a mechanical soft diet, would receive Malt-o Meal (hot cereal) instead of the prepared meal so she would not choke. Interview on 02/21/24 at 4:19 P.M. with Dietetic Technician (DT) #337 and Registered Dietitian (RD) #379 revealed each House developed its own menu through a web-based menu program. The menu was approved weekly by RD #379 or another RD who worked at the facility once weekly. Continued interview with RD #379 confirmed the menu provided the expected portion size to provide to residents to meet their nutritional needs. RD #379 confirmed if correct portions were not used, the facility could not ensure each resident received the daily calorie and nutrient needs as estimated in the menu program. Continued interview with DT #337 stated a recipe book was available for staff, and if no recipe was available, DT #337 would provide verbal guidance on meal preparation to the staff. Observation and interview on 02/21/24 at 4:55 P.M. revealed STNA #304, in House 2, using a slotted silver spoon to serve cauliflower and a slotted spatula to serve chicken fried rice. STNA #304 confirmed the serving utensils were not intended to provide a specific portion size. STNA #304 stated she ultimately used five eggs in the chicken fried rice. Observation and interview on 02/21/24 at 5:00 P.M. with STNA #377 in House 3 revealed she made meatloaf for dinner and did not use a recipe. STNA #377 stated she used three pounds of ground beef when making the meatloaf. STNA #377 further stated there was a recipe available but she chose not to use it. Additionally, STNA #377 confirmed she used a spatula to serve the mashed potatoes and a slotted spoon to serve the mixed vegetables and neither tool was able to measure the quantity provided. Observation on 02/21/24 at 5:22 P.M. revealed STNA #377 preparing a pureed meal for Resident #5. STNA #377 pureed the meatloaf and provided a portion of mashed potatoes on Resident #5's plate. Interview at that time with STNA #377 confirmed she did not puree the mixed vegetables and did not plan to provide mixed vegetables to Resident #5 because she believed Resident #5 had plenty to eat with the meatloaf and mashed potatoes. Interview on 02/21/24 at 5:31 P.M. with STNA #304 revealed Resident #34 was on a mechanical soft diet and STNA #304 had not yet prepared or served Resident #34. Continued observation revealed STNA #304 microwaving water and preparing Malt-o Meal for Resident #34. STNA #304 stated she planned to provide a nutrition supplement with 240 kilocalories and 10 grams of protein along with the cream of wheat for the evening meal. Interview on 02/21/24 at approximately 5:40 P.M. with RD #379 confirmed the chicken fried rice and cauliflower on the menu could be prepared to an appropriate mechanical soft texture and provided to Resident #34. Observation at that time revealed a blender on the counter. Further interview with RD #379 revealed the substitution of Malt-o Meal and a nutrition supplement for the evening meal would be appropriate if it was based on Resident #34's preference. Follow-up interview on 02/21/24 at 5:44 P.M. with STNA #304 revealed STNA #304 did not offer Resident #34 the main meal because Resident #34 had impaired cognition. Review of the facility recipe for meatloaf for 12 servings revealed the portion of ground beef should be 4 and 3/4 cup and the recipe should also include one cup of ground pork. Regarding the recipe for chicken fried rice, the facility provided a statement indicating the meal should have come pre-packaged and cooked according to the directions on the bag.

Based on observation, staff interview, and record review, the facility failed to ensure dependent residents received assistance with nail care. This affected one (#43) of one resident reviewed for nail care. The facility census was 58. Findings include: Review of the medical record for Resident #43 revealed an admitted [DATE] with diagnoses of anxiety and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had impaired cognition and was dependent on staff for showering, bathing, and personal hygiene. Review of the current care plan for Resident #43 revealed she had an activities of daily life (ADL) deficit and required assistance from staff for care. An intervention included checking nail length, trimming and cleaning on bath day and as necessary. Observation on 02/20/24 at 9:58 A.M. revealed Resident #43 lying in bed. The fingernails on her right hand were irregular lengths and appeared discolored and to have debris under them. Observation on 02/21/24 at 9:20 A.M. revealed Resident #43 lying in bed. The fingernails on her right hand were irregular lengths and appeared discolored and to have debris under them. Observation on 02/22/24 at 11:56 A.M. revealed State tested Nurse Aide (STNA) #300 providing the noon meal to Resident #43 in her room. STNA #300 repositioned Resident #43 in bed to allow her to eat her meal more comfortably. STNA #300 offered assistance with eating to Resident #43 who stated she did not need any help with her meal. STNA #300 began to leave the room when the surveyor asked her to observe Resident #43's nails on her right hand. The nails on Resident #43's right hand were long and had darkness under them. Resident #43 stated it was chocolate. Upon inquiry, STNA #300 stated Resident #43 ate chocolate the day before. STNA #300 confirmed there was darkness under Resident #43's nails. Interview on 02/22/24 at 2:45 P.M. with the Director of Nursing (DON) confirmed Resident #43's care plan stated staff should provide nail care as needed.

Based on medical record review and staff interview, the facility failed to complete a significant change assessment in the Minimum Data Set (MDS) when a resident was started on hospice. This affected one resident (#17) of two residents reviewed for hospice services. The facility census was 58. Findings include: Record review for Resident #17 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #17 included anemia, dementia, chronic obstructive pulmonary disease, heart disease, and anxiety. Review of the Minimum Data Set (MDS) comprehensive assessments revealed there was no significant change assessments in the resident's medical records. Review of Resident #17's care plans dated 11/20/23 revealed the resident had a focus for hospice services relating to chronic obstructive pulmonary disease and dementia. Interventions were appropriate for the focus. Interview on 02/22/24 at 1:55 P.M. Licensed Practical Nurse (LPN) #311 revealed he was the facility's MDS nurse and responsible for entering all MDS assessments into residents' medical records. LPN #311 verified after Resident #17 received an order on 11/20/23 to receive hospice services the MDS nurse had 14 days to complete a significant change assessment in the resident's medical records. LPN #311 verified he did not initiate or complete a significant change assessment in the medical records for Resident #17 after she started receiving hospice services.

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure residents with indwelling catheters had their catheters managed in a dignified manner. This affected one (Resident #5) of two residents reviewed for catheter dignity. The facility identified three residents with indwelling catheters. In addition, the facility failed to provide a dignified dining experience to Resident #157 related to disposable dishware and utensils which had the potential to affect 11 additional residents in the 500 home (Residents #2, #4, #13, #23, #35, #51, #158, #159, #160, #161, and #162). The facility census was 58. Findings include: 1. Review of Resident #5's medical record revealed an admitted [DATE]. Diagnoses included multiple sclerosis, type II diabetes, schizoaffective disorder, major depressive disorder, and contractures of the right elbow, left elbow, right knee and left knee. Review of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had short and long term memory problem. Resident #5 was severely impaired with cognitive skills. Resident #5 required maximal assistance with all activities of daily living. Resident #5 was on hospice at the time of the review. Review of Resident #5's care plan revised 01/24/24 revealed supports and interventions for self-care deficit, risk for falls, potential for discomfort, anticoagulant use with risk for side effects, potential for drug related complications, multiple sclerosis, hospice services, risk for pain, and potential for impaired skin integrity. Observation on 02/20/24 at 10:56 A.M. of Resident #5 found him lying in bed with his urinary catheter bag hanging on the side of his bed near the foot of the bed. The urinary catheter bag was 1/4 full of yellow urine and visible from the hallway. Interview on 02/20/24 at 11:00 A.M. with Resident #5's daughter revealed Resident #5 always had his catheter bag hanging on the side of the bed facing the door. Resident #5's daughter reported she had never seen it covered and commented it would be nice. Observation on 02/20/24 at 4:19 P.M. of Resident #5 found his catheter bag hanging on the side of his bed with yellow urine visible from the hallway. Interview on 02/20/24 at 4:23 P.M. with State tested Nursing Assistant (STNA) #334 verified Resident #5's catheter bag was uncovered and visible from the hallway. STNA #334 reported Resident #5's catheter bag had always been that way and she was not aware there was a cover for it. 35035 2. Observation on 02/20/24 from 11:45 A.M. to 12:30 P.M. of the lunch meal service in the 500 unit revealed all residents were served lunch with plastic cups, plastic spoons, plastic forks, and Styrofoam cups. Interview on 02/20/24 at 12:30 P.M. with State tested Nurse Aide (STNA) #307 verified the residents were being served their meals with plastic cups, plastic silverware, and Styrofoam cups. Record review of Resident #157's medical record revealed the resident was admitted on [DATE]. Diagnoses for Resident #157 included cellulitis of left lower limb, diabetes type two, insomnia, heart failure, chronic kidney disease, and lymphedema. Review of Resident #157's physician orders dated 02/15/24 revealed the resident was ordered to have a regular diet. Observation on 02/21/24 T 10:00 A.M. of Resident #157 revealed the resident was eating breakfast in her room. Resident #157 was observed drinking out of a Styrofoam cup and eating with plastic silverware. Interview on 02/21/24 at 10:02 A.M. with Resident #157 revealed the resident stated she did not like eating with plastic silverware and drinking from a Styrofoam cup. Review of the undated facility policy titled, Resident Rights, revealed the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes, maintains, and enhances quality of life.

Based on closed medical record review, staff interviews, nurse practitioner interview, review of laboratory (lab) draw log, and review of facility policy regarding a change in a resident's condition, the facility failed to timely notify the physician of a significant change in condition for one resident (Resident #03). This resulted in Immediate Jeopardy and serious life-threatening harm when Resident #03 was refusing medications, refusing oral intake of food and fluids, and showing signs of dehydration with no notification to the physician. The lack of notification resulted in the resident not receiving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to provide timely notification to Resident #03's family of the resident's change in condition. Furthermore, the facility failed to timely notify the family following a fall for a second resident (Resident #01) that did not result in actual harm but had the potential for more than minimal harm that is not Immediate Jeopardy. This deficient practice affected two (#01 and #03) of five residents (#01, #03, #04, #08, and #09) reviewed for change in condition. The facility census was 48. On [DATE] at 1:19 P.M., the Administrator, Director of Nursing (DON) and Assistant Vice President of Clinical Quality #600 were notified Immediate Jeopardy began on [DATE] when Nurse Practitioner (NP) #181, from the pulmonary and critical care specialist office, assessed Resident #03 to be very weak and documented the resident was not eating and drinking. NP #181 ordered intravenous (IV) fluids, noting the resident may require additional fluids. NP #181 provided instructions to notify pulmonary and critical care specialist of any changes. On [DATE], Resident #03 was assessed to be sleeping the entire shift, was refusing all food and fluids, and had only urinated once on the shift. The physician was notified and ordered a laboratory (lab) test to be obtained the next day. The lab test was not attempted to be obtained until [DATE], at which time the facility was notified the phlebotomist was unable to obtain the blood sample. There was no notification of the physician of the inability to draw the resident's lab test or the continued refusal of medications. On [DATE], NP #179 assessed Resident #03 and found her to have signs of severe dehydration and ordered IV fluids. The residents condition deteriorated, with hospice consulted on [DATE]. Resident #03 expired on [DATE] at 2:00 P.M. The Immediate Jeopardy was removed on [DATE] at 5:30 P.M. when the facility implemented the following corrective actions: · On [DATE], the DON began to educate all nurses on notification of change. All nurses were educated on [DATE]. · On [DATE], Assistant Vice President of Clinical Quality #600 completed a chart audit of all current residents to review laboratory tests ordered since [DATE]. The audit was to identify any discrepancies, notify the physician of any discrepancies found, and re-draw labs if necessary. · On [DATE], Assistant Vice President of Clinical Quality #600 and the Administrator conducted a phone conference with the NP #179 to develop a communication plan for all new orders going forward. · On [DATE], Assistant Vice President of Clinical Quality #600 conducted a chart review of all current residents to audit any change of condition, any residents with decreased oral intake, any residents refusing medications, and the physician notification. The facility did not identify any other affected residents. · On [DATE], Dietary Technician #203 and/or designee began auditing all intake documentation to identify any resident with decreased intake, and to ensure notification to physician and responsible party occurred. The audit will be conducted daily Monday through Friday for four weeks, weekly for two weeks, and monthly for one month thereafter. The audit will be reviewed weekly by the Quality Assurance Performance Improvement (QAPI) committee for one month and will be adjusted as needed. · On [DATE], the DON and/or designee began reviewing all new orders to ensure proper notification to family and physician occurred. The audit will be conducted daily Monday through Friday for four weeks, weekly for two weeks, and monthly for one month thereafter. The audit will be reviewed weekly by the QAPI committee for one month and will be adjusted as needed. · On [DATE], the DON and/or designee began reviewing all progress notes daily Monday through Friday for any change of condition to ensure notification was made to the physician and responsible party, if appropriate. The audit will be conducted daily for four weeks, weekly for two weeks, and monthly for one month thereafter. The audit will be reviewed weekly by the QAPI committee for one month and will be adjusted as needed. · On [DATE], the DON and/or designee began reviewing the Medication Administration notes for any refused medications to ensure notification to the physician was completed. The audit will be conducted daily Monday through Friday for four weeks, weekly for two weeks, and monthly for one month thereafter. The audit will be reviewed weekly by the QAPI committee for one month and will be adjusted as needed. · On [DATE], the DON and/or designee began educating all nurses on notification of change in condition and communication with practitioners. All nurses will be educated by 5:30 P.M. · Beginning [DATE], the QAPI committee will meet weekly for four weeks, then monthly for two months, and quarterly thereafter to review all audits and education and make changes as needed. · On [DATE], review of the medical records for Resident #04, Resident #05, and Resident #09, revealed no concerns with physician notification. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of Resident #03's medical record revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the five-day Medicare Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #03 had moderate cognitive impairment. Resident #03 had required a one-person extensive physical assist for eating during the reference period. Review of the current care plan dated, revealed Resident #03 was at risk for dehydration related to diuretic use. The goal included to be free of symptoms of dehydration, maintain moist mucous membranes, and good skin turgor. Interventions included to report as needed any signs and symptoms of dehydration, such as decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, and dry/sunken eyes. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #03 had refused medications on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. There was no documentation the physician was notified Resident #03 was refusing medications. Review of the progress note, dated [DATE] at 11:23 A.M., revealed the DON documented NP #179 was notified Resident #03 was positive for COVID-19. Review of the telehealth visit on [DATE], NP #179 revealed Resident #03 was positive for COVID-19 and had a decreased oral intake/appetite. Review of the progress note dated [DATE] at 11:45 A.M., LPN #145 documented it was reported the resident had been refusing her medications and food. Review of NP #179's note dated [DATE] at 2:32 P.M., revealed a telehealth visit follow-up was conducted secondary to new COVID-19 with decreased oral intake/appetite follow up management. Upon review, Resident #03's weight remained stable. The note documented to provide supportive care, monitor closely, and report any acute changes immediately. Review of the pulmonary and critical care specialist note written by NP #181, dated [DATE], revealed Resident #03 was assessed for [CONDITION(S)] and dyspnea. Resident #03 appeared pale with shallow breathing, had coarse rhonchi in the left lung, weak cough, and had a pulse of 136. She did awaken with verbal stimulation but was very weak. Documentation revealed it was difficult to perform a review of systems due to Resident #03's medical status at the time. NP #181 documented a discussion with staff members which revealed Resident #03 was not eating and drinking at this time. NP #181 ordered one liter of normal saline to be delivered via IV. The note revealed Resident #03 may require more fluid; however, staff will notify the pulmonary and critical care specialist of any changes. Resident #03 is a Do Not Resuscitate Comfort Care (DNRCC) status. Reviewed the chart. Discussed pulmonary status with nursing. Continue current orders. NP #181 documented for staff to notify their office if any complications regarding COVID-19 or her pulmonary status. Review of the progress notes dated [DATE] through [DATE], revealed no evidence Resident #03's family had been notified Resident #03 had been refusing her medications, food and drink until [DATE]. Review of the progress note dated [DATE] at 9:05 P.M., written by LPN #113, revealed Resident #03 was in bed the entire shift sleeping. The resident had been refusing medications, all meals and drinks, as well as personal care. Resident #03 only urinated once on the shift. The physician was notified at this time of the change. The physician ordered a basic metabolic panel (BMP) to be completed on [DATE]. There was no documentation Resident #03's family was notified of this new order and the continued refusal of medications, meals, and fluids. Review of the lab draw log, dated [DATE], revealed a handwritten note which read Couldn't get under Resident #03's lab work. There was no evidence any physician was notified Resident #03's ordered lab tests were unable to be obtained. No lab results were in the medical record for a BMP that was ordered for [DATE]. Review of the NP progress note, dated [DATE], revealed NP #179 assessed Resident #03 due to recent illness of COVID-19. The note revealed Resident #03 has had a decline over the past couple weeks and has not been eating or drinking. NP #179 documented Resident #03's skin tenting (a sign of dehydration) was noted to back of the hand and the chest, unable to visualize Resident #03's mucous membranes. Resident with severe dehydration, decreased oral intake, and medications reviewed. Resident #03 had a new/acute decline status post [MEDICAL RECORD OR PHYSICIAN ORDER] . NP #179 ordered a consult ultrasound guided peripheral IV or midline IV insertion to administer 0.9% normal saline at 200 milliliter (ml)/hour IV for three hours, then decrease to 100 ml/hour for four hours, then 60 ml/hour for one liter. Hold [MEDICATION(S)] (diuretic) for three days, check weight, check blood sugar two times a day, and hold [MEDICATION(S)] if blood sugar is less than 125 milligrams per deciliter (mg/dL). Lab tests including a BMP, serum osmolality, and complete blood count with differential were ordered to be obtained on [DATE]. NP #179 noted Resident #03's code status was DNRCC. Review of the progress note, dated [DATE] at 10:05 A.M., revealed Social Services (SS) #132, spoke with Resident #03's daughter to review her mom's health decline. The family was informed Resident #03 was looking lethargic but would be continuing with her IV. SS #132 asked the daughter how they would like to proceed with her care. The daughter voiced she would need to be called back at noon to discuss things. Review of the progress note, dated [DATE] at 12:00 P.M., revealed MDS Nurse #136 and SS # 132 notified Resident #03's daughter of a decline in status. The daughter voiced she would like a Hospice consult. Hospice was contacted for consult. The residents' daughter was notified the Hospice nurse will be at the facility at 5:30 P.M. and will meet the daughter. Review of the physician orders, dated [DATE], revealed Resident #03's code status was Do Not Resuscitate Comfort Care Arrest (DNRCC-Arrest). Review of the progress note dated [DATE] at 2:00 P.M., revealed MDS Nurse #136 was called to Resident #03's room by the floor nurse. Resident #03 had no vital signs, no heart sounds, and no breath sounds present. The family was notified at 2:15 P.M. and NP #179 was notified at 2:30 P.M. Interview on [DATE] at 10:43 A.M., LPN #145 verified she did not notify the physician or NP on [DATE] when it was reported to her Resident #03 had not been eating, drinking, or taking her medications. Interview on [DATE] at 11:30 A.M., the DON revealed the lab work ordered for [DATE] was not completed due to the phlebotomist was unable to obtain the blood sample on [DATE]. The DON stated the phlebotomist thought the resident was dehydrated. The DON verified the physician was not notified of the lab work not being completed due to the inability of the phlebotomist to draw the blood. The DON verified there was no documentation the physician or family were notified Resident #03 was refusing medications on [DATE], [DATE], [DATE], [DATE], and [DATE] and had been refusing all medications, food, and drinks for multiple days prior to [DATE]. Interview on [DATE] at 10:57 A.M. with NP #179 revealed she was not notified Resident #03 had been refusing her medications since [DATE]. NP #179 stated if she had been notified, she would have recommended a hospice consult. NP #179 also verified she was not notified the labs were not drawn due to dehydration or she would have sent Resident #03 to the local emergency room for evaluation and treatment. NP #179 stated she came to see Resident #03 on [DATE] for a routine rounding visit. NP #179 stated she was not made aware prior to that day of the resident's decline in condition and that the resident had continued to not eat, drink, or take her medications. NP #179 checked her rounding sheet from [DATE] and stated that she had no notes from that day to address any issues with Resident #03. NP #179 stated if the facility would have notified her sooner, she could have intervened sooner, and the outcome may have been different for Resident #03. Review of the policy titled Notification of Change in Condition, revised [DATE], revealed the facility will immediately inform the resident, consult with the resident's physician, NP, or Clinical Nurse Specialist, and if known, notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment significantly. 2) Review of the medical record for Resident #01 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated [DATE], revealed Resident #01 had moderate cognitive impairment. Resident #01 was assessed to have used extensive assistance with two- person physical assist for bed mobility, transfers, and toilet use. Review of the Hospice note dated [DATE] at 3:00 P.M., revealed Resident #01's daughter was upset she was not notified of the resident's fall on [DATE]. Review of the progress notes revealed no documentation of a fall that occurred on [DATE]. Review of the incident log revealed Resident #01 had a fall on [DATE]. Interview on [DATE] at 3:33 P.M., Health Care Coordinator #303 verified Resident #01 had a fall on [DATE] and there was no documentation the family was notified of the fall. Review of the policy titled Notification of Change in Condition, revised [DATE], revealed the facility will immediately inform the resident, consult with the resident's physician, NP, or Clinical Nurse Specialist, and if known, notify the resident's representative when there is an accident involving the resident, which results in injury and has the potential for requiring physician intervention. This deficiency substantiates Complaint Number OH 626.

Based on closed medical record review, nurse practitioner interview, review of facility policy, and staff interview, the facility failed to provide monitoring and assessments of a significant change of condition for one resident (Resident #03). This resulted in Immediate Jeopardy and serious life-threatening harm when Resident #03 was refusing medications, refusing oral intake of food and fluids, and showing signs of dehydration with no assessments of the resident's physical condition, monitoring of the resident's oral food and fluid intake, and not monitoring the resident's frequency of urinary output. The lack of assessment and monitoring resulted in the resident's physician not being notified of her condition, not receiving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the facility failed to monitor the oxygen levels and temperature for one (#08) resident with pneumonia and COVID-19 and failed to provide daily COVID-19 screenings for one (#09) resident per facility policy that did not result in actual harm but had the potential for more than minimal harm that is not Immediate Jeopardy. This affected three (#03, #08, #09) of five residents (#01, #03, #04, #08, and #09) reviewed for change in condition. The facility census was 48. On [DATE] at 1:19 P.M., the Administrator, Director of Nursing (DON) and Assistant Vice President of Clinical Quality #600 were notified that Immediate Jeopardy began on [DATE] when Nurse Practitioner (NP) #181, from the pulmonary and critical care specialist office, assessed Resident #03 to be very weak and documented the resident was not eating and drinking. NP #181 ordered intravenous (IV) fluids, noting the resident may require additional fluids. NP #181 provided instructions to notify pulmonary and critical care specialist of any changes. The record revealed no assessments by nursing staff of Resident #03's condition from [DATE] until [DATE]. On [DATE], Resident #03 was assessed to be sleeping the entire shift, was refusing all food and fluids, and had only urinated once on the shift. The physician was notified and ordered a laboratory (lab) test be obtained the next day. The lab test was not attempted to be obtained until [DATE], at which time the facility was notified the phlebotomist was unable to obtain the blood sample. On [DATE], NP #179 assessed Resident #03 and found her to have signs of severe dehydration and ordered IV fluids. There were no nursing assessments of Resident #03's physical condition from [DATE] until the resident was found expired on [DATE] at 2:00 P.M. Additionally, there was no monitoring of her daily meal intakes or the frequency of the resident's urinary output. The Immediate Jeopardy was removed on [DATE] at 5:30 P.M. when the facility implemented the following corrective actions: · On [DATE], Assistant Vice President of Clinical Quality #600 conducted a chart review of all current residents to audit any change of condition, any residents with decreased oral intake, any residents refusing medications, and the physician notification. The facility did not identify any other affected residents. · On [DATE], Dietary Technician #203, and/or designee, began auditing all intake documentation to identify any resident with decreased intake, to ensure follow up occurred, and to ensure notification to physician and responsible party occurred. The audit will be conducted daily Monday through Friday for four weeks, weekly for two weeks, and monthly for one month thereafter. The audit will be reviewed weekly by the Quality Assurance Performance Improvement (QAPI) committee for one month and will be adjusted as needed. · On [DATE], the DON, or designee, began reviewing all progress notes daily Monday through Friday for any change of condition. The audit will be conducted daily for four weeks, weekly for two weeks, and monthly for one month thereafter. The audit will be reviewed weekly by the QAPI committee for one month and will be adjusted as needed. · On [DATE], the DON, or designee, began reviewing the Covid-19 Daily Screen form and the skilled charting form for accuracy and for any change of condition. This audit will be conducted daily Monday through Friday for four weeks, weekly for two weeks, and monthly for one month thereafter. Audits will be reviewed weekly by the QAPI committee for one month and will be adjusted as needed. · On [DATE], the DON, or designee, began auditing the Medication Administration notes for any refused medications. The audit will be conducted daily Monday through Friday for four weeks, weekly for two weeks, and monthly for one month thereafter. The audit will be reviewed weekly by the QAPI committee for one month and will be adjusted as needed. · On [DATE], Dietary Technician #203 and Dietitian #201 developed a Risk for Dehydration protocol. On [DATE], the QAPI committee met to review the incident, immediate actions taken, and audit plan. · On [DATE], the DON or designee educated all nurses on identifying dehydration and the facilities new Risk for Dehydration protocol and proper documentation of assessments. All nurses were educated by 5:30 P.M. · On [DATE], the Assistant Administrator or designee will educate all State tested Nurse Aides (STNA) on signs and symptoms of dehydration, the new Risk for Dehydration, protocol, identifying residents who have decreased meal intakes and the notification process. All STNAs will be educated by end of day [DATE] or removed from the schedule until education received. · Beginning [DATE], the QAPI committee will meet weekly for four weeks, then monthly for two months, then quarterly thereafter to review all audits, education, and make changes as needed. · On [DATE], review of the medical records for Resident #01, Resident #04 and Resident #05 revealed no concerns with nursing monitoring and assessing the resident's condition. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of Resident #03's medical record revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the five-day Medicare Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #03 had moderate cognitive impairment. Resident #03 had required a one- person extensive physical assist for eating during the reference period. Review of the current care plan revealed Resident #03 was at risk for dehydration related to diuretic use. The goal included to be free of symptoms of dehydration, maintain moist mucous membranes, and good skin turgor. Interventions included to report as needed any signs and symptoms of dehydration, such as decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, and dry/sunken eyes. Review of the progress note, dated [DATE] at 11:23 A.M., revealed the DON documented NP #179 was notified Resident #03 was positive for COVID-19. Review of the telehealth visit on [DATE], NP #179 revealed Resident #03 was positive for COVID-19 and had a decreased oral intake/appetite. Review of the progress note dated [DATE] at 11:45 A.M., LPN #145 documented it was reported the resident had been refusing her medications and food. There was no assessment of the resident's physical condition. Review of NP #179's note dated [DATE] at 2:32 P.M., revealed a telehealth visit follow-up was conducted secondary to new COVID-19 with decreased oral intake/appetite follow up management. Upon review, Resident #03's weight remained stable. The note documented to provide supportive care, monitor closely, and report any acute changes immediately. Review of the pulmonary and critical care specialist note written by NP #181, dated [DATE], revealed Resident #03 was assessed for [CONDITION(S)] and dyspnea. Resident #03 appeared pale with shallow breathing, had coarse rhonchi in the left lung, weak cough, and had a pulse of 136. She did awaken with verbal stimulation but was very weak. Documentation revealed it was difficult to perform a review of systems due to Resident #03's medical status at the time. NP #181 documented a discussion with staff members which revealed Resident #03 was not eating and drinking at this time. NP #181 ordered one liter of normal saline to be delivered via IV. The note revealed Resident #03 may require more fluid; however, staff will notify the pulmonary and critical care specialist of any changes. Resident #03 is a Do Not Resuscitate Comfort Care (DNRCC) status. Reviewed the chart. Discussed pulmonary status with nursing. Continue current orders. NP #181 documented for staff to notify their office if any complications regarding COVID-19 or her pulmonary status. Review of the physician order dated [DATE] revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress notes from [DATE] through [DATE] revealed no documentation of an assessment of Resident #03's physical condition, including her hydration status. Review of the progress note dated [DATE] at 9:05 P.M., written by LPN #113, revealed Resident #03 was in bed the entire shift sleeping. The resident had been refusing medications, all meals and drinks, as well as personal care. Resident #03 only urinated once on the shift. The physician was notified at this time of the change. The physician ordered a basic metabolic panel (BMP) to be completed on [DATE]. There was no documentation Resident #03's family was notified of this new order and the continued refusal of medications, meals, and fluids. There were no further progress notes regarding any assessment of Resident #03's condition. Review of Resident #03's physician orders, revealed an order dated [DATE] for a BMP in the morning. Review of the lab draw log, dated [DATE], revealed a handwritten note which read Couldn't get under Resident #03's lab work. There was no evidence any physician was notified Resident #03's ordered lab tests were unable to be obtained. No lab results were in the medical record for a BMP that was ordered for [DATE]. Review of the NP progress note, dated [DATE], revealed NP #179 assessed Resident #03 due to recent illness of COVID-19. The note revealed Resident #03 has had a decline over the past couple weeks and has not been eating or drinking. NP #179 documented Resident #03's skin tenting (a sign of dehydration) was noted to back of the hand and the chest, unable to visualize Resident #03's mucous membranes. Resident with severe dehydration, decreased oral intake, and medications reviewed. Resident #03 had a new/acute decline status post [MEDICAL RECORD OR PHYSICIAN ORDER] . NP #179 ordered a consult ultrasound guided peripheral IV or midline IV insertion to administer 0.9% normal saline at 200 milliliter (ml)/hour IV for three hours, then decrease to 100 ml/hour for four hours, then 60 ml/hour for one liter. Hold [MEDICATION(S)] (diuretic) for three days, check weight, check blood sugar two times a day, and hold [MEDICATION(S)] if blood sugar is less than 125 milligrams per deciliter (mg/dL). Lab tests including a BMP, serum osmolality, and complete blood count with differential were ordered to be obtained on [DATE]. NP #179 noted Resident #03's code status was DNRCC. Review of the medical record revealed no documentation of any additional assessments on [DATE] of Resident #03's physical condition, were conducted by the facility staff. Review of the progress note, dated [DATE] at 10:05 A.M., revealed Social Services (SS) #132, spoke with Resident #03's daughter to review her mom's health decline. The family was informed Resident #03 was looking lethargic but would be continuing with her IV. SS #132 asked the daughter how they would like to proceed with her care. The daughter voiced she would need to be called back at noon to discuss things. Review of the progress note, dated [DATE] at 12:00 P.M., revealed MDS Nurse #136 and SS # 132 notified Resident #03's daughter of a decline in status. The daughter voiced she would like a Hospice consult. Hospice was contacted for consult. The residents' daughter was notified the Hospice nurse will be at the facility at 5:30 P.M. and will meet the daughter. Review of the physician orders dated [DATE], revealed Resident #03's code status was Do Not Resuscitate Comfort Care Arrest (DNRCC-Arrest). Review of the progress note dated [DATE] at 2:00 P.M., revealed MDS Nurse #136 was called to Resident #03's room by the floor nurse. Resident #03 had no vital signs, no heart sounds, and no breath sounds present. The family was notified at 2:15 P.M. and NP #179 was notified at 2:30 P.M. Review of the medical record revealed no documentation of Resident #03's condition or hydration status between [DATE] and [DATE] when the resident expired. Interview on [DATE] at 11:30 A.M., the DON revealed the lab work ordered for [DATE] was not completed due to the phlebotomist was unable to obtain the blood sample on [DATE]. The DON stated the phlebotomist thought the resident was dehydrated. The DON verified the physician was not notified of the lab work not being completed due to the inability of the phlebotomist to draw the blood. The DON verified there was no documentation the physician or family were notified Resident #03 was refusing medications on [DATE], [DATE], [DATE], [DATE], and [DATE] and had been refusing all medications, food, and drinks for multiple days prior to [DATE]. Interview on [DATE] at 10:57 A.M. with NP #179 revealed she was not notified Resident #03 had been refusing her medications since [DATE]. NP #179 stated if she had been notified, she would have recommended a hospice consult. NP #179 also verified she was not notified the labs were not drawn due to dehydration or she would have sent Resident #03 to the local emergency room for evaluation and treatment. NP #179 stated she came to see Resident #03 on [DATE] for a routine rounding visit. NP #179 stated she was not made aware prior to that day of the resident's decline in condition and that the resident had continued to not eat, drink, or take her medications. NP #179 checked her rounding sheet from [DATE] and stated that she had no notes from that day to address any issues with Resident #03. NP #179 stated if the facility would have notified her sooner, she could have intervened sooner, and the outcome may have been different for Resident #03. Review of the policy titled Notification of Change in Condition, revised [DATE], revealed the facility will immediately inform the resident, consult with the resident's physician, NP, or Clinical Nurse Specialist, and if known, notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment significantly. 2) Review of the medical record for Resident #08 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment, dated [DATE], revealed Resident #08 had moderate cognitive impairment. Review of the care plan dated [DATE], revealed Resident #08 was at risk for alteration in respiratory status. Interventions included auscultate lung sounds and document findings. Report abnormal findings. Monitor for shortness of breath, chest pain or change in cognition. Monitor cough and notify the physician if cough persists greater than 48 hours. Monitor oxygen saturation. Monitor skin color and condition. Monitor vital signs as directed. Review of the physician orders revealed an order dated [DATE] for DNRCC code status and keep oxygen saturation 90% or greater. An order dated [DATE] revealed pulse oxygenation as needed, humidified oxygen at two liter per nasal cannula per minute continuous to maintain oxygen saturation greater than 88%. Review of Resident #08's COVID-19 screening revealed he was in quarantine and was to have his temperature checked daily. There was no temperature documented [DATE], [DATE], and [DATE]. There was no oxygen saturation documented on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. There was no documentation of assessments completed on [DATE] and [DATE]. Interview on [DATE] at 10:30 A.M. with the DON verified Resident #08 did not have documentation of monitoring of the oxygen saturation on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. There was no documentation Resident #08's temperature was obtained on [DATE], [DATE], and [DATE]. There was no documentation of assessments completed on [DATE] and [DATE]. 3) Review of the medical record for Resident #09 revealed an original admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive MDS assessment, dated [DATE], revealed Resident #09 had severe cognitive impairment. Review of the COVID-19 daily screenings revealed there was no documentation of COVID-19 screening on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Interview on [DATE] at 10:30 A.M. with the DON verified Resident #09 did not having COVID-19 daily screening completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the facility policy titled COVID-19 Policy and Procedure, dated [DATE] and revised [DATE], revealed under Screening, the facility will actively screen all residents daily for signs and symptoms of COVID-19. This deficiency substantiates Complaint Number OH 626

Based on a closed medical record review, staff interview, review of the Emergency Medical Services (EMS) run report, review of the facility investigation, review of the facility policy for Advanced Directives, review of the facility policy for Code Status, and review of the American Heart Association Journal, the facility failed to timely initiate Cardiopulmonary Resuscitation (CPR) for one (#50) resident found unresponsive, without a pulse, and who was identified as a Full Code. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury and/or ultimate death when Resident #50 did not receive CPR for 14 minutes after she was discovered unresponsive, with no pulse, and cold to the touch. This affected one (#50) of three residents (#49, #50, and #51) who were reviewed for death in the facility. The facility census was 44. On [DATE] at 2:55 P.M., the Administrator and the Assistant Vice-President were notified Immediate Jeopardy began on [DATE] at 8:13 A.M. when Resident #50, who had a Full Code status, was found in her bed by Therapy Student (TS) #501 to be unresponsive and cold to the touch. TS #501 immediately notified Therapy Director (TD) #505. TD #505 approached Resident #50 at 8:13 A.M., verified unresponsiveness, and immediately notified State tested Nursing Assistant (STNA) #403 and STNA #405. At 8:14 A.M., STNA #405 called Licensed Practical Nurse (LPN) #313, who was in a separate building, to notify LPN #313 of the situation. STNA #405 then left House #05 and went to House #04, where LPN #313 was to ensure the LPN responded immediately. LPN #313 and STNA #405 returned to Resident #50's bedside at approximately 8:16 A.M. STNA #405 called the Director of Nursing (DON) at 8:18 A.M. to notify her of Resident #50 being unresponsive without a pulse and cold to the touch. The DON instructed LPN #313 to initiate CPR. LPN #313, the only CPR certified staff on duty, did not initiate CPR as instructed by the DON. LPN #313 stated I don't feel comfortable doing CPR on a dead person. This statement was confirmed by STNA #403, STNA #405, and TD #505. The DON called 911 at 8:20 A.M. Emergency Medical Services (EMS) arrived on scene at 8:27 A.M. and Resident #50 was pronounced deceased by EMS at 8:38 A.M. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 8:30 A.M., the DON and the Administrator initiated a comprehensive investigation of the incident. LPN #313 was immediately relieved of her duties. The Medical Director was notified of Resident #50's death. · On [DATE], the Administrator, the Vice President of Neighborhoods, the Assistant Vice President of Clinical Quality, and the Vice President of Clinical Quality conducted an ad hoc meeting via conference call to develop an internal Quality Assurance Performance Improvement (QAPI) plan. The Medical Director was notified of the QAPI plan. · On [DATE], the DON posted the Change of Condition policy and the Code Status education for immediate staff review. Starting on [DATE], the Administrator assumed responsibility to ensure all staff were educated. On [DATE] at 8:06 P.M., all staff had been educated on resident code status and resuscitative measures. · On [DATE], the DON notified the temporary staffing agency LPN #313 was no longer permitted to return to the facility. · On [DATE], the DON completed a clinical records audit of all residents in house for accuracy of code status in the record. · On [DATE], the Administrator initiated mortality review audits to evaluate whether code status protocols were correctly implemented for 100% of resident deaths, as applicable. The findings will be referred to the Assistant Vice President of Clinical Quality for final review. · On [DATE], an education binder for agency nurses was developed and implemented. This binder includes the most recent staff education including the Change in Condition policy and the code status review. Each agency nurse is to review the binder with the off-going nurse prior to the beginning of their shift. The DON notified all agencies of this communication binder on [DATE]. The binders are kept at each nurse's station. · On [DATE], weekly audits of three staff interviews regarding code management were conducted to ensure understanding of code management procedures. These interviews were completed on [DATE], [DATE] and [DATE]. This audit will continue for another week and then random audits will be conducted thereafter. · On [DATE] and [DATE], the Administrator conducted mock resident codes with nursing staff over all three shifts. Appropriate staff responses to the mock code drills were identified. · The QAPI Committee will review all QAPI audits on a monthly basis until otherwise directed by the committee. · Review of the medical records for Resident #49 and Resident #51, reviewed for death, revealed no issues with the residents' care at the time of death. The facility reported Resident #50 was the only resident who had been found lifeless with a Full Code status. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #50's medical record revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders revealed no order related to code status. Review of an untitled form used by the hospital, dated [DATE] at 8:50 A.M., revealed Resident #50 was a Full Code status. Review of a nursing progress note dated [DATE] at 8:15 A.M., documented by the DON, revealed Resident #50 was found unresponsive, 911 was called, and the EMS called time of death. Resident #50's granddaughter was called but did not answer with a message left to call back as soon as possible. The doctor was notified, and the county coroner was notified but declined the case. The coroner stated they would assume cause of death to be natural. Review of an investigation related to the death of Resident #50 dated [DATE] at 8:30 A.M. revealed the investigation was initiated by the Administrator and the DON. The Administrator's statement revealed she was notified by the DON that Resident #50 had passed away, but CPR had not been initiated. The DON stated she had called 911 and notified staff to initiate CPR as Resident #50 was a Full Code. The Minimum Data Set (MDS) nurse was immediately sent to relieve LPN #313 of her duties and LPN #313 was sent home until further information was gathered. The physician was notified and requested the county coroner be called. The county coroner was called and ruled the death as natural. The investigation interview on [DATE] with STNA #405 revealed she had been notified by TS #501 and TD #505 that Resident #50 was unresponsive. STNA #405 called LPN #313 and then followed up by going to the next house to get LPN #313. They both returned to House #05 and LPN #313 assessed Resident #50. As LPN #313 was assessing Resident #50, STNA #405 called the DON who advised to start CPR if not already done. LPN #313 stated Resident #50 was cold and she had already passed away. STNA #405 told LPN #313 the DON had stated to start CPR, and LPN #313 stated I do not feel comfortable doing CPR on a dead person. STNA #405 called nursing leadership to notify them and immediately returned to the room and was going to start CPR when EMS arrived. STNA #405 then returned to the other residents. The investigation interview on [DATE] with LPN #313 revealed she had been in House #04 when she received a call from STNA #405 stating Resident #50 was unresponsive. LPN #313 stated she completed the medication pass, already in her hand, and reported to House #05. Her assessment revealed Resident #50's oral [MEDICATION(S)] was dry, and she was cold. LPN #313 called the DON to notify her Resident #50 was cold and had no pulse. LPN #313 stated she had been told to start CPR and was headed to start CPR when the EMS arrived. The investigation interview on [DATE] with the DON revealed she received a telephone call from STNA #405 stating Resident #50 had passed away. The DON informed STNA #405 Resident #50 was a Full Code, and she would call 911. The DON immediately called 911 and notified the family. LPN #313 called the DON and reported Resident #50 was cold and had no pulse. The DON gave LPN #313 a directive to start CPR no matter what and LPN #313 hung the phone up. STNA #405 called the DON to notify her EMS had arrived and LPN #313 did not feel comfortable starting CPR. The investigation interview on [DATE] with TS #501 revealed around 8:13 A.M. she had gone to get Resident #50 up for treatment. Resident #50 was not moving, and TS #501 could not find a pulse. TS #501 immediately notified TD #505. The investigation interview on [DATE] with TD #505 revealed TS #501 alerted her to Resident #50 not breathing. TD went to Resident #50 and found her cold. TD #505 stated she notified STNA #405 who was already on the phone with LPN #313. STNA #405 stated LPN #313 was coming. LPN #313 arrived to Resident #50's room, and TD #505 went to the door to allow EMS access. The investigation interview on [DATE] with STNA #403 revealed she had arrived at 6:00 A.M. and had received a report Resident #50 had been sleeping a lot and had been placed on her side for comfort. STNA #403 stated she had conducted a visual check at 6:45 A.M. and Resident #50 was lying on her side. STNA #403 reported she had begun care of the other residents in her assignment. STNA #403 reported around 8:13 A.M. TD #505 stated they needed the nurse. STNA #405 was already on the phone with the nurse. LPN #313 reported to House #05, assessed Resident #50, and stated, She's gone. STNA #403 reported having heard STNA #405 say Resident #50 was a Full Code and LPN #313 stated she Did not feel comfortable doing CPR on a dead person. The investigation interview on [DATE] with STNA #401 revealed she had provided care to Resident #50 at 5:30 A.M. and she was responsive at that time. The facility conclusion of the investigation revealed the nurse on duty was immediately notified Resident #50 was unresponsive. LPN #313 completed her assessment and did not feel comfortable administering CPR related to her assessment. LPN #313 utilized ethical consideration in her nursing judgement and failed to recognize the ethical guidelines do not apply to a nursing facility nor do they comply with the facility policy. Review of the EMS run report, dated [DATE], revealed EMS received the call on [DATE] at 8:20 A.M. The EMS arrived at the facility at 8:26 A.M. and was at Resident #50's bedside at 8:27 A.M. The report revealed upon entering Resident #50's room the resident was found lying on her left side with blankets on and unresponsive. Resident #50 was cold to the touch on the face, neck, and extremities, and cool to the touch on her back, abdomen, and sternum. Her pupils were assessed to be four millimeters and nonreactive. No rigor mortis was noted. Staff reported they had not started CPR. Staff reported entering the room at 8:15 A.M. to wake Resident #50 and found her in this state. A four-lead electrocardiogram completed on Resident #50 revealed asystole at 8:52 A.M., with the statement indicating the time on the electrocardiogram monitor being incorrect. The EMS report noted the EMS call was closed at 8:38 A.M. The police department was on scene and the officer was given report. The report revealed the call was closed was 8:38 A.M. Interview on [DATE] at 12:47 P.M. with Assistant Vice President (AVP) #101, the Administrator, and the DON revealed a quality assurance plan has been started to address the incident with Resident #50. The nurse on duty, LPN #313, at the time of Resident #50's passing had an ethical issue with starting CPR on Resident #50. During an interview on [DATE] at 2:12 P.M., STNA #403 revealed she could not confirm presence of life at the visual round on [DATE] at 6:45 A.M. STNA #403 stated Resident #50 had been lying on her side with the covers pulled up to her neck and eyes were closed. STNA #403 stated she only observed Resident #50 for a brief look at that time. STNA #403 stated she had heard TS #501 state to TD #505 I think she is gone. TD #505 retrieved Resident #50's medical record and ensured Resident #50 was a Full Code. STNA #403 stated she was not CPR certified. STNA #403 stated she overheard LPN #313 state I don't feel comfortable starting CPR on a dead person. Interview on [DATE] at 3:52 P.M. via telephone with TD #505 revealed she had been in the hallway immediately outside of Resident #50's room while TS #501 entered to begin a therapy session. TS #501 was in the room [ROOM NUMBER] to 20 seconds and exited saying I think she is dead. TD #505 entered the room and attempted to rouse Resident #50 by shaking her and noted her to be cold to the touch. TD #505 stated she waited on directions from the nurse and was shocked when she heard LPN #313 state She is cold and I'm not starting CPR. TD #505 stated she did not recall Resident #50 having rigor mortis, she was just cold. Interview on [DATE] at 4:00 P.M. with STNA #405, via telephone, revealed she had given her statement of the events to the Administrator and the DON about 45 minutes after the EMS left. STNA #405 stated she had called LPN #313, who was in House #04 passing medications, and told her it was an emergency. LPN #313 told STNA #405 I'll be there shortly. STNA #405 stated she ran from House #05 to House #04 to get LPN #313. LPN #313 followed her back to House #05 immediately. STNA #405 stated she called the DON maybe three to four minutes after discovery of Resident #50 being cold and unresponsive. STNA #405 reported LPN #313 stated DON told me to start CPR but if she wants it started, she can do it herself. Review of the facility policy titled Code Status Review, undated, revealed a Full Code status indicated EVERYTHING would be done to keep the Resident alive. CPR is to be performed on anyone who does not have a Do Not Resuscitate (DNR) order. This includes finding a resident without a heartbeat or respirations. Review of the facility policy titled Advanced Directives Policy, last revised [DATE], revealed CPR would be initiated if: 1) the resident is not a DNR Comfort Care or a DNR Comfort Care-Arrest resident; 2) the resident's DNR order or request has not become effective; or 3) the resident at any time asks for resuscitation. Review of the American Heart Association Journal, Vol. 122, No.18, found at https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.110XXX 5, revealed the goals of resuscitation are to preserve life. Criteria for not starting CPR would include: Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril; Obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition); or a valid, signed, and dated advance directive indicating that resuscitation is not desired, or a valid, signed, and dated do not resuscitate order. This deficiency substantiates Complaint Number OH 871.

Based on medical record review and staff interview, the facility failed to assess and treat a pressure ulcer. This resulted in Actual Harm when one resident (#21) was admitted with an open area on the coccyx, no assessment of the area was completed, and no treatment was provided to aide in the healing of the pressure ulcers, resulting in the pressure ulcer increasing in size and developing slough tissue. This affected one (#21) of one resident with current pressure ulcers. The facility census was 44. Findings include: Review of the medical record of Resident #21 revealed an admitted [DATE] and a readmit of 10/16/21 after a hospital stay related to COVID-19. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day Minimum Data Set assessment dated [DATE] revealed Resident #21 had low moderate cognition deficit and required the extensive assistance for bed mobility, transfers, toileting, and personal hygiene. No pressure ulcer was documented on the assessment. Review of the plan of care dated 05/01/20 indicated Resident #21 was resistive to care and refused to get out of bed. A plan of care dated 10/28/19 revealed Resident #40 had the potential for skin breakdown related to fragile skin. Interventions included pressure reduction devices as ordered. Review of the progress note dated 10/16/21 at 8:00 P.M. revealed Resident #21 was noted to have open area on her bottom upon readmission for the hospital. The note indicated wound care was consulted and they would follow Resident #21 after she was removed from quarantine. Barrier cream was to be applied to the open areas and the intervention included off-loading. There were no measurements and no assessment of the open area. Review of the Skin and Wound-Total Body Skin assessment dated [DATE] revealed Resident #21 had no wounds. Review of the Skin & Wound Evaluation form dated 10/22/21 revealed Resident #21 had a pressure ulcer to the sacrum which was identified as a Stage 3 ulcer. The form indicates the area was present on admission. The ulcer measured 0.6 centimeters (CM) by 1.9 cm and 0.9 cm; depth. The wound bed was described as pink or red, with light exudate and serosangeunous drainage. The form indicated there was a treatment in place of calcium alginate. The only intervention identified was a turning and repositioning program. No pressure reduction was identified on the form to be in use. Review of the Skin & Wound Evaluation form dated 10/25/21, revealed the resident's pressure ulcer was a Stage 3. The wound had increased in size measuring 1.3 cm by 3.6 cm by 0.8 cm. The wound bed now was assessed as having slough with 70% of the wound filled. Light amount of serosangeunous exudate and no odor. Additional care of a mattress with pump was documented and the progress was documented as stable. The note section of the form indicated Two areas in the picture. One on coccyx-unstageable and one on buttocks-Stage 3. Wound care rounding and took measurements at the time of the picture. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no prior orders to treat the pressure ulcer and no orders for pressure relief. Interview on 10/26/21 at 3:24 P.M. with DON provided verification of the lack of care for the pressure ulcer, noted upon admission. This was an incidental finding at the time of the complaint survey.