Every finding on record at Aventura at Carriage Inn

Based on interview and record review, the facility failed to ensure a resident's code status was accurate and matched in all areas of the resident's medical record. This affected one (#56) out of the 24 residents reviewed for advanced directives. The facility census was 60. Review of Resident #56's chart revealed an admission date of [DATE]. Diagnosis included acute kidney failure, unspecified severe protein calorie malnutrition, unspecified mood disorder, muscle weakness, adult failure to thrive, unspecified hearing loss, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease and generalized anxiety disorder. Review of Resident #56's electronic physician order dated [DATE] revealed Resident #56's code status was a do not resuscitate comfort care (DNRCC). Review of Resident #56's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required maximal assistance with eating, upper body dressing, rolling left and right, sitting to lying and lying to sitting. Resident #56 was dependent with oral hygiene, toileting, showering, lower body dressing, putting on and taking off footwear and personal hygiene. Review of Resident #56's paper chart on [DATE] at 7:15 A.M., revealed a form that indicated the resident was a Full code status . The full code form was sitting on top of a blank DNR form that did not contain any resident name and was not signed by the physician. Review of Resident #56's electronic chart on [DATE] at 7:15 A.M., revealed Resident #56 did not have a signed DNR form scanned into the electronic medical record. Interview with the Director of Nursing (DON) on [DATE] at 7:15 A.M., verified Resident #56's paper chart contained a form that indicated the resident wished to be a Full code. The DON also confirmed the full code form was sitting on top of a blank DNR form that did not contain any resident name and was not signed by the physician. The DON verified Resident #56 did not have a signed DNRCC form scanned into the electronic medical record despite the physician orders from [DATE]. The DON stated she did not know where Resident #56's DNRCC form signed by the physician was located and if Resident #56 had coded she would have to do CPR until staff found the form. Review of the facility's DNR order policy dated [DATE], revealed DNR orders must be signed by the resident's attending physician on the physician's order sheet and maintained in the resident's medical record. The facility should only use state approved DNR forms. This deficiency represents non-compliance investigated under Complaint Number 3043112.

Based on record review, staff interview, and policy review the facility failed to ensure residents' medical records were complete and accurate. This affected one (#69) one out of five residents reviewed for discharged and transfer. The facility census is 60.Findings include:Record review for Resident #69 revealed this resident was admitted to the facility on [DATE] and discharged on 06/26/26. Diagnoses included encounter for orthopedic aftercare following surgical amputation, osteomyelitis, and acquired absence of right leg above knee. Review of Resident #69's medical record revealed no documented evidence of Resident #69 leaving the facility.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had intact cognition.Interview on 07/29/26 at 1:57 P.M., the Director of Nursing (DON) confirmed the facility did not any documentation of Resident #69 leaving the facility for an appointment and did not have any documentation related to resident being hospitalized . The DON stated Resident #69 went out to a burn clinic appointment and was transferred to the hospital from the clinic. Review of facility policy Transfer and Discharge Policy revealed the facility will document relevant information regarding the transfer in the medical record.This deficiency represents non-compliance investigated under Complaint Number 3043112.

Based on medical record reviews, observations, staff interviews, and policy review, the facility failed to ensure resident's medications were administered as ordered resulting in five medication errors out of 33 opportunities or a 15 percent (%) error rate. This affected two (#04 and #59) residents out of four reviewed for medication administration. The facility census was 65.Findings included:1.Review of the medical record for Resident #04 revealed an admission date of 04/08/25 with medical diagnoses of chronic obstructive pulmonary disease (COPD), morbid obesity, congestive heart failure (CHF), constipation, and chronic kidney disease stage III.Review of Resident #04's Minimum Data Set (MDS) assessment, dated 04/23/26, revealed Resident #04 had moderate cognitive impairment and was dependent upon staff for toilet hygiene and transfers, required substantial/maximum staff assistance for bathing and bed mobility and was independent with eating. Review of Resident #04's physician orders revealed orders dated 04/12/26 for furosemide 40 milligram (mg) tablet one by mouth two times per day, gabapentin 300 mg two tablets by mouth four times per day, and apixaban 5 mg one tablet by mouth two times per day, and orders dated 04/13/26 for potassium chloride 20 milliequivalent (meq) one tablet by month daily, Diltiazem 120 mg one tablet by mouth daily, metoprolol 20 mg one tablet by mouth daily, hydrochlorothiazide (HCTZ) 25 mg one tablet by mouth daily, escitalopram oxalate 20 mg give one half tab by mouth daily, Vitamin B-12 1000 micrograms (mcg) one tablet by mouth daily, cholecalciferol 25 mcg one tablet by mouth daily, magnesium hydroxide oral suspension 400 mg per 5 milliliter (ml) to give 30 ml by mouth every morning (constipation), and MiraLAX 17 grams by mouth daily. Further review revealed physician orders dated 04/20/26 for senna 8.6-50 mg give two tablets by mouth every morning (constipation) and ipratropium-albuterol solution 2.5 (3) mg per 3 ml to give 3 ml inhale orally via nebulizer every four hours. Observation on 05/14/26 at 8:02 A.M. revealed Licensed Practical Nurse (LPN) #201 prepared Resident #59's medications for morning medication administration. The observation revealed LPN #201 placed furosemide, potassium chloride, gabapentin, diltiazem, metoprolol, HCTZ, apixaban, escitalopram, Vitamin B-12, cholecalciferol into the medication cup as ordered. LPN #201 was observed to place one Senna 8.6-50 mg tablet into the medication cup. The observation also revealed that magnesium hydroxide oral solution was not available for administration. The observation revealed LPN #201 observed Resident #04 consuming the medications and Resident #04 refused the ipratropium-albuterol solution.Interview on 05/14/26 at 8:12 A.M. with LPN #201 confirmed Resident #04's order for senna was for two tablets to be administered and she had only administered one tablet. LPN #201 also confirmed that she was unable to administer the magnesium hydroxide oral suspension because the medication was not available and had to be ordered from the pharmacy. 2.Review of the medical record for Resident #59 revealed an admission date of 01/20/21 with medical diagnoses of CHF, COPD, atrial fibrillation, hypertension, bilateral hypertensive retinopathy, and glaucoma. Review of Resident #59's significant change MDS assessment, dated 04/23/26, revealed Resident #59 had moderate cognitive impairment and was dependent upon staff for toilet hygiene and transfers, required substantial/maximum staff assistance for bathing and bed mobility and was independent with eating. Review of Resident #59's physician orders revealed orders dated 06/24/24 for HCTZ 25 mg one tablet by mouth daily, metoprolol 50 mg one tablet by mouth daily, and cetirizine 5 mg one tablet by mouth daily, an order dated 07/18/24 for artificial tears ophthalmic solution to instill one drop in both eyes four times a day for dry eyes, an order dated 01/24/25 for dorzolamide HCL-Timolol ophthalmic solution 2-0.5% (used to lower high eye pressure caused by glaucoma or ocular hypertension) to instill one drop in left eye two times per day, an order dated 07/13/25 for senna 8.6 mg one tablet by mouth two times per day, an order dated 07/31/25 for brimonidine tartrate ophthalmic solution 2% to instill one drop in left eye two times per day for glaucoma, and orders dated 08/03/25 for levetiracetam 100 mg one tablet by mouth two times per day and buspirone 5 mg one tablet by mouth two times per day. Further review of Resident #59's physician orders revealed an order dated 08/20/25 for meclizine 12.5 mg one tablet by mouth three times per day, an order dated 11/25/25 for potassium chloride oral solution 40 meq per 15 ml to give 15 ml by mouth every morning, an order dated 01/17/26 for cyanocobalamin 500 mcg one tablet by mouth daily and an dated 04/20/26 for gabapentin 600 mg two tablets by mouth three times per day.Observation on 05/14/26 at 8:33 A.M. revealed LPN #203 prepared Resident #59's medication for morning medication administration. The observation revealed LPN #203 placed cetirizine, cyanocobalamin, HCTZ, metoprolol, meclizine, gabapentin, levetiracetam, buspirone, and senna tablets into a medication cup as ordered and poured 15 ml of potassium chloride solution into a medication cup. The observation revealed LPN #203 was unable to locate Resident #59's brimonidine tartrate ophthalmic solution or artificial tear bottles in the medication cart. The observation revealed LPN #203 observed Resident #59 consume medications and LPN #203 was observed to administer dorzolamide HCL-timolol ophthalmic solution to both of Resident #59's eyes. Interview on 05/14/26 at 8:56 A.M. with LPN #203 confirmed Resident #59's brimonidine tartrate ophthalmic solution or artificial tears were not administered because the medications were not available and had to be ordered from the pharmacy. LPN #203 stated she even checked the medication storage room and was not able to locate a bottle of artificial tears. LPN #203 also confirmed that she administered the dorzolamide HCL-timolol ophthalmic solution eye drops to both of Resident #59's eyes not just the left eye as ordered. Review of the facility policy titled, Administering Medications, revised April 2019, stated medications are to be administered in a safe and timely manner and as prescribed. This deficiency represents non-compliance investigated under Complaint Number 2998003.

Based on record review, staff interviews, review of facility investigation, and review of a clinical resource guidance, the facility failed to implement appropriate safety interventions to prevent an avoidable fall by not ensuring the resident was safely positioned in bed during incontinence care. This affected one (#70) of three residents reviewed for accidents. The facility census was 65.Findings include:Medical record review for Resident #70 revealed diagnoses included dementia, high blood pressure, and kidney disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 was cognitively impaired and required total dependence from one staff for care. Review of the progress notes dated 03/06/26 revealed Resident #70 was on the floor beside her bed in a fetal position. Both side rails were raised. Review of the facility investigation dated 03/06/26 revealed Certified Nursing Assistant (CNA) #39 was providing incontinence care to Resident #70. CNA #70 rolled Resident #70 away from her causing the resident to fall from the bed feet first. Post fall evaluation revealed multiple bruises. A bruise was noted below the right eye measuring approximately 2.5 centimeters (cm) in length and 1.5 cm in width with no depth; an abrasion to the left arm; bruise noted right side of the left forearm measuring 2.0 cm in length and 1.5 cm. in width with no depth; A skin tear on right forearm measuring 7.5 cm in length and 0.5 cm in width with no depth; a skin abrasion to the right elbow measuring 5.0 cm in length and 5.0 cm in width with no depth; and an abrasion the middle of her back. Resident #70 was returned to bed. The doctor was notified and x-rays were obtained which revealed no fractures. Review of CNA #39's witness statement revealed the CNA was changing Resident #70. CNA #39 rolled the resident away from her instead of towards her. Resident #70 began sliding feet first from the bed to the floor. The facility determined the staff did not follow standards of practice and turned the resident away from the staff.Interview on 04/22/26 at 1:15 P.M. with CNA #39 confirmed she was provided counseling and knew when providing care by yourself, you should never roll a resident away from you to prevent them from falling out of bed. Interview with the Administrator on 04/22/26 at 2:30 P.M. revealed CNA #39 was counseled regarding positioning the residents in center of bed and rolling the resident towards her during care. Review of an online and undated clinical resource titled Turning Patients Over in Bed: Medline Plus Medical Encyclopedia found at: https://medlineplus.gov/ency/patientinstructions/000426.htm#:~:text=Standing%20with%20one%20foot%20ahead,the%20person's%20hip%20toward%20you revealed the following steps should be followed when turning a resident in bed: explain to the resident what you are planning to do so they know what to expect, encourage the person to help if possible, stand on the opposite side of the bed the resident will be turning towards, move the patient towards you, step around to the other side of the bed, and ask the resident to look towards you (this will be the direction in which the person is turning).This deficiency represents noncompliance investigated under Complaint Numbers 2802307, 2799717, and 2729262.

Based on review of the facility menu, observations, staff interview, and policy review, the facility failed to ensure food was served per the facility menu. This affected nine (#28, #32, #33, #34, #35, #36, #40, #41, and #71) resident who did not receive coleslaw on their lunch trays. The facility census 62. Findings include: Review of the facility menu for the lunch meal for 12/10/25 revealed that residents would receive baked pork chop, baked beans, creamy coleslaw, cornbread, and whipped jello parfait. Observation of the lunch service on 12/10/25 at 1:04 P.M. revealed that the kitchen ran out of coleslaw and Resident #28, #32, #33, #34, #35, #36, #40, #41, and #71 did not receive coleslaw on their trays. Interview on 12/10/25 at 1:06 P.M. with Dietary Manager (DM) #179 verified the facility ran out of coleslaw. DM #179 verified Resident #28, #32, #33, #34, #35, #36, #40, #41, and #71 did not receive coleslaw and were not given any substitutions. Review of the facility policy titled, Menu Substitutions date 04/25/24 revealed substitutions shall be made when menu items are not available for service. This deficiency represents non-compliance investigated under Complaint Number 1263340 (OH00161682) and Complaint Number 1263335 (OH00161111).

Based on medical record review and staff interview, the facility failed to notify resident representative of a resident's change of condition. This affected one (#64) out of three reviewed for changes in conditions. The facility census was 62. Findings include: Review of the medical record for Resident #64 revealed an admission date of 06/10/25 with medical diagnoses of right femur fracture, chronic obstructive pulmonary disease, dementia, chronic kidney disease Stage IV, and pneumonitis. Review of the medical record revealed Resident #64 was discharged to the hospital on [DATE]. Review of the medical record for Resident #64 revealed an admission Minimum Data Set (MDS) assessment, dated 06/16/25, which indicated Resident #64 had severely impaired cognition and was dependent upon staff for toilet hygiene, bathing, bed mobility and transfers. The MDS indicated Resident #64 required substantial/maximum staff assistance for eating. Review of the medical record for Resident #64 revealed a nurses' note, dated 06/16/25 at 6:18 P.M. which stated Resident #64 had copious amount of rectal bleeding noted one time. The note indicated the nurse notified the facility Telemed (physician on-call) service and no new orders were received. Review of the medical record revealed no documentation to support Resident #64's representative was notified of the change in condition. Further review of the medical record revealed Resident #64 was transferred to the hospital on [DATE] for rectal bleeding. Interview on 12/10/25 at 3:22 P.M. with Director of Nursing (DON) confirmed the medical record for Resident #64 did not have any documentation to support Resident #64's representative was notified of the change in condition on 06/16/25. DON stated the facility only had a policy related to notifying the physician of change in condition. This deficiency represents non-compliance investigated under Complaint Number 1263342 (OH00167356).

Based on medical record review, review of hospital records, staff interviews, and policy review, the facility failed to provide wound care as ordered for an arterial ulcer to a resident's foot and failed to complete a comprehensive wound assessment for surgical wound on a resident's foot. This affected one (#66) out of three residents reviewed for wounds. The facility census was 62. Findings include: Review of the medical record for Resident #66 revealed an admission date of 12/01/24 with medical diagnoses of chronic obstructive pulmonary disease, diabetes mellitus, and peripheral vascular disease. Review of the medical record revealed Resident #66 was discharged to the hospital on [DATE], readmitted to the facility on [DATE] and admitted to the hospital on [DATE]. Review of the medical record for Resident #66 revealed a quarterly Minimum Data Set (MDS) assessment, dated 03/08/25, which indicated Resident #66 was cognitively intact and required supervision with bed mobility, eating, and transfers and partial/moderate staff assistance with toilet hygiene and bathing. The MDS indicated Resident #66 had a surgical wound and care was provided. Review of the medical record for Resident #66 revealed an initial wound evaluation completed on 02/04/25 which indicated an arterial ulcer to the right foot second digit. The evaluation indicated the wound had 100% eschar and measured 1 centimeter (cm) by 1 cm with an order to apply barrier skin wipes/spray daily and as needed. Review of the medical record for Resident #66 revealed a Wound Physician note, dated 02/04/25, which stated Resident #66 had an arterial ulcer to the right foot second digit which measured 1.0 cm by 1.5 cm with 100% eschar. The note indicated an order for barrier wipes/spray daily and as needed. The note stated the right foot toes were dusky, warm and capillary refill was present but diminished. Review of the medical record for Resident #66 revealed a physician order dated 02/04/25 to apply barrier spray/wipes to the right foot second toe daily, every 12 hours as needed for skin integrity. Review of the medical record for Resident #66 revealed a February 2025 Treatment Administration Record (TAR) which revealed no documentation to support the facility completed treatment to the second digit on the right foot as ordered on 02/04/25. Review of the medical record for Resident #66 revealed a hospital note, dated 02/10/25, which stated resident complained of her right foot second toe being dead. Further review of the medical record revealed a hospital discharge summary and transfer orders dated, 02/28/25, which stated Resident #66 later underwent a right foot second digit toe amputation on 02/14/25 and a right transmetatarsal amputation on 02/25/25. Review of the medical record for Resident #66 revealed an admission nursing evaluation, dated 02/28/25, which indicated Resident #66 had amputated toes but no documentation to support which foot, measurements, or description of surgical site. Further review revealed weekly skin assessments completed on 03/02/25 and 03/10/25 which indicated amputation to right foot but did not have documentation to support measurements or description of the surgical wound. Review of the medical record revealed a nurses' note, dated 03/12/25 at 3:39 P.M. which stated the Wound Clinic informed the facility that Resident #66 was admitted to the hospital from the appointment for possible wound infection. Interview on 12/09/25 at 2:27 P.M. with Administrator confirmed the medical record for Resident #66 did not contain documentation to support the facility completed wound care to the second digit on the right foot as ordered by the Wound Physician on 02/04/25. Administrator stated the order for treatment to second digit on the right foot was entered into Resident #66's electronic health records for the treatment to be done as needed instead of daily and as needed. Administrator also confirmed Resident #66 was admitted to the hospital on [DATE] for right foot pain and later underwent an amputation of second digit on right foot on 02/14/25. Interview on 10/10/25 at 10:20 A.M. with Director of Nursing (DON) confirmed that the medical record did not have documentation to support Resident #66's surgical wound had been measured or an included description of the wound on 02/28/25 though stay until discharged on 03/12/25. Review of the facility policy titled, Wound Care, revised October 2010 stated the purpose of the procedure was to provide guidelines for care of wounds to promote healing. The policy stated to verify there was a physician order for the procedure. The policy stated the following information should be recorded in the resident's medical record: 1) type of wound; 2) date and time wound care was given; 3) position in which the resident was placed; 4) the name and title of the individual performing the wound care; 5) any change in the resident's condition; 6) all assessment data (wound bed color, size, drainage, etc.); 7) how the resident tolerated the procedure; 8) any problems or complaints made by the resident related to the procedure; 9) if resident refused treated and reason why; 10) the signature and title of the person recording the data. This deficiency represents non-compliance investigated under Complaint Number 1263342 (OH00167356) and 1263337 (OH00163933).

Based on medical record review, staff interview, and policy review, the facility failed to properly assess a surgical wound to include measurements and description of the wound. This affected one (#64) out of three residents reviewed for wounds. The facility census was 62. Findings include: Review of the medical record for Resident #64 revealed an admission date of 06/10/25 with medical diagnoses of right femur fracture, chronic obstructive pulmonary disease, dementia, chronic kidney disease Stage IV, and pneumonitis. Review of the medical record revealed Resident #64 was discharged to the hospital on [DATE]. Review of the medical record for Resident #64 revealed an admission Minimum Data Set (MDS) assessment, dated 06/16/25, which indicated Resident #64 had severely impaired cognition and was dependent upon staff for toilet hygiene, bathing, bed mobility and transfers. The MDS indicated Resident #64 required substantial/maximum staff assistance for eating and had a surgical wound. Review of the medical record for Resident #64 revealed an admission Observation and Assessment, dated 06/10/25, which indicated Resident #64 had a surgical site to right hip with 29 staples that were well approximated. The observation did not have document to support measurements or a description of the wound. Review of the medical record revealed a weekly skin observation, dated 06/18/25, which stated Resident #64 had an unstageable to right thigh. The observation did not contain documentation to support information related to Resident #64's surgical site or measurements or description for the wound to Resident #64's right thigh. Interview on 12/10/25 at 9:45 A.M. with Licensed Practical Nurse (LPN) #136 stated she assessed Resident #64's skin on 06/11/25 and noted the surgical wound to her right hip/thigh areas and denied any other skin issues. LPN #136 confirmed the medical record for Resident #64 did not contain documentation of the surgical wound measurements or description of the wound during Resident #64's stay from 06/10/25 to 06/21/25. Review of the facility policy titled, Wound Care, revised October 2010 stated the purpose of the procedure was to provide guidelines for care of wounds to promote healing. The policy stated to verify there was a physician order for the procedure. The policy stated the following information should be recorded in the resident's medical record: 1) type of wound; 2) date and time wound care was given; 3) position in which the resident was placed; 4) the name and title of the individual performing the wound care; 5) any change in the resident's condition; 6) all assessment data (wound bed color, size, drainage, etc.); 7) how the resident tolerated the procedure; 8) any problems or complaints made by the resident related to the procedure; 9) if resident refused treated and reason why; 10) the signature and title of the person recording the data. This deficiency represents non-compliance investigated under Complaint Numbers 1263342 (OH00167356) and 1263337 (OH00163933).

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were free of significant medication errors. This affected two (Residents #10 and #11) of three residents reviewed for medication administration. The facility census was 65 residents. Findings include: 1.Review of the medical record for Resident #10 revealed an admission date of 06/28/24 with diagnoses including infection and inflammation of internal right hip prosthesis, chronic obstructive pulmonary disease, alcoholic cirrhosis of liver with ascites, and hypertension. Resident #10 was discharged to the hospital on [DATE] and returned on 04/05/25. Review of the hospital discharge orders for Resident #10 revealed an order dated 04/05/25 for Levaquin (an antibiotic) 750 milligrams (mg) once daily by mouth until 05/13/25. Review of the Medication Administration Record (MAR) for Resident #10 dated April 2025 revealed Levaquin was administered twice daily on 04/06/25, 04/07/25, 04/08/25, and 04/09/25. Interview on 10/30/25 at 1:03 P.M. with the Administrator confirmed the facility staff had not administered Resident #10's Levaquin as ordered. 2. Review of the medical record for Resident #11 revealed an admission date of 09/17/25 with diagnoses including nontraumatic subarachnoid hemorrhage, atrial fibrillation, and chronic obstructive pulmonary disease. Resident #11 was discharged to the hospital on [DATE] and returned on 10/23/25. Review of the hospital discharge orders for Resident #11 revealed an order dated 10/23/25 revealed to hold Eliquis (an anticoagulant) 5 mg until 10/26/25 and an order for cefuroxime (an antibiotic) 500 mg twice daily by mouth for three days. Review of the MAR for Resident #11 dated October 2025 revealed Eliquis was administered once on 10/23/25 and twice on 10/24/25 and10/25/25. Further review of the MAR dated 10/23/25 to 10/30/25 revealed cefuroxime was not signed off as administered. Interview on 10/30/25 at 1:03 PM with the Administrator confirmed the facility had not administered Resident #11's Eliquis nor the cefuroxime as ordered. Review of the facility policy titled Administering Medication dated April 2019 revealed medications should be administered in accordance with prescriber orders, including any required timeframe.This deficiency represents noncompliance investigated under Complaint Number 1263206 and is a recite to the survey dated 10/21/25.

Based on medical record review and staff interview, the facility failed to ensure laboratory services were provided as ordered. This affected one (Resident #10) of three residents reviewed. The facility census was 65 residents.Findings include: Review of the medical record for Resident #10 revealed an admission date of 06/28/24 with diagnoses including infection and inflammation of internal right hip prosthesis, chronic obstructive pulmonary disease, alcoholic cirrhosis of liver with ascites, and hypertension. Resident #10 was discharged to the hospital on [DATE] and returned on 04/05/25. Review of the hospital discharge orders for Resident #10 dated 04/05/25 revealed an order for Vancomycin (antibiotic) intravenous (IV) one gram every 12 hours and an order to obtain a Vancomycin level every Monday. Review of the Medication Administration Record (MAR) for Resident #10 revealed the resident was given the first dose of IV Vancomycin on 04/06/25 at 8:00 P.M. Review of the lab results for Resident #10 revealed the facility did not obtain obtain a Vancomycin level for Resident #10 until 04/14/25. Interview on 10/30/25 at 12:20 PM with Pharmacist #165 confirmed Vancomycin levels should be drawn prior to the administration of the fourth dose of Vancomycin for safe dosing. Pharmacist #165 further confirmed the pharmacy sent recommendations to the facility on [DATE] indicating the need to obtain a pre-dose Vancomycin level. Interview on 10/30/25 at 1:15 PM with the Administrator confirmed Resident #10 had an order for Vancomycin every 12 hours and an order to obtain Vancomycin levels every Monday. The Administrator further confirmed the facility began administration of Vancomycin to Resident #10 on 04/06/25 at 8:00 P.M. but did not obtain a Vancomycin level until 04/14/25. This deficiency represents noncompliance investigated under Complaint Number 1263206.

Based on observation and staff interview, the facility failed to maintain kitchen equipment and furnishings in a clean and sanitary manner. This had the potential to affect all of the residents residing in the facility with the exception of three facility-identified residents who did not consume food by mouth. The facility census was 63 residents.Findings include:1.Observation on 10/20/25 at 9:24 A.M. revealed there were plastic containers on the clean dish rack which had been stacked while wet and were nesting. Interview on 10/20/25 at 9:25 A.M. with Dietary Manager (DM) #21 verified that the containers were wet and were being stored nested together so they couldn't dry properly. 2.Observation on 10/20/25 at 9:28 A.M. revealed the knife storage rack above the prep table contained two knives each with several missing metal chips along the blades and three knives with residue on the blade. Interview on 10/20/25 at 9:28 A.M. with DM #21 verified that the two knives had missing metal chips along the blades and the three knives were unclean. 3. Observation on 10/20/25 at 9:29 A.M. revealed there was a metal plate warmer with food debris stored on the clean dish drying rack. Interview on 10/20/25 at 9:29 A.M. with DM #21 verified that the plate warmer was dirty. 4. Observation on 10/20/25 at 9:30 A.M. revealed the can opener attached to the prep table had dried food debris on the blade. Interview on 10/20/25 at 9:30 A.M. with DM #21 verified that the can opener was unclean. 5. Observation on 10/20/25 at 9:33 A.M. revealed there was a build up of debris at the bottom of the steam table wells. Interview on 10/20/25 at 9:33 A.M. with DM #21 verified the steam table wells were dirty. 6. Observation on 10/20/25 at 9:35 A.M. revealed there was a build-up of ice on the vinyl strip curtains and floor in the walk-in freezer.Interview on 10/20/25 at 9:35 A.M> with DM #21 verified the walk-in freezer had a build-up of ice on the vinyl strip curtains and on the floor. 7. Observation on 10/20/25 at 9:37 A.M. revealed the walk-in cooler metal floors and walls were rusted with the metal flooring separating. Further observation revealed the condenser was leaking with a bucket below it containing gray stagnant water and water on the floor. Interview on 10/20/25 at 9:37 A.M. with DM #21 confirmed the cooler had been leaking for a while and the maintenance department had placed the bucket below the condenser. This deficiency represents noncompliance investigated under Complaint Number 2640037.

Based on medical record review, review of the facility menu, observation, staff interview, and review of the facility policy, the facility failed to prepare pureed foods in a method that conserved nutritive value, flavor and appearance. This affected four (Residents #7, #13, #21,and #35) of four residents with orders for pureed diets. The facility census was 63 residents. Findings include: Review of the medical records for Residents #7, #13, #21,and #35 revealed the residents had physician orders to receive a pureed diet. Review of the puree diet menu for 10/20/25 revealed the following items were on the lunch menu: beef burgundy, vegetable rice pilaf, green peas, mandarin oranges, dinner roll, chocolate chip cookie. Review of the substitution log revealed beef stew was substituted for beef burgundy on 10/20/25. Observation on 10/20/25 at 11:07 A.M. revealed [NAME] #14 prepared pureed peas. [NAME] #14 added 10 ounces (oz) of peas, one cup of water, and three scoops of thickener to a food processer and blended the peas. [NAME] #14 then prepared pureed beef stew by adding 12 oz. stew, one cup of water and two scoops of thickener to the food processor. Interview on 10/20/25 at 11:18 A.M. with [NAME] #14 verified that she used water as a thinning agent when making pureed foods.Review of the facility policy titled Summary of House Diets dated August 1015 revealed fruit or vegetable juices, meat broths, or milk should be used to thin pureed food to the appropriate consistency. This deficiency represents noncompliance investigated under Complaint Number 2640037.

Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) for residents on enhanced barrier precautions. This affected three (Residents #61, #21, #14) of three residents observed for care. The facility also failed to ensure staff practiced proper hand hygiene. This affected one (Resident #21) of three residents observed for care and one (Resident #15) of two residents observed for medication administration. The facility census was 63 residents.Findings include:1.Review of the medical record for Resident #61 revealed an admission date of 09/23/25 with diagnoses including cerebral atherosclerosis, tracheostomy, and gastrostomy. Review of the physician's orders for Resident #61 revealed an order dated 09/24/25 for the resident to be on enhanced barrier precautions Observation on 10/21/25 at 8:27 A.M. revealed Licensed Practical Nurse (LPN) #30 was in Resident #61's room providing care without a gown. Interview on 10/21/25 at 8:29 P.M. with LPN #30 confirmed Resident #61 had an order for enhanced barrier precautions and the nurse had been caring for the resident's gastrostomy tube, but had not donned a gown prior to entering the room. 2.Review of the medical record for Resident #15 revealed an admission date of 04/08/25 with a diagnosis of pneumonia. Observation on 10/20/25 at 10:01 A.M. revealed LPN #30 entered Resident #15's room to check the resident's blood pressure and to administer medications and donned gloves. LPN #30 used a reusable wrist blood pressure (BP) monitor to take BP, administered medications, doffed gloves, and returned to the medication cart and began to pull medication for Resident #11. LPN #30 then administered medications to Resident #11 without performing hand hygiene between residents. Interview on 10/20/25 at 10:40 A.M. with LPN #30 confirmed she had not performed hand hygiene after administering medication to Resident #15 and prior to administering medication to Resident #11. 3. Review of the medical record for Resident #21 revealed an admission date of 01/15/24 with diagnoses including cerebral palsy, stage three pressure ulcer, severe protein malnutrition, and dysphagia. Observation on 10/21/25 at 2:14 P.M. revealed Resident #21 had a sign outside his door indicating he was on EBP. Observation of wound care for Resident #21 per LPN #10 assisted by Certified Nursing Assistant (CNAs) #14 and #64 revealed the staff did not don gowns prior to entering the room to perform care. LPN #10, CNA #14, and CNA #64 doffed gloves after performing care, but then exited Resident #21's room without performing hand hygiene. Interviews on 10/21/25 at 2:30 P.M. with LPN#10, CNA #14 and CNA #64 confirmed Resident #21 was on EBP and they should have donned gowns prior to entering the room to perform care and they had not performed hand hygiene after caring for the resident. 4. Review of the medical record for Resident #14 revealed an admission date of 03/01/19 with diagnoses including hemiplegia and hemiparesis, cerebral infarction, diabetes, and stage three pressure ulcer. Observation on 10/21/25 at 2:41 P.M. revealed Resident #14 had a sign outside the door indicating the resident was on EBP. LPN #29 performed wound care for Resident #14 but did not don a gown. Interview on 10/21/25 at 2:55 P.M. with LPN #29 confirmed Resident #14 was on EBP, but she had not donned a gown for performing wound care for the resident. Review of facility policy titled Handwashing/Hand Hygiene dated October 2023 revealed hand hygiene was indicated immediately before touching a resident, after touching a resident, after touching a resident's environment and immediately after glove removal. Review of the facility policy titled Isolation-Categories of Transmission Based Precautions (TBP) dated 2001 revealed staff should consult with the nurse to determine what type of PPE should be donned prior to caring for a resident on TBP.

Based on medical record review, observation, staff interview, and review of policy, the facility failed to ensure medications were not left unattended in resident rooms. This affected one (Resident #15) of two residents observed for medication administration. The facility census was 63 residents. Findings include: Review of the medical record for Resident #15 revealed an admission date of 04/08/25 with diagnoses including atrial fibrillation, malignant prostate cancer, and pneumonia. Review of the Minimum Data Set (MDS) assessment for Resident #15 dated 07/15/25 revealed the resident had intact cognition and required moderate staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #15 dated October 2025 revealed there was no order for the resident to self-administer medications. Observation on 10/20/25 at 10:01 A.M. with License Practical Nurse (LPN) #30 revealed the nurse entered Resident #15's room with an ampule of albuterol, an inhalant medication to assist with breathing. LPN #30 placed the contents of the ampule into the nebulizer and told the resident the medication was there for him whenever he was ready to use. The nurse then left the room. Interview on 10/20/25 at 10:03 A.M. with LPN #30 confirmed Resident #15 did not have a physician's order to self-administer albuterol. Review of facility policy titled Administering Medications dated April 2019 revealed residents may self-administer medications only if the attending physician and interdisciplinary care team had determined the resident had the decision-making capacity to do so safely. This deficiency represents noncompliance investigated under Complaint Number 2640037.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff administered blood pressure medications according to physician-ordered parameters. This affected one (Resident #15) of two residents observed for medication administration. The facility census was 63 residents. Findings include: Review of the medical record for Resident #15 revealed an admission date of 04/08/25 with diagnoses including atrial fibrillation, malignant prostate cancer, and pneumonia.Review a physician's order for Resident #15 revealed an order dated 04/09/25 for Diltiazem 120 milligram (mg) once daily with parameters to hold the medication if the resident's systolic blood pressure was less than 110.Review of the Minimum Data Set (MDS) assessment for Resident #15 dated 07/15/25 revealed the resident had intact cognition and required moderate staff assistance with activities of daily living (ADLs.)Observation on 10/20/25 at 10:05 A.M. with Licensed Practical Nurse (LPN) #30 revealed the nurse withheld Resident #15's dose of Diltiazem because the resident's blood pressure was 104/66 with the systolic blood pressure reading as lower than 110. LPN #30 then disposed of the medication in the sharps container. Review of Medication Administration Record (MAR) for Resident #15 dated 10/20/25 LPN #30 signed off administration of the dose of Diltiazem at 1:03 P.M. The MAR did not include a recheck of Resident #15's blood pressure. Interview on 10/21/25 at 4:30 P.M. with the Director of Nursing (DON) confirmed LPN #30 signed off administration of Diltiazem for Resident #15 on 10/20/25 at 1:03 P.M. and the MAR did not include a recheck of Resident #15's blood pressure. The DON confirmed Resident #15's Diltiazem order included physician-ordered parameters to withhold the medication if the systolic blood pressure was lower than 110. The DON stated she called LPN #30 and got confirmation the nurse had administered Resident #15's dose of Diltiazem on 10/20/25 at 1:03 P.M. along with other medications ordered for 1:00 P.M. Review of facility policy titled Administering Medications dated April 2019 revealed medications should be administered as ordered by the physician. This deficiency represents noncompliance investigated under Complaint Number 2640037.

Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure staff followed the policy to check placement of the resident's gastrostomy tube (G-tube) before medication was administered. This affected one (#62) of four residents observed for medication administration. The facility census was 60. Findings included: Review of an admission medical record for Resident #62 revealed an admission on 12/04/24. Diagnoses for Resident #62 included: moderate protein-calorie malnutrition and dysphagia (difficulty swallowing foods or liquids) in the oral phase. Review of the admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/11/24, revealed Resident #62 had severe cognitive impairment. The MDS indicated Resident #62 was dependent on staff for completion of all activities of daily living (ADLs). The MDS also revealed Resident #62 received 51% or more of their total calories and fluid intake through their feeding tube. Review of Resident #62's care plan dated 12/10/24, included a focus area, for at nutritional and dehydration risk related to dependence on a G-tube and the need for a therapeutic formula. The care plan directed staff to provide tube feeding and check residuals per orders. Review of Resident #62's Physician Order Summary Report for active physician orders as of 12/11/24, revealed an order dated 12/04/24, to check the residual volume, hold the tube feeding, and notify the physician if the residual was over 60 milliliters. The Physician Order Summary Report also revealed an order dated 12/09/24, to check the resident's G-tube placement every shift. Observation on 12/11/24 at 8:40 A.M., during the medication administration, Registered Nurse (RN) #3 prepared medication to administer to Resident #62 by way of the G-tube. After preparation, at 9:10 A.M., RN #3 placed the G-tube feeding pump on hold, flushed the tube with water, and then pulled back on the syringe to check residual, which was clear with tan colored particles. The observation revealed RN #3 proceeded to administer Resident #62's medications. Interview on 12/11/24 at 9:20 A.M., with RN #3 stated she instilled water by way of a syringe to check the placement of Resident #62's G-tube. RN #3 stated she should not have used water to check placement because there was a danger that water could have gone into the wrong place (somewhere other than the resident's stomach). Interviewed on 12/12/24 at 2:16 P.M., with the Director of Nursing (DON) stated nurses should not use water to check G-tube placement because if the tube was not in the correct location, the installation of water could cause harm to the resident. Interview on 12/12/24 at 2:20 P.M., the Administrator stated she expected the nurses to use the facility policy when they checked G-tube placement. Review of the policy titled, Confirming Placement of Feeding Tubes, revised November 2018, indicated, the purpose of this procedure is to ensure proper placement of an existing feeding tube prior to administering enteral feedings or medication. According to the policy, To confirm placement of an existing feeding tube at the bedside: 1. Test whether the tube is properly positioned: a. Observe for symptoms of elevated gastric residual volume (GRV): (1) A sharp increase in residual volume may indicate that a small bowel tube has moved into the stomach. (2) Little to no residual volume may suggest that the tube has migrated from the stomach to the esophagus. b. Observe and check the pH [potential of hydrogen] of aspirate: (1) Fasting stomach contents will have a clear and colorless or grassy green and brown appearance. (2) Fluids from the pleural space [lungs] may have a pale yellow, serous appearance. (3) Post-pyloric/small bowel contents can be bile-stained, light to dark yellow or greenish-brown. (4) Fasting stomach acid will have a pH of 5 or less. (5) Fluid from the pleural space will have a pH of 7 or higher. (6) A pH of 5 or less suggests that the tube is placed in the stomach. However, a pH of 6 or greater is not definitive of placement outside the stomach. 2. If the above suggests improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse or Physician. When correct tube placement has been verified, flush tubing with at least 30 mL [milliliters] warm water (or prescribed amount).

Based on observation, staff interview, and policy review, the facility failed to maintain infection control procedures when administering medications. This affected one (#111) of four residents observed for medication administration. The facility census was 60. Findings included: Observations on 12/10/24 at 8:14 A.M., during the medication administration, in the presence of Registered Nurse (RN) #2, Licensed Practical Nurse (LPN) #1 removed the following medications from the medication package and place the medications in her bare hands: amlodipine (a high blood pressure medication), Plavix (a medication to help prevent blood clots), Lexapro (an antidepressant medication), Microzide (a blood pressure medication), and Lopressor (a blood pressure medication). Interview on 12/10/24 at 8:23 A.M., with LPN #1 stated she had not been taught anything about touching medication, but stated touching the medication with her hands could contaminate the medication. Interview on 12/10/24 at 8:24 A.M., with RN #2 stated she planned to speak with LPN #1 about touching medications with her hands and had no explanation why she had not immediately stopped LPN #1 from touching the medication and educated her. Interview on 12/12/24 at 12:08 P.M., with the Infection Preventionist (IP) stated she would have expected RN #2 to stop the LPN immediately if the RN observed the LPN touching medications. The IP stated nurses were not allowed to touch medications with their bare hands because that could contaminate the medication. Interview on 12/12/2024 at 1:56 P.M., with the Director of Nursing (DON) stated she did not expect nurses to touch medications with their bare hands due to infection control issues. The DON stated if a mentor (RN #2) watched the medication pass she expected RN #2 to stop the nurse and provide education on why they should not touch the medications with their bare hands. Review of the policy titled, Administering Medications, revised August 2024, revealed Medications are administered in a safe and timely manner, and as prescribed. The policy specified, Staff follows established facility infection control procedures for the administration of medications, as applicable.

Based on observation, staff interview, medical record review, and policy review, the facility failed to maintain a medication error rate of less than five percent (%). There were 3 medication errors of 38 medication opportunities, which resulted in a medication error rate of 7.89%. This affected two (#62 and #111) of four residents observed for medication administration. The facility census was 60. Findings included: 1. Review of an admission medical record for Resident #111 revealed an admitted [DATE]. Diagnoses for Resident #111 included: hypertensive urgency, hypertensive chronic kidney disease, atherosclerotic heard disease, and essential hypertension. Observation on 12/10/24 beginning at 8:14 A.M., during medication administration, Licensed Practical Nurse (LPN) #1 prepared one vitamin B12, 500 micrograms (mcg) and one enteric coated aspirin, 81 milligrams (mg). The medications were administered to Resident #111. Review of Resident #111's physician Order Summary Report for active orders as of 12/11/24, revealed orders dated 12/05/24, for one chewable aspirin (not enteric coated), 81 mg in the morning for stroke prevention and for cyanocobalamin (vitamin B12) 2000 mcg, one tablet every morning related to a vitamin B12 deficiency. Interview on 12/12/24 at 10:50 A.M., with LPN #1 stated she had only seen 81 mg on the aspirin bottle and did not read that the order was for a chewable aspirin. LPN #1 stated she was unable to remember giving vitamin B-12 to Resident #111, but remembered the surveyor looked at the medications and counted the number of pills placed in the resident's medication cup. Interview on 12/12/24 at 1:56 P.M., with the DON stated before medications are administered, she expected the nurse to check the resident's medication administration record (MAR), pull the medication, and check the medication against the MAR to make sure it was the right medication, right time, right route of administration, right dose, and the right resident. The DON stated if LPN #1 gave Resident #111 enteric coated aspirin and did not give the correct vitamin B-12 dosage, those were medication errors because the medications given did not match the physician's order. Interview on 12/12/24 at 2:05 P.M., with the Administrator stated before medications were administered, she expected the nurse to check the dose and to make sure it was the correct medication and the right time for the medication. 2. Review of an admission medical record for Resident #62 revealed an admission on 12/04/24. Diagnoses for Resident #62 included: moderate protein-calorie malnutrition and dysphagia (difficulty swallowing foods or liquids) in the oral phase and epilepsy. Observation on 12/11/24 at 8:40 A.M., during medication administration, Registered Nurse (RN) #3 prepared levetiracetam (an anti-seizure medication) 100 milligrams/milliliter (mg/ml) oral solution for Resident #62. RN #3 poured 10 ml of levetiracetam solution into a medication cup and administered the medication to the resident by way of the resident's gastrostomy tube (G-tube). Review of Resident #62's Physician Order Summary Report, with active orders as of 12/11/24, revealed an order dated 12/04/24, for levetiracetam 500 mg/5 ml oral solution, give 5 ml per G-tube twice a day. Interview on 12/11/24 at 12:33 P.M., with RN #3 stated she could have sworn the order for the levetiracetam was for 10 ml. RN #3 reviewed Resident #62's medication administration record (MAR) and stated the order for the resident's levetiracetam was to give 5 ml. RN #3 stated she made an error and looked at the wrong entry on the MAR. RN #3 stated if a resident received too much levetiracetam, it could cause levetiracetam toxicity, and she would notify the physician about the medication error. Interview on 12/12/24 at 2:16 P.M., with the Director of Nursing (DON) stated she expected the nurse to administer the right dose of medication to the right resident. The DON stated the danger of getting too much levetiracetam could be an elevated level of the medication. Review of the policy titled, Administering Medications, revised August 2024, indicated, Medications are administered in accordance with prescriber orders, including any required time frame. The policy specified, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, resident interview, staff interview, medical record review, and policy review, the facility failed to ensure medications were not left unattended at the bedside. This affected one (#45) of three sampled residents reviewed for potential accidents. The facility census was 60. Findings included: Review of the admission medical record for Resident #45 revealed an admitted [DATE]. Diagnoses for Resident #45 included: neurocognitive disorder with Lewy bodies (a neurological brain disorder with symptoms of Alzheimer's disease) and aphasia (the inability to verbally express ideas and thoughts). Review of the quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 09/20/24, revealed Resident #45 had severe cognitive impairment. Review of Resident #45's care plan, revised 03/20/23, included a focus area indicating the resident had impaired decision-making ability and impaired memory. The care plan indicated Resident #45 would be assisted in decision making and care. Observation on 12/09/24 at 10:28 A.M., revealed on the top of Resident #45's nightstand, there were two bottles of saline nasal spray and in the top drawer of the nightstand, there was an opened bottle of Dulcolax (a laxative medication) and two bottles of digestive aid. Review of Resident #45's Physician Order Summary Report with active orders as of 12/10/24, revealed the resident did not have a physician's orders for saline nasal spray, Dulcolax, or a digestive aid. Observation on 12/10/24 at 10:03 A.M., revealed on the top of Resident #45's nightstand were two bottles of saline nasal spray and in the top drawer of the nightstand, there was an opened bottle of Dulcolax and two bottles of a digestive aid. A Certified Nursing Assistant (CNA) was observed in the resident's room to assist the resident with dressing. The CNA did not remove the medications. Observation on 12/10/24 at 3:10 P.M., revealed on the top of Resident #45's nightstand were two bottles of saline nasal spray and in the top drawer of the nightstand, there was an opened bottle of Dulcolax and two bottles of a digestive aid. Observation on 12/10/24 at 12:56 P.M., revealed on the top of Resident #45's nightstand were two bottles of saline nasal spray and in the top drawer of the nightstand, there was an opened bottle of Dulcolax and two bottles of a digestive aid. Interview with Resident #45, at the time of the observation, revealed the resident was able to identify one medication as nasal spray but was unable to recall who had given the medication to them. Resident #45 was unable to verbalize when to use the medications or how to use the medications that were at their bedside, including the nasal spray, Dulcolax, and the digestive aid. Interview on 12/11/24 at 12:59 P.M., with CNA #5 stated she worked the hall on which Resident #45 resided and usually was assigned to care for Resident #45. CNA #5 stated if she found medications at the bedside, she reported to the nurse on the hall and then to the supervisor. CNA #5 stated she had been in Resident #45's room earlier in the day and had not seen the medications in the resident's room. Interview on 12/11/24 at 1:18 P.M., with Licensed Practical Nurse (LPN) #6 acknowledged he was assigned to care for Resident #45. LPN #6 stated if he went into a resident's room and observed over-the-counter medications, he would explain to the resident that they could not have the medications at the bedside. LPN #6 stated he would also remove the medications from the room and notify the Director of Nursing (DON) and the physician. LPN #6 stated he had not found any medications at a resident's bedside during his shift. During the interview, LPN #6 went into Resident #45's room and observed the medications and stated he did not see the medications that day when he gave Resident #45 their medications. Interview on 12/11/24 at 1:28 P.M., with the Director of Nursing (DON) stated with Resident #45's having impaired cognition, the resident was not capable of self-administration of medications. The DON stated prior to any resident being able to self-administer medications there had to be a physician's order for self-administration and an assessment to determine the resident's ability. The DON stated the danger of having medications in a resident's room would be the resident could overdose or someone else could potentially get the medications. Interview on 12/12/24 at 1:51 P.M., with the Administrator, stated she expected medications from any source not to be left at a resident's bedside. The Administrator stated she expected staff to remove medications from a resident's room when the staff member left the room. Review of the policy titled, Self-Administration of Medications, revised December 2016, indicated, staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident's representative was notified of development of new pressure ulcer and treatment plan. This affected one (#75) out of three residents reviewed for pressure ulcers. The facility census was 61. Findings include: Review of the medical record for Resident #75 revealed an admitted [DATE] with medical diagnoses of cerebral atherosclerosis, protein calorie-malnutrition, chronic obstructive pulmonary disease, and obstructive and reflux uropathy. Review of the medical record for Resident #75 revealed a quarterly Minimum Data Set (MDS) assessment, dated 06/17/24, which indicated Resident #75 had severe cognitive impairment and required partial/moderate staff assistance with toilet hygiene, bed mobility, and transfers. The MDS indicated Resident #75 required substantial/maximum staff assistance with bathing and no pressure ulcer/injuries were noted. Review of the medical record for Resident #75 revealed a wound observation evaluation, dated 07/25/24, which stated Resident #75 had a Stage III pressure ulcer to the left heel. The evaluation stated the wound was first observed on 07/25/24, the physician was notified, and a treatment was ordered. Review of the evaluation revealed no documentation to support the facility notified Resident #75's representative of the new pressure ulcer or treatment plan. Interview on 09/11/24 at 10:56 A.M. with Administrator confirmed the medical record for Resident #75 did not contain documentation to support Resident #75's representative was notified of the left heel pressure ulcer and treatment. Review of the facility policy titled, Change in Resident's Condition or Status, revised May 2017 stated the facility shall promptly notify the resident, his/her attending physician, and representative of changes in the resident's medical/mental condition and/or status. This deficiency represents non-compliance investigated under Complaint Number OH00156810.

Based on closed medical record review, review of the facility policy, interviews with facility staff, and Primary Care Physician/Medical Director #33, the facility failed to notify the physician for one resident (#01), who had a significant change in condition. This resulted in Immediate Jeopardy and potential serious life-threatening harm when the facility failed to notify the physician when Resident #01 experienced diaphoresis, chest discomfort requiring [MEDICATION(S)] (a medication for chest pain), low blood pressure, and decreased oxygen saturation requiring oxygen. The resident had a continual decline throughout the day and there was no evidence the physician had been notified of the decline. Resident #01 became unresponsive and required initiation of Cardiopulmonary Resuscitation (CPR) that was unsuccessful. Emergency Medical Services pronounced Resident #01 deceased on [DATE] at 2:08 P.M. This affected one (#01) of three residents reviewed for notification. The facility census was 62. On [DATE] at 5:00 P.M., the Administrator and the Director of Nursing (DON) were notified that Immediate Jeopardy began on [DATE] at 7:25 A.M., when Resident #01 had a change in condition and a continual decline in condition and Licensed Practical Nurse (LPN) #80 and LPN #85 failed to notify Resident #01 ' s Primary Care Physician/Medical Director #33 of a significant change in condition. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 7:00 P.M. through [DATE] at 10:30 A.M., LPN #20 and LPN #22 assessed all residents and completed a vital sign check. There were no abnormal findings to report to the physician. · On [DATE] at 7:15 P.M., Registered Nurse (RN) #90 and LPN #40 reviewed all residents for physician notification due to changes in condition for the past week. Residents who had changes of condition also had physician notifications documented. · On [DATE], the DON, RN #50, RN #90, RN #91, and/or LPN #40 will provide education to 100% of the Licensed Staff on Notifying the Physician of a change in condition and any abnormal assessment, as well as the family/representative. This education will occur before 7:00 P.M. on [DATE]. · On [DATE], a Quality Assurance and Performance Improvement (QAPI) meeting was held with Medical Director #33, the DON, the Administrator, RN #50, LPN #40, RN #90, and RN #91 to discuss the identified deficient practice, root cause, and the QAPI plan. · On [DATE], the DON, RN #50 and/or LPN #40 will complete daily audits of all current residents for any documented change in condition. The audits will include verifying the physician and the family were notified of any change in condition. These daily audits will continue for four weeks and will be reviewed weekly on Fridays with the Quality Assurance (QA) Team to discuss the need for any adjustments that need made in the QAPI plan. 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: Review of the closed medical record for Resident #01 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #01 expired in the facility on [DATE]. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #01 ' s son has been spoken to at length regarding her code status, decrease in intake with food and fluid and hospice care. Resident #01 ' s family continues to not make any changes. Review of the nurses notes dated [DATE] revealed a care conference was held with Resident #01 ' s son to discuss options for hospice care due to decreased appetite and weight loss. The family decided for a hospice referral and code status was discussed and no changes made. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurses notes dated [DATE] revealed the physician was in and new orders for [MEDICATION(S)] 0.25 milliliters (ml) sublingually every four hours as needed for pain and shortness of breath and [MEDICATION(S)] 0.5 mg every four hours as needed for anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 had severe cognitive impairment. Review of the physician orders dated [DATE] revealed Resident #01 was a Full Code status as of [DATE] and was under hospice care effective [DATE] for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #01 had orders for antihypertensive medication [MEDICATION(S)] 5 mg by mouth one time a day for hypertension, heart, and chronic kidney disease. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #01 remained baseline for cognition. The resident had poor intake, chronically ill, was on hospice and in no acute distress. The examination revealed congested heart failure and to continue medications, the plan of care, and to continue treatment. Resident #01 had no complaints as well as no shortness of breath, [CONDITION(S)], chest pain, palpitations, or abnormal breathing. The resident ' s vital signs were reviewed and show no decline or extreme abnormalities. The plan was to have vital signs monitored, dietary support, and currently the resident was at baseline with no acute changes. Resident #01 will be monitored by nursing staff and any acute changes will be reported to the providers. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #01 and she remained at baseline for cognition. The treatment plan would be continued as well as the plan of care and the provider would be updated of any acute changes. The vital signs were reviewed and documented no decline or extreme abnormalities. The plan was to have vital signs monitored, dietary support, and currently the resident remained at baseline with no acute changes. Resident #01 will be monitored by nursing staff and any acute changes will be reported to the providers. Review of nurses notes dated [DATE] at 6:56 A.M. written by LPN #80 revealed Resident #01 was diaphoretic with excess saliva noted to mouth. Vital signs were obtained and within normal limits. Resident #01 was alert and talking but continued to moan. The Hospice service was notified and awaiting a return call from Hospice RN #73. There was no documented evidence of physician notification. Review of the significant change communication form filled out by LPN #80 started on [DATE] and closed on [DATE] by RN #50 revealed Resident #01 had a start of change in condition on the morning of [DATE], blood pressure was ,d+[DATE] millimeters of mercury (mm/Hg), pulse 79 beats per minute (BPM), respirations 17 breaths per minute, and temperature was 98.3 degrees Fahrenheit. Resident #01 had chest pain/tightness that was new/abrupt in onset and accompanied by diaphoresis and had occasional moan or groan. Resident #01 ' s son and hospice nurse were notified on [DATE] at 7:25 A.M. There was no evidence of physician notification documented. Review of the nurses notes dated [DATE] at 7:45 A.M. written by LPN #85 revealed [MEDICATION(S)] was administered to Resident #01 due to complaints of discomfort to her chest, the residents blood pressure was ,d+[DATE] mm/Hg, pulse 58 BPM, and respirations were 18 breaths per minute. Resident #01 was able to respond to staff members and answer questions. There was no evidence of physician notification documented. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and [MEDICATION(S)] was held at 8:00 A.M. Again, there was no evidence of physician notification documented or further treatment directions. Review of the nurses notes dated [DATE] at 8:15 A.M. written by LPN #85 revealed that nursing staff assisted the resident with feeding her breakfast and the resident had refused; however, she ate her nutritional treat and drank 75 percent of her orange juice. A note dated [DATE] at 8:40 A.M. written by LPN #85 revealed the resident ' s blood pressure was ,d+[DATE] mm/Hg, pulse 62 BPM, and she was moving around in bed. When asked about her pain she denied pain and reported she just could not get comfortable. Oxygen was started due to a low oxygen saturation reading of 88 percent. There was no documented evidence the physician was notified. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Review of the nurses notes dated [DATE] at 9:35 A.M. written by LPN #85 revealed the resident was resting in bed, her blood pressure was ,d+[DATE] mm/Hg, pulse 64 BPM and oxygen saturation reading was 99 percent. A nurses ' note dated [DATE] at 10:30 A.M. written by LPN #85 revealed the resident ' s vital signs were documented as blood pressure of ,d+[DATE] mm/Hg, respirations 20 breaths per minute, and she continued to rest in bed. She was offered juice and she refused. A nurse note dated [DATE] at 12:30 P.M. written by LPN #85 revealed Resident #01 ' s blood pressure was ,d+[DATE] mm/Hg, her pulse was 62 BPM, and oxygen on at two liters per minute was 96 percent. She was repositioned in bed for lunch and she refused to eat. She drank 25 percent of her nutritional med pass supplement and staff assisted her to eat 75 percent of her nutritional treat and she stated she was full. Resident #01 then stated she had general discomfort and no chest pain she just was uncomfortable, and [MEDICATION(S)] was administered. Review of the nurses notes dated [DATE] at 1:20 P.M. written by LPN #85 revealed nursing care was given and no issues noted. A note dated [DATE] at 1:35 P.M. written by LPN #85 revealed Resident #01 needed help from staff and all nurses were called to her room. A note dated [DATE] at 1:40 P.M. written by LPN #85 revealed the local emergency squad was called and chest compressions and suction were started. A note dated [DATE] at 1:43 P.M. written by LPN #85 revealed Resident #01 ' s son was called and informed of the condition of the resident. A note dated [DATE] at 1:50 P.M. written by LPN #85 revealed the emergency squad had arrived. A note dated [DATE] at 2:08 P.M. written by LPN #85 revealed the squad had left and the time of death was documented at 2:08 P.M. A note dated [DATE] at 2:30 P.M. written by LPN #85 revealed the funeral home was called and informed of the resident ' s death. A note dated [DATE] at 2:35 P.M. written by LPN #85 revealed Physician #33 was informed and a new order was obtained to release the body to the funeral home. During an interview on [DATE] at 3:36 P.M. with LPN #85 he stated he was the nurse caring for Resident #01 on [DATE]. He stated when he arrived at work at 7:00 A.M. he received report from the night nurse (LPN #80) that she had chest pain and refused to take [MEDICATION(S)] for her pain. He stated together they went into Resident #01 ' s room and he was able to administer her the [MEDICATION(S)]. He stated after breakfast, Resident #01 had no pain and that her blood pressure was a little low, so he held her blood pressure medicine ([MEDICATION(S)]). LPN #85 verified he had not called the physician or hospice nurse to report Resident #01 ' s chest pain and that he had held the resident's blood pressure medication due to low blood pressures. He verified again he had not talked to Resident #01 ' s son, physician, or hospice nurse on [DATE] prior to Resident #01 expiring at the facility. He stated Hospice RN #73 came during the code and called the physician. During a telephone interview on [DATE] at 8:56 A.M. with the son of Resident #01, he stated the facility called him and left a message early in the morning of [DATE] that the hospice nurse was coming in to check on his mother. He stated he had not received any additional phone calls until 2:00 P.M. when the nurse (LPN #85) called to tell him Resident #01 had passed. Telephone interview on [DATE] at 11:13 A.M. with Physician #33 confirmed he was not made aware of Resident #01 ' s condition on [DATE], and only received a call after she had expired and that she was on hospice so he had no reason to question even though she was a Full Code. He stated he was not made aware of Resident #01 being diaphoretic, having chest pains, low oxygen, and continued low blood pressures. During a telephone interview on [DATE] at 11:50 A.M. with LPN #80 stated she was going off her shift on the morning of [DATE] when Resident #01 was diaphoretic and having chest pain. She stated she tried to give her ordered [MEDICATION(S)], but she would not take the medication and spit it out. She stated LPN #85 knew Resident #01 better, so he gave it to her without difficulty. She stated she called the hospice company and called Resident #01 ' s son and a detailed message was left. LPN #80 verified she had not contacted the physician. A follow-up telephone interview on [DATE] at 12:18 P.M. with Physician #33 revealed he would not have immediately sent Resident #01 out; however, he would have had hospice come in and assess the resident, notify the family of changes to see if they continued to want a Full Code status and try to intervene at that point. He stated he would have ordered the hospice nurse to come in and evaluate and notify him of the findings. Telephone interview on [DATE] at 1:33 P.M. with Hospice RN #73 revealed she received only one call early the morning of [DATE] and that Resident #01 was stable at that point and she told the nurse that if there were any changes to let her know. She stated when she arrived at the facility the emergency squad was already there, and CPR was initiated prior to her arrival. She stated she saw Resident #01 weekly and that she talked to the son and he wanted Resident #01 to remain a Full Code status and during any care conferences, his stance never changed. She verified she was not made aware of Resident #01 ' s low blood pressure and low oxygen throughout the day on [DATE] or she would have come in sooner to evaluate her. Review of the facility policy titled Change in a Resident ' s Condition or Status dated [DATE] revealed the facility shall promptly notify the resident ' s attending physician, and representative of changes in the resident ' s medical condition. This deficiency substantiates Complaint Number OH 516.

Based on closed medical record review, review of the facility policy and procedures related to notification of change in condition, interviews with facility staff, and Primary Care Physician/Medical Director #33, the facility failed to seek timely and appropriate care and treatment for one resident (#01), who experienced diaphoresis, chest discomfort requiring [MEDICATION(S)] (a medication for chest pain), low blood pressure, and decreased oxygen saturation requiring oxygen. This resulted in Immediate Jeopardy and potential serious life-threatening harm when the facility failed to notify the physician when Resident #01 developed diaphoresis and chest discomfort, low oxygen saturation, and experienced a continual decline in her blood pressure, became unresponsive and required initiation of Cardiopulmonary Resuscitation (CPR) that was unsuccessful. Emergency Medical Services pronounced Resident #01 deceased on [DATE] at 2:08 P.M. This affected one resident (#01) of three residents reviewed for a change in condition/quality of care. The facility census was 62. On [DATE] at 5:00 P.M., the Administrator and the Director of Nursing (DON) were notified that Immediate Jeopardy began on [DATE] at 7:25 A.M., when Resident #01 had a change in condition and a continual decline in condition and Licensed Practical Nurse (LPN) #80 and LPN #85 failed to recognize and seek timely and appropriate care and treatment and notify Resident #01's Primary Care Physician/Medical Director #33 of a significant change in condition. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 7:00 P.M. through [DATE] at 10:30 A.M., LPN #20 and LPN #22 assessed all residents and completed a vital sign check. There were no abnormal findings. · On [DATE] at 7:15 P.M., Registered Nurse (RN) #90 and LPN #40 reviewed all residents for any changes in condition for the past week with no abnormal findings. · On [DATE] the DON, RN #50, RN #90, RN #91, and/or LPN #40 will provide education to 100% of the Unlicensed Staff on what a change of condition is and how to respond. This education will occur before 7:00 P.M. on [DATE]. · On [DATE], the DON, RN #50, RN #90, RN #91, and/or LPN #40 will provide education to 100% of the Licensed Staff on Notifying the Physician of a change in condition and any abnormal assessment, as well as the family/representative. This education will occur before 7:00 P.M. on [DATE]. · On [DATE], a Quality Assurance and Performance Improvement (QAPI) meeting was held with Medical Director #33, the DON, the Administrator, RN #50, LPN #40, RN #90, and RN #91 to discuss the identified deficient practice, root cause, and the QAPI plan. · On [DATE], the DON, RN #50 and/or LPN #40 will complete daily audits of all current residents for any documented abnormal vital signs or change in condition. The audits will also include verifying the physician and the family were notified of any change in condition. These daily audits will continue for four weeks and will be reviewed weekly on Fridays with the Quality Assurance (QA) Team to discuss the need for any adjustments that need made in the QAPI plan. 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: Review of the closed medical record for Resident #01 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #01 expired in the facility on [DATE]. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #01's son has been spoke to at length regarding her code status, decrease in intake with food and fluid and hospice care. Resident #01's family continues to not make any changes. Review of the nurses notes dated [DATE] revealed a care conference was held with Resident #01's son to discuss options for hospice care due to decreased appetite and weight loss. The family decided for a hospice referral and code status was discussed and no changes made. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #01's blood pressures and adjust as needed for extreme highs and lows with symptoms. Review of the nurses notes dated [DATE] revealed the physician was in and new orders for [MEDICATION(S)] 0.25 milliliters (ml) sublingually every four as needed for pain and shortness of breath and [MEDICATION(S)] 0.5 mg every four hours as needed for anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 had severe cognitive impairment. Review of the physician orders dated [DATE] revealed Resident #01 was a Full Code status as of [DATE] and was under hospice care effective [DATE] for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #01 had orders for antihypertensive medication [MEDICATION(S)] 5 mg by mouth one time a day for hypertension, heart, and chronic kidney disease. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #01 remained baseline for cognition. The resident had poor intake, chronically ill, was on hospice and in no acute distress. The examination revealed congested heart failure and to continue medications, the plan of care, and to continue treatment. Resident #01 had no complaints as well as no shortness of breath, [CONDITION(S)], chest pain, palpitations, or abnormal breathing. The resident's vital signs were reviewed and show no decline or extreme abnormalities. The plan was to have vital signs monitored, dietary support, and currently the resident was at baseline with no acute changes. Resident #01 will be monitored by nursing staff and any acute changes will be reported to the providers. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #01 and she remained at baseline for cognition. The treatment plan would be continued as well as the plan of care and the provider would be updated of any acute changes. The vital signs were reviewed and documented no decline or extreme abnormalities. The plan was to have vital signs monitored, dietary support, and currently the resident remained at baseline with no acute changes. Resident #01 will be monitored by nursing staff and any acute changes will be reported to the providers. Review of the nurses notes dated [DATE] at 6:56 A.M. written by LPN #80 revealed Resident #01 was diaphoretic with excess saliva noted to mouth. Vital signs were obtained and within normal limits. Resident #01 was alert and talking but continued to moan. The hospice service was notified and awaiting a return call from Hospice RN #73. Review of the significant change communication form filled out by LPN #80 started on [DATE] and closed on [DATE] by RN #50 revealed Resident #01 had a start of change in condition on the morning of [DATE], blood pressure was ,d+[DATE] millimeters of mercury (mm/Hg), pulse 79 beats per minute (BPM), respirations 17 breaths per minute, and temperature was 98.3 degrees Fahrenheit. Resident #01 had chest pain/tightness that was new/abrupt in onset and accompanied by diaphoresis and had occasional moan or groan. Resident #01's son and hospice nurse were notified on [DATE] at 7:25 A.M. Review of the nurses notes dated [DATE] at 7:45 A.M. written by LPN #85 revealed [MEDICATION(S)] was administered to Resident #01 due to complaints of discomfort to her chest, the residents blood pressure was ,d+[DATE] mm/Hg, pulse 58 BPM, and respirations were 18 breaths per minute. Resident #01 was able to respond to staff members and answer questions. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and [MEDICATION(S)] was held at 8:00 A.M. Review of the nurses notes dated [DATE] at 8:15 A.M. written by LPN #85 revealed that nursing staff assisted the resident with feeding her breakfast and the resident had refused; however, she ate her nutritional treat and drank 75 percent of her orange juice. A note dated [DATE] at 8:40 A.M. written by LPN #85 revealed the resident's blood pressure was ,d+[DATE] mm/Hg, pulse 62 BPM, and she was moving around in bed. When asked about her pain she denied pain and reported she just could not get comfortable. Oxygen was started due to a low oxygen saturation reading of 88 percent. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Review of the nurses notes dated [DATE] at 9:35 A.M. written by LPN #85 revealed the resident was resting in bed, her blood pressure was ,d+[DATE] mm/Hg, pulse 64 BPM and oxygen saturation reading was 99 percent. A nurse's note dated [DATE] at 10:30 A.M. written by LPN #85 revealed the resident's vital signs were documented as blood pressure of ,d+[DATE] mm/Hg, respirations 20 breaths per minute, and she continued to rest in bed. She was offered juice and she refused. A nurse's note dated [DATE] at 12:30 P.M. written by LPN #85 revealed Resident #01's blood pressure was ,d+[DATE] mm/Hg, her pulse was 62 BPM, and oxygen on at two liters per minute was 96 percent. She was repositioned in bed for lunch and she refused to eat. She drank 25 percent of her nutritional med pass supplement and staff assisted her to eat 75 percent of her nutritional treat and she stated she was full. Resident #01 then stated she had general discomfort and no chest pain, she just was uncomfortable, and [MEDICATION(S)] was administered. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Review of the nurses notes dated [DATE] at 1:20 P.M. written by LPN #85 revealed nursing care was given and no issues noted. A note dated [DATE] at 1:35 P.M. written by LPN #85 revealed Resident #01 needed help from staff and all nurses were called to her room. A note dated [DATE] at 1:40 P.M. written by LPN #85 revealed the local emergency squad was called and chest compressions and suction were started. A note dated [DATE] at 1:43 P.M. written by LPN #85 revealed Resident #01's son was called and informed of the condition of the resident and Resident #01's daughter-in-law got on the phone and asked what was going on and asked LPN #85 if CPR was started which it had been initiated. A note dated [DATE] at 1:50 P.M. written by LPN #85 revealed the emergency squad had arrived. A note dated [DATE] at 2:08 P.M. written by LPN #85 revealed the squad had left and the time of death was documented at 2:08 P.M. A note dated [DATE] at 2:30 P.M. written by LPN #85 revealed the funeral home was called and informed of the resident's death. A note dated [DATE] at 2:35 P.M. written by LPN #85 revealed Physician #33 was informed and a new order was obtained to release the body to the funeral home. Review of the hospice notes dated [DATE] revealed Resident #01 was a Full Code. Review of the hospice note dated [DATE] and untimed written by RN #73 revealed upon entering the facility, 911 had been called and Resident #01 was a Full Code with time of death at 2:08 P.M. Physician #33 was notified, and the body was released to the funeral home. During an interview on [DATE] at 3:36 P.M. with LPN #85 he stated he was the nurse caring for Resident #01 on [DATE]. He stated when he arrived at work at 7:00 A.M. he received report from the night nurse (LPN #80) that she had chest pain and refused to take [MEDICATION(S)] for her pain. He stated together they went into Resident #01's room and he was able to administer her the [MEDICATION(S)]. He stated after breakfast, Resident #01 had no pain and that her blood pressure was a little low, so he held her blood pressure medicine ([MEDICATION(S)]). LPN #85 verified he had not called the physician or hospice nurse to report Resident #01's chest pain and that he had held the resident's blood pressure medication due to low blood pressures. He stated Resident #01 refused breakfast but did take her nutritional treat. He stated he went to recheck on her and take her vitals after breakfast and she wanted a pop and she drank it. He stated Resident #01 refused lunch but took about 50 percent of supplement and ate her nutritional treat. He stated after about 1:00 P.M., State tested Nursing Assistant (STNA) #61 had provided care for her and then staff saw her on her knees on the floor next to the bed in a praying position and when they placed her in bed, she coded. LPN #85 stated CPR was started and he did call Resident #01's son to inform him of the condition after CPR was started. LPN #85 stated he knew she was on hospice and was a Full Code. LPN #85 stated the night nurse (LPN #80) had called the son about 6:00 A.M. and left a message for him. He verified again he had not talked to Resident #01's son, physician, or hospice nurse on [DATE] prior to Resident #01 expiring at facility. He stated Hospice RN #73 came during the code and called the physician. LPN #85 verified that Hospice was not in the facility on [DATE] prior to Resident #01 expiring. Telephone interview on [DATE] at 8:56 A.M., the son of Resident #01 stated the facility called him and left a message early in the morning of [DATE] that the hospice nurse was coming in to check on his mother. He stated he had not received any additional phone calls until 2:00 P.M. when the nurse (LPN #85) called to tell him Resident #01 had passed. He stated he was shaken up so bad that his wife had to talk to the nurse, and she asked if CPR had been started. The son stated he wanted her a Full Code and that the only reason she was placed on hospice was because she was not eating and hospice would be in three days a week and he thought that was extra eyes on his mom. Telephone interview on [DATE] at 11:13 A.M., Physician #33 stated he was not made aware of Resident #01's condition on [DATE], and only received a call she had expired and that she was on hospice so he had no reason to question even though she was a Full Code. He stated he was not made aware of Resident #01 being diaphoretic, having chest pains, low oxygen, and continued low blood pressures. Telephone interview on [DATE] at 11:50 A.M., LPN #80 stated she was going off her shift on the morning of [DATE] when Resident #01 was diaphoretic and having chest pain. She stated she tried to give her ordered [MEDICATION(S)], but she would not take the medication and spit it out. She stated LPN #85 knew Resident #01 better, so he gave it to her without difficulty. She stated she called the hospice company and called Resident #01's son and a detailed message was left. She stated she could not recall what Resident #01's vital signs were but she had told Hospice RN #73. LPN #80 verified she had not contacted the physician. Interview on [DATE] at 12:11 P.M., RN #50 stated he was called into Resident #01's room by LPN #85 on [DATE] and LPN #85 had told him Resident #01 was not feeling right in the morning, then perked up some, then not feeling right again. RN #50 stated as soon as he entered Resident #01's room she gasped and then coded, and they immediately began CPR and continued until emergency medical staff arrived and took over. A follow-up telephone interview on [DATE] at 12:18 P.M., Physician #33 stated he would not have immediately sent Resident #01 out; however, he would have had hospice come in and assess the resident, notify the family of changes to see if they continued to want a Full Code status and try to intervene at that point. He stated he would have ordered the hospice nurse to come in and evaluate and notify him of the findings. Interview on [DATE] at 1:23 P.M., STNA #61 stated she was Resident #01's aide on [DATE]. She stated she and LPN #85 were in and out of the residents' room all day. She stated Resident #01 had not eaten breakfast or lunch and had not gotten out of the bed all day. She stated Resident #01 made no complaints of pain to her. She stated the last time she checked on her was after lunch and then she saw nursing staff performing CPR. Telephone interview on [DATE] at 1:33 P.M., Hospice RN #73 stated she received only one call early the morning of [DATE] and that Resident #01 was stable at that point and she told the nurse that if there were any changes to let her know. She stated when she arrived at the facility the emergency squad was already there, and CPR was initiated prior to her arrival. She stated she saw Resident #01 weekly and that she talked to the son and he wanted Resident #01 to remain a Full Code status and during any care conferences, his stance never changed. She verified she was not made aware of Resident #01's low blood pressure and low oxygen throughout the day on [DATE] or she would have come in sooner to evaluate her. Review of the facility policy titled Change in a Resident's Condition or Status dated [DATE] revealed the facility shall promptly notify the resident's attending physician, and representative of changes in the resident's medical condition. This deficiency substantiates Complaint Number OH 516.

Based on record review and staff interview, the facility failed to prevent an avoidable fall. This resulted in actual harm when Resident #25 was transferred incorrectly and suffered a fractured femur requiring surgical intervention. Three residents were reviewed for falls. The facility census was 76. Findings include: Record review revealed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive quarterly assessment dated [DATE] documented the resident had cognitive impairment and required extensive assistance with a two plus staff for transfer. Review of the State tested Nurse Assistant (STNA) care kardex dated 08/09/15 and 08/10/15 documented Resident #25 required two staff for manual transfer and two staff for hoyer transfer. The nursing note dated 08/10/15 documented Resident #25 fell on the floor was assisted back to bed and denied pain. STNA #5 was educated on two person assist for resident with right sided weakness. Review of the fall investigation dated 08/11/15 documented STNA #5 transferred Resident #25 onto her affected side and she fell . Review of the nursing note dated 08/12/15 documented Resident #25 was crying out in pain and was transferred to the local hospital for increased right leg swelling and pain. Review of the physician progress notes [REDACTED].#25 for a fall a couple of days ago with increased pain and swelling. Sent to local hospital for evaluation and treatment. Review of the hospital admission paperwork dated 08/12/15 Resident #25 was admitted with [DIAGNOSES REDACTED]. During an interview on 09/14/15 at 1:20 P.M., the Director of Nursing (DON) stated STNA #5 had the chair on the wrong side when she completed the transfer. She pivoted her on the weaker side. During a telephone interview on 09/14/15 at 1:40 P.M., STNA #5 stated she was transferring Resident #25 by herself and the resident was a little shaky when she was getting her on and off the toilet. She then stated when she went to transfer Resident #25 to the bed, she pivoted her on her affected side and Resident #25 lost her balance. Resident #25 fell so hard on her right side she pulled STNA #5 down on top of her. She then continued to say she fell really hard. She called out for help, another STNA came in and then got the nurse. This deficiency substantiates Complaint Number OH 584.