Every finding on record at Avenue at Aurora

Based on record review, observation, interview and review of facility policy, the facility failed to ensure medications were accurately documented as administered. This affected one resident (Resident #83) of three residents who were observed for medication administration. The facility census was 96.Findings include:Review of the medical record for Resident #83 revealed an admission date of 08/20/25. Pertinent diagnoses included sepsis with an unspecified organism, urinary tract infection, chronic obstructive pulmonary disease (COPD), metabolic encephalopathy, gastroesophageal reflux disease (GERD), unspecified atrial fibrillation, unspecified heart failure, diastolic congestive heart failure, and anxiety. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 12/05/25 revealed Resident #83 had intact cognition and no history of behaviors or rejection of care. High risk drugs included medications from the antidepressant, anticoagulant, and opioid categories. Review of the active medication orders revealed Resident #83 had an order for pantoprazole sodium 40 milligrams (mg) delayed release granule tablets, one tablet via PEG-tube (percutaneous endoscopic gastrostomy tube, a tube that is inserted into the abdominal wall into the stomach with the help of a thin, flexible camera, that can be used for tube feeding, medication administration, and/or fluid administration) in the morning for GERD. Orders for scheduled respiratory medication included umeclidinium bromide inhalation aerosol powder breath activated 62.5 micrograms per actuation (mcg/ACT), inhale one puff orally in the morning for COPD and fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/ACT, inhale one puff inhale orally two times a day for COPD. Both inhalers included instructions to rinse the mouth with water and spit after each use. Further review of the medications revealed an order for acetaminophen 325 mg oral tablet, give two tablets by mouth or PEG tube every six hours as needed for pain. Review of the care plan dates 08/21/25 through 01/16/26 revealed Resident #83 had COPD. Interventions included giving bronchodilators and aerosols as ordered and documenting the effectiveness of these medications and any noted side effects. Further review of the care plan revealed Resident #83 was on pain management therapy and that analgesics (pain medications) were to be administered as ordered and documented and monitored for effectiveness and for side effects. The care plan also revealed that Resident #83 had GERD. Interventions included giving medications as ordered and observing for side effects and effectiveness. Observation on 01/14/25 between 9:05 A.M. and 9:50 A.M. revealed Licensed Practical Nurse (LPN) #177 prepared and administered Resident #83's morning medications, which consisted of one topical medication, one intravenous medication, and placing tablets or capsules into individual clear medication cups, each consisting of a different medication type that needed crushed or opened and dissolved prior to administration. The total number of medicine cups was 13, which was confirmed by LPN #177 at the time of the observation. During this observation, LPN #177 confirmed that one of the 13 medicine cups contained two tablets of acetaminophen, which Resident #83 had ordered as needed for pain, and the other 12 medicine cups contained the following: one zenpep 3,000-10,000-14,000-unit delayed release capsule, one bupropion hydrochloride (HCL) 75 mg tablet, one 0.6 mg colchicine tablet, one 5 mg Eliquis tablet, one 1,000 mcg folic acid tablet, one 37.5 mg metoprolol tablet, one 10 mg paroxetine HCL tablet, one 20 milliequivalent( mEq) potassium chloride tablet, two one gram (gm) sodium chloride tablets, one 100 mg thiamine HCL tablet, one vitamin D3 tablet, and one 25 mg hydroxyzine pamoate tablet. The medicine cups did not include the ordered pantoprazole 40 mg tablet that was to be administered each morning. The medications observed being prepared and administered did not include the two inhalers (umeclidinium bromide 62.5 mcg/ACT and fluticasone-salmeterol100-50 mcg/ACT). Review of the Medication Administration Record (MAR) dated 01/14/25 at 11:31 A.M. revealed a checkmark with the initials of LPN #177 in the boxes indicating that the morning doses of the 40 mg pantoprazole via PEG tube, one puff of umeclidinium bromide 62.5 mcg/ACT, and one puff of fluticasone-salmeterol100-50 mcg/ACT had been administered as ordered. Further review of the MAR revealed no documentation that acetaminophen, two 325 mg tablets, were administered to Resident #83 during the morning medication pass or documentation that Resident #83 indicated she expressed or exhibited signs of pain. Review of the progress notes revealed a linked electronic medication administration record (eMAR) note dated 01/14/25 indicating that Resident #83 received hydroxyzine pamoate 25 mg for anxiety at 10:57 A.M. (which was observed as administered between 9:05 A.M. and 9:55 A.M.). Interview on 01/14/25 at 3:20 P.M. with Resident #83 confirmed she had received Tylenol with her morning medications and since she had received an additional aerosol treatment earlier that morning, she did not want the two inhalers that were prescribed to be taken with the morning medication pass. Interview on 01/14/25 at 3:32 P.M. with LPN #177 confirmed two acetaminophen tablets were administered to Resident #83 during the observed morning medication pass for discomfort, but he must have forgotten to document the administration and reason for administration. At the time of the interview, LPN #177 confirmed there was no documentation of Resident #83 receiving acetaminophen since 12:36 A.M., during the previous shift. LPN #177 further confirmed that the two ordered inhalers (umeclidinium bromide 62.5 mcg/ACT and fluticasone-salmeterol100-50 mcg/ACT) were not given because resident had a breathing treatment earlier and typically refused the inhalers afterward. During the interview, LPN #177 confirmed that the MAR reflected that pantoprazole, umeclidinium bromide, and fluticasone-salmeterol were administered. LPN #177 could not recall whether pantoprazole was administered or not, though was able to recall the number of medicine cups counted during the observation was 13, not the expected 14. Review of the policy titled Medication Administration - General Guidelines, dated December 2017, revealed that the person who administered the medications to the resident was to document administration on the MAR, directly after the medication administration. Further review of the policy revealed that when a PRN (as needed) medication was administered, the date, time, and reason for the medication administration was to be documented upon administration. The policy also stated that if a medication was refused, the MAR should reflect that the medication was not given and the medical record was to include an explanatory note indicating the reason.

Based on observation, record review, review of facility fall investigations, review of hospital records, interviews and policy review, the facility failed to develop and implement a comprehensive, individualized and effective fall prevention program to ensure Resident #98's safety and supervisory needs were met to decrease the resident's risk of falls including a fall with major injury. The facility also failed to ensure fall safety interventions were in place as planned for Resident #53. This affected two (Resident #53 and #98) of three residents reviewed for falls. The facility census was 96. Actual Harm occurred on [DATE] when Resident #98, who was a new admission, was assessed at risk for falls with a history of falls following admission and with moderately impaired cognition, sustained an unwitnessed fall resulting in a cervical fracture and intracranial hemorrhage. At the time of the fall, Resident #98 was seated in a wheelchair in a common area with no staff supervision. The resident was transported to the hospital where he subsequently expired on [DATE]. Prior to the unwitnessed fall on [DATE], Resident #98 sustained falls on [DATE] and [DATE]. There was no evidence the facility had effective and individualized interventions in place or had interventions in place to meet the resident's supervisory needs to decrease his risk of falls. Findings Include: 1. Review of the closed medical record for Resident #98 revealed the resident was admitted to the facility on [DATE] with diagnoses including mild protein-calorie malnutrition, history of falls, diabetes, benign prostatic hyperplasia, mild cognitive impairment, congestive heart failure, right heel pressure ulcer, anxiety disorders, myeloproliferative disease, supraventricular tachycardia, benign paroxysmal vertigo, diverticulosis, and abnormalities of gait and mobility. Resident #98 was discharged to the hospital on [DATE] and expired at the hospital on [DATE].Review of the Fall Risk assessment dated [DATE] revealed Resident #98 was at risk for falls with a score of 20 (a score over 10 was at risk for falls).Review of the admission Care Plan dated [DATE] revealed Resident #98 was at risk for falls, safety, and elopement with a goal to minimize risks for falls and minimize injuries related to falls through the next review. Interventions included to encourage the use of a call light, instruct the resident on safety measures, maintain the call light within reach, educate the resident to use the call light, and therapy referral as needed.Review of an undated Nursing Assistant's Bedside Kardex Report for Resident #98 revealed, under the safety section, the call light was to be within reach and encourage the resident to use it for assistance as needed, encourage non-skid footwear when out of bed to minimize slipping as tolerated, follow facility fall protocol, use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface, and when conflict arises, remove resident to a calm safe environment and allow to vent and share feelings. The Kardex did not include the use of a Dycem (non-slip mat) to the resident's chair, a low bed, nor did the Kardex report address the resident's staff supervisory needs as it pertained to the resident's fall risk or accident prevention.Review of the physician orders dated [DATE] revealed Resident #98 had orders for physical therapy, occupational therapy, and bilateral grab bars for mobility and positioning.Review of the Physical Therapy Evaluation dated [DATE] revealed Resident #98 presented with a decline in functional mobility and strength after a recent hospital stay secondary to a fall (prior to admission). Upon assessment, the resident demonstrated bilateral lower extremity weakness, impaired bed mobility, impaired transfers, impaired gait, impaired balance, impaired functional activity tolerance, and guarded safety awareness preventing a safe return at home alone. The resident's needs exceeded the resources available to him as he currently required minimum assistance for bed mobility and contact guard assistance (light steady touch) for transfers and gate. Clinically the resident presented as evolving with changing characteristics recovering from the above deficits complicated by a history of congestive heart failure and recent coronavirus (COVID-19). For these reasons, the evaluation revealed the resident was a moderate complexity. It noted that physical therapy services were medically necessary at this time and if physical therapy services were not provided, the resident was at risk for further functional decline, increased dependency on others, falls, skin breakdown, social isolation, pneumonia, depression, and transitioning to an alternative living situation. The plan of treatment was for the resident to demonstrate good rehabilitation potential as evident by his ability to follow multi-step directions, he was able to make needs known, he was attentive to tasks, he had a high prior level of function, was motivated to participate, and had a strong family support system.Review of a late entry nursing note dated [DATE] at 6:58 P.M. revealed at the start of the shift Resident #98 was out in the common area sitting in a chair. At approximately 4:00 P.M. the nurse witnessed Certified Nursing Assistant (CNA) #334 assist Resident #98 into his room. The note revealed the nurse was called to the resident's room at 4:14 P.M. by the CNA #334 and observed Resident #98 lying on his left side, on the floor with his head not touching the floor. Two staff assisted the resident to a standing position to help him into his wheelchair. The note documented Resident #98 had on gripper socks, the call light was not on, and his walker was in an upright position next to the chair in his room. When asked, Resident #98 stated he needed to go find the furniture that was moved out of his room. A head-to-toe assessment was completed, and neurological checks were initiated and within normal limits. The resident had full range of motion and an abrasion to his mid upper back that measured 5.5 centimeters (cm) in length by four cm in width. A new order was received to cleanse the open area with normal saline, apply antibiotic ointment, cover with a foam dressing, change every day and as needed. Resident #98 was re-educated on the importance of using the call light for assistance. Resident #98's responsible party, the Director of Nursing (DON), and physician were made aware. Following the incident the facility documented the resident required a low bed.Review of the signed witness statement completed by Licensed Practical Nurse (LPN) #238 dated [DATE] revealed she was walking past the room of Resident #98 as he was standing up and took a few steps then fell backwards into his dresser and slid down the dresser onto the floor. LPN #238 was unable to get to him in time to prevent the fall.Review of the undated, signed witness statement completed by LPN #302 revealed on [DATE], Resident #98 was confused and restless. Resident #98 was in the common area throughout the day for safety reasons. Resident #98 was toileted every two hours as per policy. He started to fall asleep in his wheelchair at approximately 3:45 P.M. so he was toileted and put to bed at 4:00 P.M. Around 4:15 P.M., LPN #302 was called to the room of Resident #98 because he was observed on the floor.Record review revealed no written statement was obtained from CNA #334 who assisted the resident to his room prior to the fall.Review of a Root Cause Analysis for the fall dated [DATE] at 2:15 P.M. revealed the root cause of the fall was confusion, restlessness, and possibly hospital delirium, new admission, unfamiliar environment, attempting to move the furniture, and the resident thought he was at home. The current intervention that was in place to address these factors was the use of gripper socks. The comment section of the form documented the resident's bed would be in a low position and Resident #98 be brought out in the common area. However, the analysis did not address Resident #98'ss supervisory needs when out in the common area and/or interventions to address root cause of the fall (i.e. confusion, restlessness). During the investigation, administrative staff indicated the analysis being timed two hours prior to the fall was documented in error. Review of the Fall Risk assessment dated [DATE] (completed after the [DATE] fall) revealed Resident #98 was at risk for falls with a score of 21. Fall safety interventions at this time were noted to be the use of gripper socks and a low bed.Record review revealed a Fall Incident Report dated [DATE] at 3:00 P.M was completed by the DON. The report stated at 1:20 P.M., Resident #98 was found on the floor. The report documented Resident #98 was seen approximately 10 minutes prior for a neurological assessment (from the fall that occurred on [DATE]). Resident #98 was unable to state what he had been doing and the fall was unwitnessed. Resident #98 was assessed and had an abrasion to his head. He was transferred to the emergency room for an evaluation and treatment. A new intervention included on the report was to adjust the resident's wheelchair seat for proper positioning. Record review revealed no written facility investigation was completed for this fall. There were no staff witness statements from staff assigned to care for the resident on this date, no information related to the circumstances of the fall and/or no evidence what safety interventions were in place at the time of the fall. There was no documentation in the nursing notes referencing this fall.Review of a Fall Root Cause Analysis also completed by the DON for the fall on [DATE] at 1:20 P.M. revealed the root cause included the resident was in an unfamiliar environment, he was observed the floor, at times he needed reminded to sit back in chair and he was newly admitted . Current interventions listed were gripper socks and the bed in the low position. In the comments section it noted the resident was in the common area and they would now implement a tilt chair (a type of wheelchair that pivots the entire seat and backrest backwards for pressure relief and postural support) for improved positioning and seating. Again, there was no indication the root cause addressed the resident's supervisory needs when out in the common area and/or interventions to address root cause of the fall (i.e. the need for reminders to sit back in the chair). Review of a nursing note dated [DATE] at 9:48 P.M. revealed Resident #98 returned to the facility via emergency medical service (EMS) from the emergency room (ER) at 9:14 P.M. with his daughter at his side. Resident #98 was diagnosed with a hematoma to his head and was to apply ice packs 15 minutes out of every hour to help with swelling and pain. A lidocaine patch was ordered for both shoulders with instructions to apply for 12 hours on and 12 hours off.Record review revealed no updates to Resident #98's plan of care following this second fall on [DATE] to ensure a comprehensive, individualized and effective fall management program was in place to decrease the resident's risk of falls/falls with injury and to address the resident's total safety and supervisory needs. There was no evidence physical therapy staff provided input or coordinated care to address the resident's increased falls and safety/supervisory needs at this time. A physician order dated [DATE] revealed Resident #98 had an order for a Dycem to always remain on the wheelchair cushion as an enabler to promote safety and for a dump seat (a fixed, angled/downward slope of the wheelchair seat that increases stability and propulsion efficiency) to the wheelchair to promote positioning, comfort, and safety. The orders did not mention a tilt chair per the Root Cause Analysis. During the onsite investigation, it could not be determined how this intervention (a dump seat would benefit the resident, who made the recommendation and/or how it was determined to be appropriate to meet the resident's safety needs. The resident's plan of care was not updated to address the resident's supervisory needs pertaining to his fall risk. Review of a handwritten facility work order dated [DATE] at 2:00 P.M. revealed the resident's wheelchair seat was lowered in the back and higher in the front for Resident #98.Review of the Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #98 had moderately impaired cognition, had no behaviors, utilized a walker, and had no upper or lower extremity limitations. The assessment revealed Resident #98 required moderate assistance for bed mobility and sitting on the side of the bed, he required touching assistance with standing and walking within 10 feet. Resident #98 had a fall within the last month of admission and he had fallen since admission on e time with an injury.Review of a Nursing Home Initial Psychiatric Evaluation dated [DATE] revealed Resident #98 had problems with falls, agitation, questionable confusion, and visual hallucinations while sleeping. The resident's son stated Resident #98 regularly had hallucinations while sleeping, and also stated his father was happy and had not been having as many hallucinations lately. The plan was to start Buspar (a medication utilized to treat anxiety) five milligrams twice a day, though this order was not implemented due to the resident's hospitalization on [DATE].Review of a nursing note dated [DATE] at 10:35 A.M. authored by LPN #221 revealed at approximately 9:45 A.M. the nurse observed Resident #98 relaxing in the common area. The note included the nurse stepped away for a few minutes and then heard Resident #98 shouting and came running to assess. Upon return, the nurse observed Resident #98 lying on his right side with his right arm under his head. Resident #98 was actively bleeding from a laceration to the right front of his head/hairline. The nurse called for help, applied pressure to the wound, and completed an assessment on resident. The nurse directed a nursing assistant to contact 911. Resident #98 remained conscious, continued to talk and converse with the nurses and nursing assistants. When he was asked what he was trying to do, he stated he did not know. Education was provided to the resident. Neurological checks were started and were within normal limits. The resident had had full range of motion and the note revealed there were no other injuries observed. The resident's responsible party and manager on call were notified, the physician was notified, and the resident was transferred to the emergency room for an evaluation. Resident #98 left the facility at 9:48 A.M. via 911. Report was called to the emergency room nurse. The note documented Resident #98 had on gripper socks but did not include any other fall safety interventions that were in place at the time of the fall. The resident's vital signs included blood pressure at 94/60 millimeters of Mercury (mmHg) (normal ranges around 120/80 mmHg), pulse at 62 beats per minute (normal ranges from 60 to 100 bpm), and respirations at 17 breaths per minute (normal ranges from 12 to 20 breaths per minute).Review of a signed witness statement completed by LPN #221 dated [DATE] revealed she had seen Resident #98 sitting in the main parlor area calmly sitting in his wheelchair. She sated she ran to the bathroom, that was behind the nurse's station, for a few minutes. While she was in the bathroom washing her hands, she heard shouting and ran out to see what was wrong and that was when she saw Resident #98 lying on his right side with his arm under his head and blood coming from a laceration.Review of a Fall Root Cause Analysis from the fall on [DATE] at 9:40 A.M. revealed the facility determined the root cause of the resident's fall to be restlessness, confusion, and cognitive impairment. It noted the resident appeared comfortable, his gripper socks were on, he had just eaten, was being supervised, and was toileted prior to getting up. Current interventions were Buspar as added, placed Dycem to the chair, dump chair, and the bed in the low position. There was no evidence the root cause addressed the resident's supervisory needs as it pertained to his fall risk or that it addressed the resident's fall risk associated with his identified restlessness, confusion and cognitive impairment.Review of the emergency room Report dated [DATE] revealed Resident #98 presented to the emergency room by EMS for an evaluation of a fall. Resident #98 recently transferred to the skilled nursing facility for rehabilitation after multiple falls in the last few weeks. Today, he stated he was sitting up in his wheelchair after breakfast. He stated they removed his breakfast tray but had left him sitting there longer than he had anticipated. He stated he was leaning in his chair to the right and began to fall forward. He stated he fell out of his chair and struck the right side of his head. He stated she was helped up immediately by the staff though the fall was not directly witnessed. The resident was sitting upright in bed, was alert and answering questions appropriately and the resident's daughter was at bedside. Review of a Hospital Trauma Service Note dated [DATE] at 12:14 P.M. revealed Resident #98 had a left inferior fifth cervical vertebra articular facet fracture with mild subluxation of cervical 5 to cervical 6 left facet joint, a subdural hematoma, a right scalp abrasion and a right elbow skin tear.Review of a nursing note dated [DATE] at 4:49 P.M. revealed Resident #98 was admitted to the hospital for a neck fracture and an intracranial hemorrhage.Review of the death certificate dated [DATE] revealed the cause of death for Resident #98 was blunt impact to the head and neck with subdural hemorrhage and cervical spine fracture.During an interview on [DATE] at 2:40 P.M. the DON stated she had not witnessed Resident #98 fall on [DATE] however she had completed the incident report because the nurse working, LPN #333, was a new nurse. The DON stated LPN #333 did not know she was supposed to complete a note in the resident's progress notes or complete an incident report for a fall. The DON revealed there was a Unit Manger on duty who could have assisted LPN #333 with handling the paperwork for the fall, however that never happened so she filled out the incident report even though she never witnessed the fall and was not aware if fall interventions that were in place at the time of the fall.During an interview on [DATE] at 3:25 P.M. Registered Nurse (RN) #224 stated the low bed at night was a click intervention already in the system and she just clicked on it to put it on the care plan. During an interview on [DATE] at 9:55 A.M. CNA #234 stated she would look at the Kardex in Point of Care for fall interventions. She stated everyone was to get gripper socks when they were admitted , and it was not individualized for Resident #98 specifically.During an interview on [DATE] at 10:07 A.M. CNA #232 stated she would look at the Kardex or ask the nurse about fall interventions.During an interview on [DATE] at 10:20 A.M, the DON stated staff had been placing Resident #98 in the main parlor room because he needed more supervision. She stated on [DATE], the resident had been in the parlor room and the nurse went to the bathroom right behind the nurse's station and Resident #98 fell, confirming the resident had no staff supervision at the time of the fall on [DATE].During an interview on [DATE] at 2:36 P.M., the Assistant Director of Nursing (ADON) stated on [DATE] she had been in a care conference when she received a text there was an emergency and staff needed her assistance. She stated she went over to the North unit and Resident #98 was on the floor in the common area and LPN #333 was calling 911. Staff kept the resident comfortable until the squad arrived. She stated she asked LPN #333 if she needed help and LPN #333 did not indicate she required any assistance with documenting, however, she never went back to see if LPN #333 completed the required documentation (a progress note and incident report) even though she was a new nurse. She indicated Resident #98 had gripper socks on when she witnessed him on the floor, but verified there was no documentation of that in the progress notes or incident report.During an interview on [DATE] at 1:55 P.M. the DON verified the Fall Risk Assessment completed on [DATE] indicated Resident #98 was at risk for falls. She stated if someone admitted at risk for falls, the facility protocol would be to initiate interventions sch as a Dycem to the wheelchair, gripper socks, and side rails to the bed. She stated after Resident #98's fall on [DATE] a new intervention was for a low bed; however she verified the intervention documented on the resident's care plan was for a low bed at night, which was not what they decided as an intervention for the fall. She stated the low bed at night was just a click intervention or generated intervention on the care plan. She stated they would normally write an order for a low bed, but she verified Resident #98 did not have an order for a low bed. The DON further stated staff were keeping the resident out in the main parlor room for more supervision but also verified this was not written as an intervention on his care plan. The DON revealed everyone would watch the residents (in the area) as they walked past the main parlor room.During an interview on [DATE] at 1:00 P.M., LPN #221 stated on the morning of [DATE] staff had assisted Resident #98 up and brought him out to the main parlor room because he wanted to watch the television out there. She stated the resident had also eaten breakfast in the main parlor at around 7:30 A.M. (from what she recalled although she stated breakfast times did vary). LPN #221 stated she left the area with no other staff present to go to the bathroom and then heard Resident #98 call out. She then went back to the parlor room and the resident was on the floor bleeding from his head. 911 was called and the resident was transported to the hospital. Resident #98 at times did try to stand up from his wheelchair and he did become agitated.During an interview on [DATE] at 1:29 P.M., the Administrator stated the facility Fall Management policy was the facility fall protocol listed on the Kardex and Care Plan. During an interview on [DATE] at 3:09 P.M., the Administrator revealed the tilt chair and the dump seat, mentioned for Resident #98's fall interventions and Root Cause Analysis for the [DATE] fall, were the same things. No additional information was provided to determine how this intervention would be appropriate or necessary to decrease the resident's risk for falls. Review of the facility policy titled, Fall Management, dated [DATE], revealed the facility would identify each resident who was at risk for falls and would develop a plan of care and implement interventions to manage falls. The facility would provide an environment that was free from potential hazards. The licensed nurse would perform a fall risk assessment immediately if the resident was deemed to be at risk. The fall risk assessment would assist the licensed nurse in identifying the appropriate prevention and management interventions and the registered nurse would ensure that the documentation of these interventions were in the residents' care plan. The interdisciplinary team would review the falls routinely to determine the most appropriate type of intervention to be implemented to attempt and preventing future incidents from occurring.2. Review of Resident #53's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including catatonic disorder, falls, generalized anxiety disorder, diabetes, disorders of bone density, hypertension, spinal stenosis, peripheral vascular disease, chronic kidney disease, major depressive disorder, dyspnea, vertigo, heart failure, and muscle weakness.Review of Resident #53's care plan dated [DATE] revealed the resident was at risk for falls related to weakness, limited mobility, atrial fibrillation, overactive bladder, malaise, and anxiety. Interventions included anti-roll backs to manual wheelchair as a safety enabler dated [DATE] and resident to be in communal areas while awake dated [DATE].Review of Resident #53's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired, she utilized a wheelchair for mobility, and she had two or more falls without injury since admission.Review of a restorative note dated [DATE] at 3:30 P.M. authored by Restorative Nurse #203 revealed Resident #53 was to be in a tilt in space wheelchair when out of bed as an enabler to promote positioning, comfort, and safety. It noted that this would be re-assessed quarterly and with any changes.Review of the [DATE] physician's orders revealed Resident #53 had an order (dated [DATE]) to be in a tilt in space wheelchair when out of bed as an enabler to promote positioning, comfort and safety.Review of Resident #53's care plan dated [DATE] revealed the resident required a tilt in space wheelchair. Interventions included for the resident to be in a tilt in space wheelchair when out of bed as an enabler to promote positioning, comfort and safety.Review of the [DATE] fall risk assessment revealed Resident #53 was at risk for falls.An observation on [DATE] at 11:45 A.M. revealed Resident #53 was sitting in the main parlor room, at the table, in a standard style wheelchair with her head down sleeping. She had shoes on, and anti-roll backs to the back wheels of the wheelchair.During an interview on [DATE] at 12:10 P.M., Unit Manager #238 verified Resident #53 was not to be in the standard wheelchair and had an order to be in the tilt in space wheelchair when she was out of bed.Review of the facility policy titled, Fall Management, dated [DATE] revealed the facility would identify each resident who was at risk for falls and would develop a plan of care and implement interventions to manage falls. The facility would provide an environment that was free from potential hazards. The licensed nurse would perform a fall risk assessment immediately if the resident was deemed to be at risk. The fall risk assessment would assist the licensed nurse in identifying the appropriate prevention and management interventions and the registered nurse would ensure that the documentation of these interventions were in the residents' care plan. The interdisciplinary team would review the falls routinely to determine the most appropriate type of intervention to be implemented to attempt and prevent future incidents from occurring.This deficiency represents non-compliance investigated under Complaint Number 2671661.

Based on record review, observation, interview and facility policy review, the facility failed to ensure fall prevention interventions were in place for Residents #59 and #86. This affected two (Residents #59 and #86) of three residents reviewed for accidents. The facility census was 91. Findings include:1. Review of the medical record for Resident #59 revealed an admission date of 07/02/25 with diagnoses including progressive supranuclear opthamoplegia (a rare, degenerative brain disease that affects movement, balance, and eye control), muscle weakness, colon cancer, failure to thrive, depression, and abnormal gait and mobility. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 was severely cognitively impaired and required setup help for eating, supervision for personal hygiene, partial to moderate assistance for oral hygiene, substantial to maximum assistance for showering and was totally dependent on staff for toileting. Review of the fall risk assessment dated [DATE] revealed Resident #59 was at risk for falls. Review of the care plan dated 08/05/25 revealed Resident #59 was at risk for falls due to weakness, history of falls and abnormal gait. Interventions included a perimeter mattress to the bed, ensuring the call light was in reach, ensuring nonslip socks were in use while in bed and ensuring she had a reacher. Review of the nursing note dated 08/07/25 at 12:00 A.M. revealed Resident #59 had an unwitnessed fall and was observed on the floor. No injury was noted; the resident's physician and daughter were notified. The resident was assessed, and her vital signs were blood pressure 144/83, temperature 97.2 degrees Fahrenheit (F), heart rate 81, and respirations 18. Review of the interdisciplinary team (IDT) fall investigation dated 08/07/25 revealed all interventions were in place at the time of the fall for Resident #59, the resident was confused and wearing improper footwear. An immediate intervention was added to encourage the resident to remain in the day room when family was not present. Observation and interview on 08/18/25 at 10:26 A.M. with Certified Nurse Aide (CNA) #204 of Resident #59's room revealed no evidence a perimeter mattress was in place nor was there a reacher anywhere in Resident #59's room. CNA #204 had no knowledge of Resident #59 having a reacher and confirmed there was not one anywhere in her room. She also confirmed Resident #59's mattress was not a perimeter mattress. Interview on 08/18/25 at 11:44 A.M, with the Director of Nursing (DON) confirmed Resident #59 had moved rooms over the weekend, and her perimeter mattress was not currently in place. She also acknowledged Resident #59 did not have her reacher in her room. 2. Review of the medical record for Resident #86 revealed an admission date of 06/27/25 with diagnoses including cerebral vascular disease, weakness of the left non-dominant side, diabetes, dementia, muscle weakness, insomnia and difficulty walking. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #86 was moderately cognitively impaired. He required setup help for eating, supervision for oral care, partial to moderate assistance for toileting, dressing and personal hygiene, and substantial to maximum assistance for showering. Review of the care plan dated 06/30/25 revealed resident number 86 was at risk for falls due to limited mobility, difficulty walking and weakness. Interventions included ensuring the call light was within reach, ensuring nonslip footwear went out of bed, placing a call before you fall sign in his room in therapy as needed. Review of the fall risk assessment dated [DATE] revealed Resident #86 was at risk for falls. Review of the nursing progress note dated 07/03/25 at 6:04 P.M. revealed Resident # 86 was transferring himself from the wheelchair to the toilet. He stated his legs began to give out, and when he tried to sit back in his wheelchair, he missed. He was assessed, and his blood pressure was 130/69, heart rate 93, respirations 18, temperature 98.6 degrees F, and pulse ox 97%. No injuries were noted. The residents' family and physician were notified. Review of the IDT fall investigation dated 07/03/25 revealed no predisposing factors could be identified regarding the fall. An immediate intervention was recommended to add a call before you fall sign to Resident #86's room. Observation and interview on 08/18/25 at 10:26 A.M. with CNA #204 revealed she was unaware Resident #86 had falls since his admission, and she was unaware of any fall prevention interventions for him. Observation at the time of the interview revealed no evidence of a call before you fall sign in Resident #86's room. CNA #204 confirmed the observation. Interview on 08/18/25 at 11:44 A.M, with the DON confirmed there was no reminder to call for help sign in Resident #86's room. Review of the facility policy titled Fall Management, dated December 2022, revealed the facility would identify residents at risk for falls and develop a care plan with interventions to manage those falls. Care plans would be updated as needed with interventions to attempt to prevent further falls. This deficiency represents noncompliance investigated under Complaint Number 2581235.

Based on observation, interviews, and facility policy, the facility failed to ensure infection control was maintained during incontinence care. This affected one resident (#32) of three residents reviewed for incontinence care. The facility census was 85. Findings included: Review of the medical record for Resident #32 revealed an admitted [DATE]. Diagnosis included type 2 diabetes mellitus with diabetic neuropathy, chronic kidney disease, difficulty walking, and hallucinations. Review of the quarterly Minimal Data Set (MDS) dated [DATE] revealed Resident #32 had intact cognition. Review of the bladder and bowel revealed Resident #32 was always incontinent of bladder and bowel. Review of the Care Plan dated 03/09/25 revealed Resident #32 had bladder incontinence related to history of urinary tract infection (UTI) and impaired mobility and bowel incontinence related to immobility. Interventions included clean peri-area with each incontinence episode. Cleanse peri-anal area with warm soap and water, check resident every two hours and assist with toileting as needed (PRN). Observation on 04/16/25 at 12:35 P.M. of incontinence care for Resident #32 revealed Certified Nursing Assistant (CNA) #319 gathered supplies, knocked on door, provided privacy, and explained the procedure to resident. CNA #319 did not wash hands or use hand sanitizer and donned gloves. CNA #319 placed two washcloths in the sink in the resident's bathroom and turned on the water. CNA #319 removed Resident #32's brief soiled with medium amount of urine. CNA #319 removed her gloves and donned new gloves without performing hand hygiene. CNA #319 went to bathroom sink where the two washcloths were sitting in the bottom of the sink, picked up one washcloth and applied soap to the washcloth and then picked up the other washcloth and carried over to Resident #32's bed. At this time CNA #259 and Registered Nurse (RN) # 270 came into the room to assist. CNA #319 provided peri care with the soapy washcloth first, then with the rinse wash cloth, and then patted dry with a towel. CNA #319 removed her gloves and donned new gloves without performing hand hygiene. CNA #319 went to resident bathroom and placed two more washcloths in the bottom of resident sink and turned the water on. CNA #319 grabbed one washcloth and applied soap and grabbed the other washcloth and went to resident bed. CNA #319 performed care on buttocks first with soapy washcloth, then rinse washcloth, then patted dry. CNA #319 removed gloves and applied new gloves without performing hand hygiene. CNA #319 applied barrier cream and then removed gloves, applied new gloves without performing hand hygiene. CNA #319 with the help of CNA #259 and RN #270 assisted resident with pillows, call light in reach and asked if she needed anything else. CNA #19 removed her gloves, didn't perform hand hygiene, and exited the room with the dirty linens. Interview on 04/16/25 at 3:06 P.M. with CNA #319 revealed she did not maintain infection control during incontinence care. CNA #319 verified she did not perform hand hygiene before entering the resident room, after changing gloves, during the incontinence care procedure and before exiting room. CNA #319 revealed she should not have placed the washcloths in the sink and should have used a basin instead. Interview on 04/16/25 at :09 P.M. with CNA #259 revealed hand hygiene was to be performed before and after glove usage and before and after exiting resident room. CNA #259 verified during incontinence care you are to use a basin with water and not place washcloths in the bottom of resident sink due to infection control. Interview on 04/17/25 at 6:29 A.M. with RN/Unit Manager #266 revealed hand hygiene was to be performed before and after glove usage and before and after exiting resident room. RN/Unit Manager # 266 revealed during incontinence care you are to use a basin and not place washcloths in the bottom of resident sink due to infection control. Interview on 04/1725 at 12:19 P.M. with Director of Nursing (DON) confirmed CNA #319 did not maintain infection control during incontinence care as hand hygiene is performed before and after donning/doffing gloves and before and after entering and exiting resident room. DON verified for incontinence care you are to use a clean basin and to not put washcloths in the resident sink and run water due to to the sink being dirty. Review of facility policy titles, Incontinence Care, revised December 2022, revealed the purpose of the policy was to ensure a resident who is incontinent of bowel and/or bladder receives appropriate treatment and services to prevent urinary tract infections. The procedure for incontinence care is to perform hand hygiene, apply clean gloves, fill a basin with warm water, perform peri care, dispose of gloves and perform hand hygiene. Review of facility policy, Handwashing, revised July 2022, revealed the purpose of the policy is to maintain the highest standard of hygiene in patient care through thorough handwashing procedures. These evidence-based practices are designed to protect healthcare staff and residents by preventing the spread of infections among residents, staff, and visitors and to ensure staff do not carry infectious pathogens on their hands or via equipment during resident care. Staff involved in direct resident contact must perform hand hygiene (even if gloves are used): before and after contact with the resident, before donning and after doffing personal protective equipment (PPE), examples, gloves, and after contact with body fluid. Gloves should be changed and hand hygiene performed before moving from a contaminated body site to a clean body site during resident care.

Based on observation, interview, record review, and policy review, the facility failed to provide sufficient staff to provide the needed care and services to all residents. This had the potential to affect all 91 residents in the facility. The facility census was 91. Findings include: Review of Resident Council Minutes dated 03/25/24 revealed residents stated call light response times were at times longer than they would like, however residents were unable to give time of day, night or weekend, weekday. Review of Resident #57's medical record revealed an admitted [DATE] and diagnoses included sepsis, unspecified organism, type two diabetes mellitus with ketoacidosis without coma, cellulitis of lower limb and acute respiratory failure with hypoxia. Review of Resident #57's care plan dated 04/01/24 included Resident #57 had bladder incontinence. Resident #57 would decrease frequency of urinary incontinence through the next review date. Interventions included to check every two hours and as required for incontinence, and to wash, rinse, and dry perineum and change clothing as needed after incontinence episodes. Resident #57 was dependent on staff for meeting emotional, intellectual, physical and social needs due to physical limitations. Interventions included encouraging and allowing choice, self-expression and responsibility. Resident #57 had an ADL (Activity of Daily Living) self-care performance deficit related to sepsis and diagnoses. Resident #57 would improve current level of function in ADL's through the review date of 07/11/24. Interventions included Resident #57 required assistance of one staff with bathing and showering as necessary; Resident #57 required assistance of one staff to dress; Resident #57 required assistance of one staff with personal hygiene and oral care. Resident #57 required assistance of one staff to turn and reposition in bed every two hours and as necessary. Resident #57 was a two person assist with slide board for all transfers. Review of Resident #57's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #57 was cognitively intact. Resident #57 was always incontinent of urine and frequently incontinent of bowel. Observation on 05/15/24 at 2:24 P.M. of Resident #57's room revealed a light was blinking above the door to her room indicating Resident #57 had activated her call light. Interview on 05/15/24 at 2:24 P.M. of Family Member (FM) #270 revealed she was visiting her mother, and on 05/15/24 around 12:00 P.M. FM #270 noticed Resident #57's call light was activated. FM #270 stated Resident #57's call light was on the entire two hours she visited her mother. Observation on 05/15/24 at 2:24 P.M. of the south side nurses station revealed a monitor sitting on the desk at the nurses station. Several resident rooms were displayed on the monitor including Resident #57's indicating call lights were activated but there no sound heard from the monitor to alert staff call lights were activated. Observation on 05/15/24 at 2:26 P.M. of State tested Nursing Assistant (STNA) #211 revealed she entered Resident #57's room to answer the call light. STNA #211 walked out of Resident #57's room and stated she was assigned to take care of Resident #57 from 6:00 A.M. until 6:00 P.M. STNA #211 accompanied the surveyor to the nurses station and confirmed the monitor had resident rooms displayed indicating call lights were activated, but no sound could be heard from the monitor. STNA #211 stated there should be a beeping sound coming from the monitor. Observation on 05/15/24 at 2:30 P.M. of Resident #57 revealed she was lying in bed, the blinds covering the window were closed and the lighting in the room was dim. Resident #57 was wearing a hospital gown and the bottom half of the gown was observed to be very wet. Resident #57 stated the gown was very wet with urine. Interview on 05/15/24 at 2:30 P.M. revealed Resident #57 stated she wanted to get out of bed, and she had her light on for at least 45 minutes. Resident #57 stated when the facility was short handed her call light was on a long time before it was answered. Resident #57 stated she talked to STNA #211 at around 8:30 A.M., and STNA #211 was too busy at that time to give her a shower, but told her she would be back to dress her, then she could have her shower later in the day. Resident #57 indicated STNA #211 never returned to help her get dressed, and now her gown was wet from her diaper because she could not hold her urine. Resident #57 stated her incontinence brief was soaked with urine, her gown was soaked with urine, she was still in her pajamas at 2:30 P.M., and shouldn't the staff check her every two hours to see if her incontinence brief needed changed? Resident #57 again stated she wanted out of bed and the blind on the window needed to be raised if nothing else could be done. Resident #57 stated the blinds were closed all day, and she could not look out of the window. Interview on 05/15/24 at 2:43 P.M. revealed STNA #211 stated the only way to know call lights were activated was to hear beeping from the monitor on the desk at the nurses station or to see the light flashing above the resident's door. Interview on 05/15/24 at 2:39 P.M. of Licensed Practical Nurse (LPN) #170 revealed she was sitting at the South nursing unit nurse's station and stated it had been a very busy day. LPN #170 confirmed the monitor at the nurses station showed resident call lights were activated, but the monitor was not making a beeping sound, or any sound at all to alert staff a call light was activated. LPN #170 stated she had not heard any sound from the monitor all day, including beeping, and did not know how to adjust the volume. LPN #170 stated she was supposed to be finished with her shift at 2:30 P.M., but she did not have time until now to complete her charting, and she would stay until she was finished. LPN #170 revealed she usually stayed 15 to 30 minutes past her shift to finish her charting. Interview on 05/15/24 at 3:10 P.M. of the Administrator and Director of Nursing (DON) revealed staff answered resident call lights when they were activated, but call lights were left on until the resident's need was met. Interview on 05/15/24 at 3:57 P.M. of STNA #211 revealed her usual assignment included Resident #57. STNA #211 confirmed she was too busy on 05/15/24 to give Resident #57 her shower until 3:00 P.M., and she was too busy to get back to her room to change her gown and help her get dressed until she gave Resident #57 a shower at 3:00 P.M. STNA #211 stated she told Resident #57 around 8:30 A.M. she would be back to help her get dressed, but things went haywire and she could not get back to Resident #57 to assist her. STNA #211 stated when she finally was able to get back to Resident #57 her gown and incontinence brief were saturated with urine. STNA #211 stated only three STNA's were assigned to the South nursing unit today from 6:00 A.M. until 2:00 P.M. and there were usually four STNA's assigned, but sometimes the STNA's did not show up. STNA #211 was not sure why there were only three STNA's today. STNA #211 indicated Resident #57 wanted to get up earlier today, but she did not have time to get her up until 3:00 P.M. when she received her shower. STNA #211 stated her assignment included resident's in two hallways of the nursing unit, and it was hard to know when a call light was activated on the first part of her assignment. STNA #211 indicated if call lights were activated on the first part of her assignment, which included Resident #57, she had to walk around the corner and look above resident's doors or check the monitor at the nurses station which should be beeping to alert her call lights were activated. Observation on 05/15/24 at 3:57 P.M. of the South nursing unit and STNA #211's resident assignment revealed the South nursing unit hall which included Resident #57's room intersected a second long hall, and a left turn around a corner had to be made to access the rest of the resident rooms in STNA #211's assignment. Call lights could only be visualized if staff walked to the intersection of the two halls, or checked the monitor at the nurses station. Interview on 05/16/24 at 8:36 A.M. Unit Manager (UM) #181 revealed she did not adjust the volume on the call light monitor located at the South nursing unit nurse's station. UM #181 stated she did not know how the volume was adjusted on the monitor, and if she could not hear the alarm beeping on the monitor she called Maintenance Supervisor (MS) #601. UM #181 stated she assisted staff with answering call lights and tried to meet resident needs. Interview on 05/16/24 at 8:54 A.M. of Maintenance Staff (MS) #601 revealed he did not know how the call light system worked, and he was not handy with computers. MS #601 stated staff did not call him with call light monitor volume issues, and he was not called when the volume on the call light monitors located at the nursing station needed turned up or down. Interview on 05/16/24 at 9:00 A.M. of STNA #235 revealed the volume on the South nursing unit call light monitor located at the nurse's station was sometimes turned off. STNA #235 stated she had Resident #57 in her assignment and walked back and forth constantly between the two halls to check call lights. STNA #235 stated you have to keep your head on a swivel to know if call lights were on in the hall around the corner. STNA #235 stated when only three STNA's were assigned to the South nursing unit it was essential to work as a team, and if an STNA who wasn't a team player was assigned it was hard to complete the work that needed done. Interview on 05/16/24 at 9:09 A.M. of the Administrator revealed she did not adjust the volume of the call light monitors located at the nurse's stations, and thought the volume could be turned up and down at the nurses station. The Administrator stated she did not know how the call light system worked, and the system had been in operation since she started working at the facility. The Administrator indicated she walked up and down the halls and answered call lights if she saw them blinking above resident doors. The Administrator stated there was not a central location for turning the call light volume on or off, or adjusting the volume. Observation on 05/16/24 at 2:25 P.M. of Unit Manager (UM) #109 revealed she pointed to the lower left corner of the call light monitor at a volume icon, and stated that was how the volume was adjusted. Observation on 05/20/24 revealed Resident #95's call light was activated from 9:08 A.M. until 9:36 A.M. (18 minutes) before it was answered by STNA #203. Interview on 05/20/24 at 9:34 A.M. of Resident #65 revealed call light response times were not very fast, she waited a long time for her call light to be answered, but could not state when her call light was not answered timely. Interview on 05/20/24 at 9:36 A.M. of STNA #203 revealed she was in a resident room assisting with bathing, and did not know Resident #95's call light was activated. STNA #203 stated when she was in a room assisting a resident the other STNA's and nurses should watch for call lights and answer them promptly. Interview on 05/20/24 at 9:51 A.M. of Resident #85 revealed the length of time it took for call lights to be answered depended on what was going on when the call light was activated. Resident #85 stated if the STNA's were passing meal trays they did not stop to answer call lights, and it took awhile to get the call light answered during meal times. Resident #85 indicated she was independent with most of her care, did not require a lot of help from the STNA's, and her call light was usually answered in about 15 to 20 minutes. Resident #85 stated the STNA's taking care of her were very good, but other residents waited much longer for their call lights to be answered by the staff. Interview on 05/20/24 at 10:23 A.M. of Resident #42 revealed she was the Resident Council President. Resident #42 stated when the facility was short handed call lights were not answered timely. Resident #42 indicated when Residents told her their call lights did not get answered timely, she told them not to be upset and to be patient because the facility was short staffed and would eventually get to them. Interview on 05/20/24 at 11:47 A.M. of Resident #95 revealed his call light was on today for around 15 to 20 minutes, it was not too long of a wait, but by the time the STNA came in to help him he was feeling like he wasn't going to be able to hold his urine. Resident #95 stated he had waited as long as an hour and a half for his call light to be answered. Resident #95 stated the staff did not come in timely to see if what he needed was urgent, or to tell him when they would be able to assist him, and they just came in his room when they were ready. Interview on 05/20/24 at 12:59 P.M. of the Administrator and Director of Nursing (DON) revealed Resident #57 refused to dress until she had her shower, and she had her shower later in the day. The Administrator stated call light audits were completed and most of the call lights were answered in about 10 to 15 minutes and that was a reasonable time frame. The Administrator stated 18 minutes was not an unreasonable amount of time to wait for a call light to be answered, and the question to ask was were the residents needs met? The DON stated resident perception could be that it took longer than it actually was for the call light to be answered. Review of a facility list of alert and oriented residents included Resident's #42, #57, #58, #65, #83 were alert and oriented. Review of the facility policy titled Resident Call System revised 03/2023 included the staff would provide an environment to assist in meeting the needs of the resident and to provide an environment which supported and enhanced each resident's quality of life, providing the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Respond to resident's call lights in a timely manner. Do not turn off the light if you were unable to meet the resident's needs. Review of the facility policy titled incontinence care dated 2022 included to ensure a resident who was incontinent of bowel and, or bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. This deficiency represents non-compliance investigated under Complaint Number OH00153017.

Based on observation, interview, record review, and review of facility policy the facility failed to ensure a resident was assisted with dressing and provided incontinence care timely. This affected one resident (#57) of three residents reviewed for Activity of Daily Living. The facility census was 91. Findings include: Review of Resident #57's medical record revealed an admitted [DATE] and diagnoses included sepsis, unspecified organism, type two diabetes mellitus with ketoacidosis without coma, cellulitis of lower limb and acute respiratory failure with hypoxia. Review of Resident #57's care plan dated 04/01/24 included Resident #57 had bladder incontinence. Resident #57 would decrease frequency of urinary incontinence through the next review date. Interventions included to check every two hours and as required for incontinence, and to wash, rinse, and dry perineum and change clothing as needed after incontinence episodes. Resident #57 was dependent on staff for meeting emotional, intellectual, physical and social needs due to physical limitations. Interventions included encouraging and allowing choice, self-expression and responsibility. Resident #57 had an ADL (Activity of Daily Living) self-care performance deficit related to sepsis and diagnoses. Resident #57 would improve current level of function in ADL's through the review date of 07/11/24. Interventions included Resident #57 required assistance of one staff with bathing and showering as necessary; Resident #57 required assistance of one staff to dress; Resident #57 required assistance of one staff with personal hygiene and oral care. Resident #57 required assistance of one staff to turn and reposition in bed every two hours and as necessary. Resident #57 was a two person assist with slide board for all transfers. Review of Resident #57's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #57 was cognitively intact. Resident #57 was always incontinent of urine and frequently incontinent of bowel. Observation on 05/15/24 at 2:24 P.M. of Resident #57's room revealed a light was blinking above the door to her room indicating Resident #57 had activated her call light. Interview on 05/15/24 at 2:24 P.M. of Family Member (FM) #270 revealed she was visiting her mother, and on 05/15/24 around 12:00 P.M. FM #270 noticed Resident #57's call light was activated. FM #270 stated Resident #57's call light was on the entire two hours she visited her mother. Observation on 05/15/24 at 2:26 P.M. of State tested Nursing Assistant (STNA) #211 revealed she entered Resident #57's room to answer the call light. STNA #211 walked out of Resident #57's room and stated she was assigned to take care of Resident #57 from 6:00 A.M. until 6:00 P.M. STNA #211 accompanied the surveyor to the nurses station and confirmed the monitor had resident rooms displayed indicating call lights were activated, but no sound could be heard from the monitor. STNA #211 stated there should be a beeping sound coming from the monitor. Observation on 05/15/24 at 2:30 P.M. of Resident #57 revealed she was lying in bed, the blinds covering the window were closed and the lighting in the room was dim. Resident #57 was wearing a hospital gown and the bottom half of the gown was observed to be very wet. Resident #57 stated the gown was very wet with urine. Interview on 05/15/24 at 2:30 P.M. revealed Resident #57 stated she wanted to get out of bed, and she had her light on for at least 45 minutes. Resident #57 stated when the facility was short handed her call light was on a long time before it was answered. Resident #57 stated she talked to STNA #211 at around 8:30 A.M., and STNA #211 was too busy at that time to give her a shower, but told her she would be back to dress her, then she could have her shower later in the day. Resident #57 indicated STNA #211 never returned to help her get dressed, and now her gown was wet from her diaper because she could not hold her urine. Resident #57 stated her incontinence brief was soaked with urine, her gown was soaked with urine, she was still in her pajamas at 2:30 P.M., and shouldn't the staff check her every two hours to see if her incontinence brief needed changed? Resident #57 again stated she wanted out of bed and the blind on the window needed to be raised if nothing else could be done. Resident #57 stated the blinds were closed all day, and she could not look out of the window. Interview on 05/15/24 at 2:39 P.M. of Licensed Practical Nurse (LPN) #170 revealed she was sitting at the South nursing unit nurse's station and stated it had been a very busy day. LPN #170 confirmed the monitor at the nurses station showed resident call lights were activated, but the monitor was not making a beeping sound, or any sound at all to alert staff a call light was activated. LPN #170 stated she had not heard any sound from the monitor all day, including beeping, and did not know how to adjust the volume. LPN #170 stated she was supposed to be finished with her shift at 2:30 P.M., but she did not have time until now to complete her charting, and she would stay until she was finished. Interview on 05/15/24 at 3:10 P.M. of the Administrator and Director of Nursing (DON) revealed staff answered resident call lights when they were activated, but call lights were left on until the resident's need was met. Interview on 05/15/24 at 3:57 P.M. of STNA #211 revealed her usual assignment included Resident #57. STNA #211 confirmed she was too busy on 05/15/24 to give Resident #57 her shower until 3:00 P.M., and she was too busy to get back to her room to change her gown and help her get dressed until she gave Resident #57 a shower at 3:00 P.M. STNA #211 stated she told Resident #57 around 8:30 A.M. she would be back to help her get dressed, but things went haywire and she could not get back to Resident #57 to assist her. STNA #211 stated when she finally was able to get back to Resident #57 her gown and incontinence brief were saturated with urine. STNA #211 indicated Resident #57 wanted to get up earlier today, but she did not have time to get her up until 3:00 P.M. when she received her shower. Review of the facility policy titled Resident Call System revised 03/2023 included the staff would provide an environment to assist in meeting the needs of the resident and to provide an environment which supported and enhanced each resident's quality of life, providing the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Respond to resident's call lights in a timely manner. Do not turn off the light if you were unable to meet the resident's needs. Review of the facility policy titled incontinence care dated 2022 included to ensure a resident who was incontinent of bowel and, or bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. This deficiency represents non-compliance investigated under Complaint Number OH00153017.

Based on interview, record review, and review of manufacturer's instructions the facility failed to ensure a resident had physician orders and instructions for the care and monitoring of her wound incision management system. This affected one resident (#92) out of three residents reviewed for post surgical care. The facility census was 91. Findings include: Review of Resident #92's medical record revealed an admitted [DATE] and diagnoses included displaced malleolar fracture of left lower leg, schizoaffective disorder, and bipolar disorder. Resident #92 was discharged from the facility on 04/12/24. Review of Resident #92's After Visit Summary for hospital stay dated 03/02/24 through 03/08/24 included Resident #92 had a left trimalleolar ankle fracture with a planned surgery scheduled on 03/12/24. Review of Resident #92's Physician progress notes dated 03/11/24 at 8:36 P.M. included Resident #92 had a left ankle trimalleolar fracture and surgery was planned for 03/12/24. Review of Resident #92's progress notes dated 03/12/24 at 9:17 A.M. revealed Resident #92 was having a procedure done at the local hospital. Review of Resident #92's After Visit Summary dated 03/12/24 included Resident #92 had an operation and the procedure was ORIF (open reduction internal fixation) ankle trimalleolar, without fixation posterior lip, Accumed fibular nail (left). A type of surgery used to stabilize and heal a broken bone. Review of Resident #92's care plan did not reveal a care plan for monitoring and ensuring Resident #92's surgical vac was functioning appropriately. Review of Resident #92's progress notes dated 03/12/24 did not reveal evidence Resident #92 returned to the facility after having surgery, no evidence an assessment of the surgical site was completed including if she had a cast on her left leg, or if Resident #92 returned to the facility with a surgical vac. The progress notes did not state Resident #92 returned with discharge instruction orders. Review of Resident #92's progress notes from 03/12/24 through 03/15/24 did not reveal evidence Resident #92 had an assessment of her surgical site, cast on left leg, or a surgical vac. Review of Resident #92's physician orders dated 03/12/24 revealed Provena wound vac on for 14 days. Review of Resident #92's physician orders from 03/12/24 through her discharge on 04/12/24 did not reveal instructions for the care and monitoring of Resident #92's surgical vac to ensure the surgical vac was functioning appropriately. Review of FAQ (frequently asked questions) information regarding Provena Incision Management System, (undated), included if at any time while using the Provena Incision Management System the cannister became full of fluid other than blood, indicated by a Maximum Capacity alert or visual inspection, turn therapy unit off and contact the treating physician. A small amount of drainage was expected in the cannister. If the cannister filled in one to two days, notify the physician. If there was no drainage from the wound, and wound V.A.C was turned on the dressing was compressed. The Wound V.A.C. was working to pull the wound edges together and increase the rate of healing. By double pressing the on and off button, the unit would display the leak rate of the system for three seconds. To prevent nuisance leak alarms, the leak rate status should be Best (one light illuminated) or Good (two lights illuminated). Review of Resident #92's Medication Administration Record (MAR) from 03/12/24 through 04/12/24 did not reveal Resident #92's surgical vac was monitored to ensure the surgical vac was functioning appropriately. Review of Resident #92's progress notes dated 03/15/24 at 11:57 A.M. included the nurse responded to Resident #92's call light and Resident #92 reported her wound vac had become disconnected. The nurse and another nurse reconnected the would vac but no suction was detected. The two nurse's attempted to achieve a suction but were unsuccessful. The oncoming nurse was notified. There was no documentation Resident #92's physician was notified of the wound vac becoming disconnected or the nurse was unable to achieve a suction. Review of Resident #92's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #92 had moderate cognitive impairment. Review of Resident #92's progress notes dated 03/15/24 through 03/23/24 did not reveal evidence Resident #92's wound vac was able to achieve a suction, and if it was draining appropriately. Review of Resident #92's progress notes dated 03/23/24 at 2:01 P.M. included the nurse spoke with Family Member (FM) #272 regarding Resident #92's surgical vac which was placed on 03/12/24 and was supposed to be on for two weeks. There was no documentation on the discharge paperwork from Resident #92's surgery that mentioned the surgical vac or how long it was supposed to stay on. Typically the surgical vac lasted five to seven days and shut off automatically. FM #272 stated the surgical vac just needed plugged in. The surgical vac had no drainage noted and Resident #92's surgeon was called for instructions on how the facility should proceed with the surgical vac. Would continue to monitor the wound vac. Review of Resident #92's progress notes dated 03/24/24 at 5:19 P.M. included Resident #92's wound vac was connected and running and no drainage was noted in the cannister or tubing. Review of Resident #92's progress notes dated 03/25/24 at 3:08 P.M. included the nurse spoke with Resident #92's surgeon and a new order was given to discontinue the wound vac. Interview on 05/16/24 at 2:30 P.M. of the director of nursing (DON) and Unit Manager (UM) #109 revealed Resident #92 left for facility on 03/12/24 for a scheduled surgery, and returned the same day. The DON stated when Resident #92 returned to the facility, the ambulance driver did not have a packet with discharge instructions to give to the nurse. The DON indicated several days went by, and FM #272 found discharge instructions on 03/16/24 in a bag which came back with Resident #92 on 03/12/24 which was the day of her surgery. The DON and UM #109 stated in their realm sometimes papers got misplaced or taken home by families. The DON stated she spoke to Registered Nurse (RN) #164, the nurse who admitted Resident #92 back to the facility after her surgery. RN #164 told the DON that Resident #92 did not return from her surgery with any discharge instructions. The DON stated Resident #92 returned the same day she had her surgery, and her previous orders did not need to be verified. The DON confirmed there were no evidence of physician orders or instructions regarding the care of Resident #92's surgical vac in her medical record. The DON stated it was just part of Resident #92's daily assessment and did not have to be documented. The DON indicated the nurse's routinely did CMS checks (circulatory motor sensory) on Resident #92's left foot but it was not documented. Interview on 05/16/24 at 5:20 P.M. of Registered Nurse (RN) #164 revealed on 03/12/24 when Resident #92 returned to the facility after having surgery it was shift change and things were very chaotic. RN #164 stated that was probably why she did not document Resident #92 returned from surgery in the progress notes, and Resident #92 did not have orders when she returned. RN #164 stated Resident #92 had a pink cast on her left ankle, she checked her foot for warmth and capillary refill, and made sure the wound vac was working. RN #164 stated she did not remember specifics about Resident #92's return and if she had a dressing or where the wound vac was located. This deficiency represents non-compliance investigated under Complaint Number OH00153139.

Based on observation, interview, record review and review of facility policy the facility failed to ensure a resident had a comprehensive pain assessment upon admission and failed to ensure a comprehensive pain reevaluation after a narcotic medication was discontinued. Additionally the facility failed to ensure Resident #95's narcotic pain medication was available. This affected one resident (#95) out of three residents reviewed for pain. Findings include: Review of Resident #95's medical record revealed an admitted [DATE] and diagnoses included burn of unspecified degree of right lower leg, burn of unspecified body region, and personal history of malignant neoplasm of other organs and systems. Review of Resident #95's progress notes dated [DATE] at 7:45 P.M. included Resident #95 was admitted to the facility via ambulance from the local hospital. Resident #95's admitting diagnosis was burn on right leg. Resident #95 was alert and oriented times four (person, place, time, event) and able to make needs known. Review of Resident #95's Nursing: Pain assessment dated [DATE] revealed it was not started or completed. Review of Resident #95's physician orders dated [DATE] revealed to assess pain every shift. If pain present, intervention and documentation required. Attempt and document non-pharmacological interventions prior to medication administration. Review of Resident #95's physician orders dated [DATE] revealed oxycodone HCl oral tablet 5 milligram (mg), give one tablet by mouth every four hours as needed for pain (burn on leg) for three days. Resident #95's order for oxycodone was discontinued on [DATE] and his medical record did not reveal evidence a comprehensive pain assessment was completed after the oxycodone was discontinued. Review of Resident #95's Medication Administration Record (MAR) dated [DATE] included to assess pain every shift. If pain present, intervention, and documentation required. Attempt and document non-pharmacological interventions prior to medication administration, every shift for routine monitoring. Further review revealed Resident #95's pain level was a zero on a scale of one to ten, and ten being the worst pain. There were no non-pharmacological interventions implemented. Review of Resident #95's hospital History and Physical dated [DATE] included Resident #95 was recently admitted to the hospital due to burn on his right leg. Resident #95 was admitted to the burn unit, and taken to the OR (operating room) several times for excision and grafting, debridement and polynovo placement (a biodegradable temporizing dermal matrix designed to aid the body in regenerating new tissue for wound closure and reconstruction of complex wounds). Wound doctor had been consulted and would be responsible for the evaluation and comprehensive management of the wound including appropriate control of complicating factors such as unrelieved pressure, infection, vascular and, or uncontrolled metabolic derangement and, or nutritional deficiency in addition to appropriate debridement. Review of Resident #95's Physical Therapy Evaluation dated [DATE] included Resident #95 had a burn of unspecified degree of right lower leg and burn of unspecified body region. Resident #95's car caught on fire while he was driving it, which resulted in a right foot burn, and he was hospitalized for severe right foot burns and subsequent skin grafting. This resulted in a new onset in decreased ability to perform functional mobility tasks at independence level required for Resident #95 to safely return to his previous living situation at this time Resident #95 stated he had pain and hurting in the last five days, and had pain that interfered with and limited functional activity. Nursing to address if skilled therapy was needed to address pain. Resident #95 had moderate pain in the right lower extremity. Review of Resident #95's Occupational Therapy Evaluation dated [DATE] included Resident #95 had pain or hurting in the last five days, and the pain was severe. The location of the pain was Resident #95's right ankle, foot, leg. Further review included due to the documented deficits and Resident #95's pain severity level and severity of functional limitations, without skilled therapeutic intervention, Resident #95 was at risk for rehospitalization , decreased ability to return to prior level of function, decreased ability to return to prior living environment, inability to remain at home, decrease in level of mobility, decreased participation with functional tasks, decreased participation in occupations of choice, falls, further decline in function and increased dependency upon caregivers. Review of Resident #95's MAR with a start date of [DATE] included to assess pain every shift. If pain present, intervention, and documentation required. Attempt and document non-pharmacological interventions prior to medication administration. Further review on [DATE], [DATE], and [DATE] revealed there was no pain assessment documented including a pain level score for pain on a scale of zero to ten, and ten being the worst pain. On [DATE] a pain level score of zero was documented with no non-pharmacological interventions implemented. Review of Resident #95's MAR dated [DATE] through [DATE] revealed to assess pain every shift, if pain present, intervention and documentation required. Attempt and document non-pharmacological interventions prior to medication administration. There were check marks documented on the MAR each shift, but no pain level was recorded. Review of Resident #95's MAR dated [DATE] revealed oxycodone HCl oral tablet 5 mg was administered at 4:04 P.M. for a pain level of 3 on a pain scale of zero to ten and ten being the worst pain, and it was effective. (Resident #95 received acetaminophen 650 mg at the same time). Further review from [DATE] at 4:04 P.M. through [DATE] revealed no oxycodone was administered. Review of Resident #95's MAR dated [DATE] revealed acetaminophen oral tablet 325 mg, give two tablets by mouth every six hours as needed for pain. Resident #95 received two Tylenol tablets at 4:05 P.M. for a pain level of four, on a scale of one to ten, and it was effective. Further review revealed on [DATE] at 7:39 P.M. Resident #95 received two Tylenol tablets for a pain level of two and it was effective. Review of Resident #95's MAR dated [DATE] at 10:39 A.M. revealed Resident #95 received acetaminophen 325 mg, two tablets and ibuprofen 400 mg by mouth for a pain level of 3. Interview on [DATE] at 11:47 A.M. of Resident #95 revealed the transition from the hospital to the facility revealed differences in the way things were done. Resident #95 stated he had to ask for pain medication in the facility and it was not automatically given when it was due. Resident #95 stated it was not explained to him when he was admitted that he would have to ask for oxycodone. Resident #95 stated he did not have oxycodone for days, and when he did ask for oxycodone the nurse told him he could not have it. Resident #95 stated his leg was throbbing, he could not sleep, and he was not given oxycodone, and this happened yesterday ([DATE]). Resident #95 stated it was hard to get answers at the facility, and the hospital was easy. Resident #95 indicated his oxycodone was not ordered, and was only ordered for a couple days, and he had to fight to have Motrin (ibuprofen) administered. Resident #95 stated he had a burn on his leg because he was driving his pickup truck, it caught on fire, he should have jumped out sooner than he did, and his leg was burned. Resident #95 stated the burn was bad, was from the knee down and the pain was horrible. Resident #95 stated he did not jump out of his pickup truck sooner because he did not want to hit a house and burn it down. Resident #95 indicated he already had two surgeries for the burns and he needed to have a third surgery. Resident #95 stated he left the hospital, they said everything would be fine and it was not fine at the facility. Resident #95 stated the Physical Therapy was so painful he was not able to do it, he asked for something for pain, and asked for oxycodone. Resident #95 stated he needed the oxycodone and last night he was in misery. Review of Resident #95's physician orders dated [DATE] at 11:49 A.M. revealed oxycodone HCl oral tablet 5 mg, give one tablet by mouth every six hours as needed for pain (burn on leg). Interview on [DATE] at 12:04 P.M. of Licensed Practical Nurse (LPN) #186 revealed she gave Resident #95 Tylenol and ibuprofen at 10:30 A.M. LPN #186 stated Resident #95 had a three day prescription for oxycodone that had to be reinstated, and she placed a call to Resident #95's Nurse Practitioner about 30 minutes ago. LPN #186 stated she did not work on [DATE] and did not know why Resident #95's oxycodone was not ordered before today. Interview on [DATE] at 2:17 P.M. of the Director of Nursing (DON) revealed when a resident was admitted to the facility the Admission Assessment should be completed within 24 hours and the other Assessments such as the Nursing Pain Assessment should be completed within three days. The DON confirmed Resident #95's Pain Assessment was not completed. The DON confirmed Resident #95's MAR had check marks each shift indicating Resident #95's pain was assessed, but there was no evidence pain assessments were completed for each shift from [DATE] through [DATE]. The DON stated Resident #95 was not consistent with taking oxy, and some nurses start with Tylenol (acetaminophen) and progress as needed. The DON stated LPN #183 educated Resident #95 that he needed to ask for pain medication, and confirmed there was no evidence of the education in Resident #95's progress notes. Interview on [DATE] at 2:02 P.M. of Director of Rehab (DOR) #273 revealed Resident #95 had Physical Therapy and Occupational Therapy, and needed to participate more in his therapy. DOR #273 stated Resident #95 was only out of bed for 20 minutes and he requested to go back to bed. DOR #273 stated Resident #95 stood up one time, said he was in pain and his pain level was a ten (severe pain on a pain scale of one to ten, ten being the worst pain). DOR #273 stated Resident #95's leg caught on fire. After Resident #95 was assisted back to bed DOR #273 stated he followed up at 1:00 P.M. and was told Resident #95 received Tylenol and ibuprofen at 10:30 A.M. DOR #273 stated at 1:00 P.M. Resident #95 confirmed he received Tylenol and ibuprofen, but said he was in too much pain because the effects of the medication were wearing off and he did not want to try therapy. DOR #273 stated Resident #95 told him there was an issue with his pain medication (oxycodone) being available to him, and if he received his pain medication, he would do therapy. Review of Resident #95's Physical Therapy Treatment Encounter Noted dated [DATE] at 2:02 P.M. revealed response to treatment included Resident #95 limited the session due to increased pain in the right lower extremity. Resident #95 requested to go back to bed despite before being up for 30 minutes prior to session. Resident #95 encouraged to increase his OOB (out of bed) time as Resident #95 routinely requested to go back to bed shortly after getting up saying shaving and toileting take a lot out of him. Resident #95 and the PTA (physical therapy assistant) discussed scheduling sessions around pain medications to maximize outcomes which Resident #95 agreed to. Resident #95 declined to have therapy after Tylenol (acetaminophen) was administered due to pain in right lower extremity. Review of Resident #95's Physical Therapy Treatment Encounter Note dated [DATE] at 2:23 P.M. included there were changes to the previous note. Resident #95 limited the session due to increased pain in right lower extremity. Observation on [DATE] at 4:02 P.M. of State tested Nurse Aide (STNA) #194 revealed she walked in Resident #95's room and had a conversation with him. STNA #194 stated Resident #95 told her his pain medication was expired and he was not receiving it and he wanted his pain medication. Interview on [DATE] at 4:30 P.M. of State tested Nursing Assistant (STNA) #233 revealed she worked on [DATE] from 6:00 P.M. through [DATE] at 6:00 A.M. STNA #233 stated Resident #95 had a burn and a skin graft, he said he was in pain and would like his pain medication. Resident #95 stated earlier in the day it was explained to him that he had to ask for his pain medication. STNA #233 stated Resident #95 said he wanted his oxycodone, and wanted to know why he could not have it. STNA #233 indicated she told the nurse Resident #95 wanted his oxycodone. Review of the facility policy titled Pain Management revised ,d+[DATE] included the purpose was to ensure residents received the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management. The licensed nurse would perform a pain assessment upon admission, quarterly, with significant change, new onset of pain and incident. Indicators of pain included non-verbal behavior such as resisting care, decreased participation in usual physical and or social activities and difficulty sleeping. The licensed nurse would assess the following as necessary including impact of pain on day-to-day activities, and activities or treatments that might precipitate pain. Discuss resident's goals for pain management and effectiveness with the current level of pain control. This deficiency represents incidental findings of non-compliance investigated under Complaint Number OH00153139.

Based on interview, record review and review of the facility policy the facility failed to ensure residents were free from significant medication errors. This affected one resident (#92) out of four residents reviewed for medications per physician orders. The facility census was 91. Findings include: Review of Resident #92's medical record revealed an admitted [DATE] and diagnoses included displaced malleolar fracture of left lower leg, schizoaffective disorder, and bipolar disorder. Resident #92 was discharged from the facility on 04/12/24. Review of Resident #92's After Visit Summary for hospital stay dated 03/02/24 through 03/08/24 included Resident #92 had a left trimalleolar ankle fracture with a planned surgery scheduled on 03/12/24. Resident #92 was evaluated by psychiatry for her schizoaffective disorder and would need a risperidone injection on 03/15/24 either in the hospital or at the rehab (facility). Review of Resident #92's progress notes dated 03/08/24 at 10:30 P.M. included Resident #92 arrived to the facility from the hospital, orders were placed and Medical Director (MD) #271 reviewed and confirmed all orders. Review of Resident #92's progress notes from 03/08/24 through 03/14/24 did not reveal documentation regarding Resident #92's risperidone injection and why it was not ordered until 03/14/24, when it was included on Resident #92's discharge instructions from the hospital on 03/08/24. Review of Resident #92's Physician progress notes dated 03/11/24 at 8:36 P.M. included Resident #92 had a left ankle trimalleolar fracture and surgery was planned for 03/12/24. Resident #92 had schizoaffective disorder with intermittent hallucinations which was new. Continue Resident #92's medications and Resident #92 would need her biweekly risperidone shot on 03/15/24. Review of Resident #92's care plan dated 03/12/24 included Resident #92 used psychotropic (included antipsychotic) medications related to schizoaffective disorder and bipolar disorder. Resident #92 would remain free of psychotropic drug related complications, including movement disorder, discomfort, cognitive or behavioral impairment through the review date. Interventions included to administer psychotropic medications as ordered by the physician and monitor for side effects and effectiveness; to monitor, document, report adverse reactions of psychotropic medications including behavior symptom not usual. Resident #92 was on pain medication therapy related to fracture of left leg and other diagnoses. Resident #92 would be free of discomfort or adverse side effects from pain medication through the review date. Interventions included to administer analgesic medications as ordered by the physician and monitor, document for side effects and effectiveness. Review of Resident #92's After Visit Summary dated 03/12/24 included Resident #92 had an operation and the procedure was ORIF (open reduction internal fixation) ankle trimalleolar, without fixation posterior lip, Accumed fibular nail (left). A type of surgery used to stabilize and heal a broken bone. Further review included Resident #92 was to start taking Gabapentin (commonly know as neurontin) 300 mg capsule, take one capsule by mouth three times a day for 30 days. Review of Resident #92's progress notes dated 03/12/24 did not reveal documentation Resident #92 returned to the facility after having surgery, an assessment of the surgical site was completed, and if she had discharge instruction orders. Review of Resident #92's physician orders dated 03/14/24 revealed risperidone ER intramuscular suspension, reconstituted ER 50 mg, inject 50 mg intramuscular in the morning every Friday related to schizoaffective disorder. Review of Resident #92's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #92 had moderate cognitive impairment. Resident #92 received antipsychotic medication. Review of Resident #92's progress notes dated 03/15/24 at 1:35 P.M. included risperidone ER intramuscular suspension reconstituted ER 50 milligrams (mg), inject 50 mg in the morning every Friday related to to schizoaffective disorder, unspecified. Patient was contacting physician office to see if Resident #92 could receive the risperidone injection at the office. There was no documentation explaining why Resident #92 did not receive the risperidone injection at the facility on 03/15/24 when it was ordered by her physician to be given, or that Resident #92's physician was notified Resident #92 did not receive the risperidone injection. Review of Resident #92's progress notes dated 03/15/24 through 03/27/24 did not reveal evidence MD #271 was notified Resident #92's risperidone injection was not administered. Review of Resident #92's physician orders dated 03/16/24 revealed Gabapentin oral capsule 300 mg, give 300 mg by mouth three times a day for leg pain for 30 days. Resident #92's After Visit Summary on 03/12/24 stated to start Gabapentin 300 mg capsule, three times a day, on 03/12/24. Review of Resident #92's Medication Administration Record (MAR) dated 03/12/24 through 03/16/24 did not reveal Gabapentin 300 mg oral capsule was administered until 03/16/24. Review of Resident #92's progress notes dated 03/18/24 the Health and Wellness Center where Resident #92 received her risperidone injection was contacted, and an appointment was made for 03/22/24. Resident #92 and Family Member (FM) #272 were notified. FM #272 stated she would call the physician office because Resident #92 should not wait that long for her injection. The nurse explained to FM #272 she called the physician office to call the risperidone in to the local pharmacy and the physician office stated it would be easier for Resident #92 to get the risperidone injection in the office. FM #272 stated she would call the physician office to see what could be done. Review of Resident #92's progress notes dated 03/22/24 at 3:31 P.M. included Resident #92 returned from her appointment and stated she did not get her shot while she was there. Resident #92 showed no behaviors this shift. Review of Resident #92's progress notes dated 03/22/24 through 03/27/24 did not reveal documentation why Resident #92 did not receive a risperidone injection while she was at her appointment on 03/22/24, what was being done to obtain the injection or when it would be administered. Review of Resident #92's physician orders dated 03/27/24 revealed risperidone ER intramuscular suspension, reconstituted ER 50 mg, inject 50 mg intramuscular in the morning every two weeks on Wednesdays related to schizoaffective disorder. Review of Resident #92's progress notes dated 03/27/24 at 5:16 P.M. included Resident #92 received her Risperdal (risperidone) injection, which was 12 days after it was ordered to be given. Review of Resident #92's progress notes dated 03/08/24 through 03/27/24 did not reveal evidence FM #272 or Resident #92's physician were notified of the reason risperidone injection was not administered to Resident #92. Interview on 05/15/24 at 4:35 P.M. of FM #272 revealed during Resident #92's care conference on 03/14/24 Unit Manager (UM) #109 said she ordered Resident #92's risperidone 50 mg injection which was due on 03/15/24. FM #272 stated Resident #92 did not receive the risperidone injection on 03/15/24, no follow-up was done until 03/19/24 when UM #109 made an appointment on 03/22/24 with Resident #92's psychiatrist for her to receive the risperidone and she still did not receive the risperidone because her physician did not have it. FM #272 stated Resident #92 returned from her appointment without receiving the risperidone injection and there was no follow up by UM #109 or the nurse until the following Monday (03/27/24). FM #272 stated she had to call Resident #92's psychiatrist to have him send a prescription for risperidone to the local pharmacy, she picked the risperidone up from the pharmacy on 03/26/24 and took it to the facility. FM #272 indicated she handed the risperidone injection to Licensed Practical Nurse (LPN) #169 at around 4:30 P.M. and thought he was going to make sure Resident #92 received the risperidone, but Resident #92 did not receive the risperidone until the next day. FM #272 stated Resident #92 called her on 03/27/24, said she still did not get her injection, and asked who she gave the injection to. FM #272 revealed she called the Director of Nursing (DON) and asked why Resident #92 did not receive her risperidone, and the DON said she would look into it and call her back. FM #272 stated the DON did not call her back, but Resident #92 called her and told her she received her injection. UM #109 called and left a message stating Resident #92 received the risperidone injection. FM #272 stated Resident #92 had a behavioral health diagnosis and received her risperidone injection on 03/27/24 instead of 03/15/24, which was 12 days after it was ordered to be administered. FM #272 stated in addition to not receiving her risperidone injection as ordered by the physician Resident #92 did not receive Gabapentin which was ordered on 03/12/24 until 03/16/24. Interview on 05/16/24 at 2:17 P.M. of Licensed Practical Nurse (LPN) #169 revealed he remembered Resident #92 received a risperidone injection, and FM #272 picked it up from the pharmacy and brought it to the facility. LPN #169 stated the risperidone injection was not at the facility on the date it was supposed to start. LPN #169 indicated it was about 4:00 P.M., he was sitting at the nurse's station, FM #272 handed the risperidone injection to him, he did not administer Resident #92's risperidone injection, but put it in the refrigerator in the medication room. LPN #169 stated his usual practice was to notify UM #109 when a medication arrived, but he did not remember if he notified her. Interview on 05/16/24 at 2:25 P.M. of UM #109 and the DON revealed they were aware on 03/08/24, when Resident #92 was admitted to the facility, that she needed a risperidone injection on 03/15/24. The DON stated Resident #92's risperidone injection was not obtained by the facility and administered to Resident #92 because it was too expensive. The DON stated FM #272 was asked if she had a risperidone injection at home they could give, but FM #272 said she did not have the medication at home. The DON stated UM #109 called Resident #92's physician, set up an appointment on 03/22/24 with the understanding she would receive the risperidone at the appointment, but Resident #92 did not receive risperidone injection at the appointment. The DON stated the physician office did not give it because they would have to pay for it. The DON stated she offered to have the risperidone called in to the local pharmacy but FM #272 wanted it given at the appointment. The DON stated because Resident #92 was receiving skilled services at the facility, the risperidone was not covered by insurance, and the facility and Resident #92's physician's office would have to eat the cost. The DON indicated that was the reason neither the facility nor the physician office administered the risperidone injection. Interview on 05/16/24 at 2:30 P.M. of the DON and UM #109 revealed Resident #92 left the faciity on [DATE] for a scheduled surgery, and returned the same day. The DON stated when Resident #92 returned to the facility, the ambulance driver did not have a packet with discharge instructions to give to the nurse. The DON indicated several days went by, and FM #272 found discharge instructions on 03/16/24 in a bag which came back with Resident #92 on 03/12/24 which was the day of her surgery. The DON stated the discharge instructions included orders for Gabapentin, FM #272 brought the instructions to their attention, and orders were placed on 03/16/24 for Gabapentin (anticonvulsant and nerve pain medication). The DON and UM #109 stated in their realm sometimes papers got misplaced or taken home by families. The DON stated she spoke to Registered Nurse (RN) #164, the nurse who admitted Resident #92 back to the facility after her surgery. RN #164 said Resident #92 did not return with any discharge instructions. The DON stated Resident #92 returned the same day she had her surgery, and her previous orders did not need to be verified. Interview on 05/16/24 at 5:20 P.M. of Registered Nurse (RN) #164 revealed on 03/12/24 when Resident #92 returned to the facility after having surgery it was shift change and things were very chaotic. RN #164 stated that was probably why she did not document Resident #92 returned from surgery in the progress notes, and Resident #92 did not have orders when she returned. Review of National Alliance on Mental Illness information on risperidone included if a dose of risperidone long-acting injection was missed, see your healthcare provider to receive your dose as soon as possible. Review of facility policy titled Medication Administration-Preparation and General Guidelines dated 12/2017 included medications were administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The right resident, right drug, right dose, right route and right time were applied for each medication being administered. If a dose of regularly scheduled medication was withheld, refused, not available, or given at time other than the scheduled time an explanatory note was entered on the record. Nursing documents the notification and physician response. This deficiency represents non-compliance investigated under Complaint Number OH00153139.

Based on observation, interview, and record review the facility failed to ensure the kitchen was maintained in a clean and sanitary condition and staff properly wore hair restraints while in the kitchen. This had the potential to affect all residents except one resident (#73) who received nothing by mouth. The facility census was 84. Findings include: Tour of the kitchen on 09/18/23 from 8:57 A.M. through 9:10 A.M. with Certified Dietary Manager (CDM) #309 revealed observation of a clear container of thickener with a small, clear plastic bowl stored in it. Next to the prep table where the container of thickener was located was a silver rack where the spices were stored, on the bottom shelf of the rack were plastic tubs stored upside down. Observed on the plastic tubs were various food crumbs on top of it. Observation of the walk-in cooler revealed various debris on the floor and along the lower back wall behind the rack was a yellowish foam material that had multiple dark colored spots along it. Interview during this time with CDM #309 verified the observations. Observation on 09/20/23 from 11:00 A.M. through 11:17 A.M. of tray line service revealed observation of Dietary Staff (DS) #316 with long bangs, past her eyebrows exposed and not covered by the hairnet, putting items on resident meal trays, and then placing the trays onto the meal cart. Interview 09/20/23 at 11:20 A.M. with CDM #309 verified observation and stated DS #316's bangs should be covered by the hairnet. Follow-up interview on 09/20/23 at 12:09 P.M. with CDM #309 stated the dark spots on the yellow foam along the wall in the walk-in cooler was dirt.

Based on observation, interview, and record review the facility failed to ensure call lights were within reach. This affected three residents (#23, #26, and #283) of 84 residents. The census was 84. Findings include: 1. Review of the medical record for Resident #23 revealed an admitted [DATE]. Pertinent diagnoses include diabetes mellitus type 1, sacrolitis, hydrocephalus, fibromyalgia, other vertebral disc displacement, presence of cerebral fluid drainage device and, ataxia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident was dependent for toileting, hygiene, bathing, and dressing. Substantial assistance was needed for transfers between surfaces and bed mobility. Review of the care plan dated 02/24/21 revealed the resident required assistance by one staff to turn and reposition in bed every two hours and as necessary. The resident required assistance by one staff with bathing/showering. The resident required assistance by one staff with personal hygiene and oral care. The resident required assistance by two staff with sit to stand positioning to transfer. Interventions included a remind to call don't fall or ask for assistance when needed. Observation on 09/18/23 at 2:30 P.M. revealed Resident #23 was in a wheelchair next to bed facing the wall with the television on it. The call light was on the bed by pillow behind Resident #23. At the time of the observation, State tested Nurses Assistant (STNA) #314 verified the call light was not in reach and handed it to Resident #23. 2. Review of the medical record for Resident #26 revealed an admitted [DATE]. Pertinent diagnoses include type II diabetes mellitus, muscle weakness, major depressive disorder, anxiety, unspecified psychosis, unspecified affective mood disorder. Pertinent orders include a hoyer lift for all transfers. A review of the Quarterly MDS assessment, section G dated 07/01/23 revealed the Need for extensive assistance for bed mobility and dependence on staff for transfers. It also revealed two or more staff for physical assistance with toileting and all other activities of daily living. A review of the care plan dated 09/09/22 revealed Resident #26 is care planned for behaviors of being rude to staff. There is nothing documented about behaviors in regards to placing call light on floor. A review of behavior tracking revealed the last documentation of any behaviors was 05/18/2020. Observation on 09/21/23 at 9:15 A.M. revealed Resident #26 was in bed. The call light was noted on the floor by the right side of the bed. Interview with Resident #26 on 09/21/2023 at 9:15 A.M. verified they utilized their call light to notify staff of need for assistance, when I can find it. Interview with Admission Director #200 on 09/21/2023 at 9:20 A.M. verified the call light was on the floor. 3. Review of the medical record for Resident #283 revealed an admitted . 09/15/23 for hospice respite stay. Pertinent diagnoses included: Alzheimer's Dementia, congestive heart failure, anxiety, dementia with psychotic disturbance. There was no MDS data to review. A functional assessment dated [DATE] revealed Resident #283 was dependent for self-care and mobility. Maximal assistance was needed for feeding. Resident #283 was dependent on staff for all activities of daily living. Resident #283 was also dependent on staff for position changes and transfers. An admission care plan dated 09/17/23 revealed Resident #283 required assistance by one staff with bathing/showering. Resident #283 required assistance by one staff to turn and reposition in bed. Resident#283 required assistance by one staff for personal hygiene. The Resident #283 required assistance by one staff for toileting. Resident #283 required assistance by one staff to move between surfaces. Interventions included to encourage the Resident #283 to use call light to call for assistance. Observation on 09/18/23 10:05 A.M. revealed Resident #283 in bed on her left side attempting to eat cereal. The cereal was spilling down the front of Resident #283. The touch pad call button was under pillow on the left side of the bed. An interview at the time of the observation with STNA #274 verified the call light was not able to be reached by Resident #283 and that Resident #283 was in poor position to eat. A review of the policy titled Resident Call System dated March 2023 revealed no procedure for routine checks of call light placement.

Based on record review and interview the facility failed to ensure staff addressed Resident #36 by her given name. This affected one resident (#36) out of three residents reviewed for resident rights. The facility census was 85. Findings include: Review of the medical record for Resident #36 revealed an admitted [DATE]. Diagnoses included atrial fibrillation, trans ischemic attacks (TIA), obstructive sleep apnea (OSA), anxiety, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had intact cognition. The resident required extensive assistance of two staff members for bed mobility. Resident #36 required extensive assistance of one staff member for eating, toileting, and personal hygiene. Resident #36 was totally dependent on one staff member for wheelchair mobility. Interview on 08/22/23 at 3:30 P.M. with the Administrator revealed State tested Nursing Assistant (STNA) #801 admitted to calling all the female residents he cares for beautiful or other terms of endearment. The Administrator stated she educated STNA #801 on calling residents anything other than their name was against the resident's rights and should only address residents by their given name. The Administrator stated STNA #801 did not do this maliciously and only wanted to make the residents feel good about themselves. Interview on 08/22/23 at 3:45 P.M. and 08/24/23 at 12:00 P.M. with Resident #36 revealed STNA #801 called her beautiful on 08/17/23 while getting her ready for bed. She stated she would rather be called by her first name. Interview on 08/24/23 at 1:24 P.M. with STNA #801 revealed he admitted to calling Resident #36 beautiful, and stated he called all the female residents beautiful or other terms of endearment, so they feel good about themselves. He did not mean this in a sexual way or to demean the resident in any way. He stated he did receive education on resident rights and to address all residents by their given names. Review of STNA #801's personal record revealed education completed on 08/17/23 on addressing residents by their given names and not as Beautiful or other terms of endearment.

Based on record review and interview the facility failed to maintain a complete and accurate medical record for Resident #36. This affected one resident (#36) out of three resident records reviewed. The facility census was 85. Findings include: Review of the medical record for Resident #36 revealed an admitted [DATE]. Diagnoses included atrial fibrillation, trans ischemic attacks (TIA), obstructive sleep apnea (OSA), anxiety, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had intact cognition. The resident required extensive assistance of two staff members for bed mobility. Resident #36 required extensive assistance of one staff member for eating, toileting, and personal hygiene. Resident #36 was totally dependent on one staff member for wheelchair mobility. Review of Resident #36's progress notes from 07/24/23 to 08/23/23 revealed there was no documentation of the resident's allegation of sexual assault in her medical record. There was no documented evidence of the physician being notified or of the investigation in progress in her medical record. Interview with the Administrator on 08/22/23 at 3:30 P.M. revealed she confirmed there was no documentation of the allegations, the investigation in progress, or notification made to the physician. She stated the physician was notified and the Nurse Practitioner (NP) saw Resident #36 on 08/21/23. The Administrator stated she nor the Director of Nursing charted the incident and should of. Review of the facility investigation dated 08/17/23 revealed the physician was notified and the NP saw Resident #36 on 08/21/23.

Based on interview, observation, record review, review of the Centers for Disease Control and Prevention (CDC) guidance and policy review, the facility failed to ensure staff covered or changed their N95 masks or cleansed their goggles after exiting a room of a resident on droplet isolation precautions. This affected two residents (Resident #287 and #289) of four residents (Resident #2, #287, #288 and #289) on droplet isolation droplet precautions. This had the potential to affect all 82 residents. Findings include: 1. Review of the medical record for Resident #289 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the immunization record for Resident #289 revealed he did not have the COVID-19 vaccination. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 08/05/21 revealed Resident #289 was on droplet precautions related to guidelines for quarantine due to recent hospitalization . Interventions included wear appropriate PPE per policy and provide all services in the room while in isolation. 2. Review of the medical record for Resident #287 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the immunization record for Resident #287 revealed he did not have the COVID-19 vaccination. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 08/06/21 revealed Resident #287 was on droplet precautions related to guidelines for quarantine due to recent hospitalization . Interventions included wear appropriate PPE per policy and provide all services in the room while in isolation. Observation and interview on 08/11/21 at 10:35 A.M. with Housekeeper #490 revealed she was cleaning recently vacated room [ROOM NUMBER] in the Blue Zone (isolation zone) behind the plastic barrier. She revealed she had already cleaned Resident #289 and Resident #287's rooms who were on droplet isolation precautions. She revealed she wore the same N95 mask into each room and did not cover or change her mask between any of the rooms in the Blue Zone. She revealed she only changed her N95 mask after she completed cleaning all the rooms in the Blue Zone. She revealed she wore the same goggles as well into each room and did not sanitize her goggles between any of the rooms in the Blue Zone as they were all on respiratory droplet precautions. She revealed she only sanitized her goggles after leaving the Blue Zone. She revealed she did change her gown and gloves between each room. Observation on 08/11/21 at 10:49 A.M. revealed Physical Therapy Assistant (PTA) #513 and Certified Occupational Therapy Assistant (COTA) #514 were in #287's room performing therapy. They had on PPE including a gown, gloves, N95 mask and goggles. PTA #513 came out of Resident #287's room after doffing her gown, gloves and performed hand hygiene. PTA #513 continued to wear the same N95 mask and goggles as she unzipped the plastic barrier to the Blue Zone and exited to obtain Resident #287 a drink from the kitchen and proceeded back and handed the drink through the plastic barrier to COTA #514 and proceeded to leave the area. Interview on 08/11/21 at 10:53 A.M. with PTA #513 verified she did not change her N95 mask or sanitize her goggles after exiting Resident #287's room who was on respiratory droplet precautions. She stated she usually does not cover or change her N95 mask after being in rooms that were on respiratory droplet precautions as she did not know she needed to do this. Observation on 08/11/21 at 12:34 P.M. revealed State tested Nursing Assistant (STNA) #492 donned gloves, gown, N95, and goggles prior to entering the Blue Zone to pass lunch trays to Resident #287 and Resident #289 who were on droplet isolation precautions. Activities #467 passed Resident #287's tray through the plastic barrier to STNA #492. She went into Resident #287's room and assisted with setting up his tray and exited Resident #287's room. She doffed the gloves, gown, and performed hand hygiene. She continued to wear the same N95 and goggles without sanitizing. STNA #492 then obtained Resident #289's tray from Activities #467 and went into Resident #289's room. She donned a gown and gloves but continued to wear the same N95 mask and goggles into #289's room and assisted with setting up his tray. Upon exiting Resident #289 room, STNA #492 doffed her gloves, gown and performed hand hygiene. STNA #492 then exited the Blue Zone out the plastic barrier and changed her N95 mask in the doffing room and then proceeded down the hall. STNA #492 was not observed to change or sanitize her goggles. Interview on 08/11/21 at 12:41 P.M. with STNA #492 verified she did not cover or change her N95 mask or sanitize her goggles between passing trays to Resident #287 or Resident #289. She verified she never changed her N95 mask or placed anything over her N95 masks between any of the rooms in the Blue Zone and she only changed her N95 after coming out of the plastic barrier. She verified she never sanitized her goggles between rooms on the Blue Zone. STNA #492 revealed she only changed her N95 mask when she came out of the Blue Zone. She verified she did not sanitize her goggles between rooms while passing the trays or upon exiting the Blue Zone plastic barrier as she stated there were no wipes to clean her goggles. Interview on 08/11/21 at 1:57 P.M. with Registered Nurse/ Infection Control Nurse #404 verified they do not train the staff to place anything over their N95 mask or change their N95 masks when staff entered or exited any of the resident rooms in the Blue Zone. She verified the staff go room to room with the same N95 mask for all the residents on the Blue Zone who are on droplet precautions due to being new admissions and were not vaccinated against COVID-19. She verified upon exiting the Blue Zone staff were to change their N95 mask. She also verified the facility does not train to sanitize their goggles between room to room of any residents on the Blue Zone, but staff should sanitize their goggles when they exit the Blue Zone. Interview on 08/11/21 at 2:35 P.M. with Registered Nurse/ Infection Control Nurse #404 stated the staff do not change their N95 mask after exiting a resident on droplet precautions as they were in crisis capacity and utilized the same N95 mask for all residents on the Blue Zone who were on respiratory droplet precautions as preventative measure. She verified staff should have sanitized their goggles upon exiting a resident room on droplet precautions. Interview on 08/11/21 at 2:46 PM with Registered Nurse/ Infection Control Nurse #404 revealed they had 1200 N95 masks in the facility. Observation and interview on 08/11/21 at 3:29 P.M. with Housekeeping Supervisor/ Central Supply #430 showed multiple boxes of approximately 1200 N95 masks. She revealed she had never had an issue with ordering and receiving any PPE including N95 masks. Interview on 08/12/21 at 11:20 A.M. with Regional Nurse #511 and Registered Nurse/ Infection Control Nurse #404 verified they do not train staff to change or cover their N95 masks between any residents residing on the Blue Zone who were on droplet isolation precautions. They revealed they train the staff to change their N95 mask upon exiting the Blue Zone, and PTA #513 should have changed her N95 mask. They verified staff should have sanitized or changed their goggles after coming out of a room of a resident on droplet isolation precautions and after exiting the Blue Zone. They verified they did not have any documentation of issues purchasing or receiving PPE including N95 masks. Review of facility policy labeled Isolation- Categories of Transmission- Based Precautions, dated January 2012, revealed droplet precautions for an individual documented or suspected to be infected with microorganism transmitted by droplets such as coughing, sneezing, talking, or by the performance of procedures such as suctioning. The policy revealed to put on a mask when entering the room or cubicle. The policy does not include any information regarding removing the mask upon exiting the room, wearing of goggles or face shield or the cleansing of goggles or face shield upon exiting the room. Review of CDC guidance labeled Responding to COVID-19 Considerations for the Public Health Response to COVID-19 in Nursing Homes, dated 04/30/20, revealed managing new admissions and readmissions whose COVID-19 status is unknown included options of placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. The guidance revealed all recommended COVID-19 PPE should be worn during care of residents under observation, which included use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Review of facility policy labeled COVID-19 Donning and Doffing, dated 12/14/20, revealed the purpose of the policy was to provide guidance during donning and doffing of PPE and to prevent the spread of COVID-19. The policy identified zone areas in the facility and the Blue Zone was for residents on 14-day quarantine who were asymptomatic. The policy revealed PPE would be donned and doffed in resident room or designated area. The policy revealed usage of gown in the Blue Zone were required to be resident specific due to risk of cross contamination. The policy revealed any PPE that became soiled or defective would be disposed of and replaced immediately. The policy did not include covering or changing of N95 mask upon exiting a room of a resident on droplet precautions or changing or sanitizing goggles after being in a room of a resident on droplet precautions. This deficiency substantiates Master Complaint Number OH 771.

Based on observation, record review and interview the facility failed to ensure Resident #41's medications were administered as ordered on [MEDICAL TREATMENT] days. This affected one resident of one resident reviewed for [MEDICAL TREATMENT] services. Findings include: Review of Resident #41's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #41 had a BIMS score of 15 indicating the resident was alert, oriented and cognitively intact. Review of a [MEDICAL TREATMENT] care plan revised on 03/04/19 revealed Resident #41 received [MEDICAL TREATMENT] services Tuesdays, Thursdays and Saturdays at 6:15 A.M. Care plans for diabetes, hypertension and acid reflux disease revealed medications were to be given as ordered. Review of Resident #41's physician orders [REDACTED]. one time a day for health maintenance, an order dated 11/21/18 for [MEDICATION NAME] 25 mg one tablet by mouth two times a day for hypertension, an order dated 11/21/18 for NAME] 40 mg one tablet by mouth two times a day for acid reflux, an order dated 11/21/18 for sevelamer [MEDICATION NAME] 800 mg with meals one tablet by mouth for health maintenance and an order dated 11/21/18 for insulin, [MEDICATION NAME] 100 units per milliliter (unit/ml) to be injected per sliding scale subcutaneously three times a day for diabetes and orders for the sliding scale included: if (blood glucose reading) was 71 to 150 (milligrams per deciliter (mg/dL)) administer zero units; if blood glucose was 151 to 200 mg/dL administer two units; if blood glucose was 201 to 250 mg/dL administer four units; if blood glucose was 251 to 300 mg/dL administer six units; if blood glucose was 301 to 350 mg/dL administer eight units; if blood glucose was 351 to 400 mg/dL administer 10 units and if blood glucose was over 400 mg/dL the physician was to be notified. Review of [MEDICAL TREATMENT] monitoring sheets for Resident #41 for (MONTH) 2019 revealed the resident was out of the facility for [MEDICAL TREATMENT] on 02/02/19, 02/05/19, 02/07/19, 02/09/19, 02/12/19, 02/14/19, 02/16/19, 02/19/19, 02/21/19, 02/23/19, 02/26/19 and 02/28/19. Review of Resident #41's medication administration records (MARs) for (MONTH) 2019 revealed the record was marked with a 3 indicative of absence from home and showed Resident #41 did not receive the 8:00 A.M. scheduled doses of [MEDICATION NAME] on 02/09/19, 02/14/19, 02/19/19, 02/23/19, 02/26/19 or 02/28/19; did not receive folic acid on 02/09/19, 02/14/19, 02/19/19, 02/23/19, 02/26/19 or 02/28/19; did not receive the renal vitamin on 02/09/19, 02/14/19, 02/19/19, 02/23/19, 02/26/19 or 02/28/19; did not receive vitamin D3 on 02/09/19, 02/14/19, 02/19/19, 02/23/19, 02/26/19 or 02/28/19; did not receive [MEDICATION NAME] on 02/09/19, 02/14/19, 02/19/19, 02/23/19 or 02/26/19; did not receive NAME] on 02/05/19, 02/09/19, 02/14/19, 02/19/19, 02/23/19, 02/26/19 or 02/28/19; did not receive sevelamer [MEDICATION NAME] on 02/02/19, 02/05/19, 02/07/19, 02/09/19, 02/12/19, 02/14/19, 02/16/19, 02/19/19, 02/21/19, 02/23/19, 02/26/19 or 02/28/19; and did not receive [MEDICATION NAME]on 02/02/19, 02/05/19, 02/09/19, 02/12/19, 02/16/19, 02/21/19, 02/23/19 or 02/26/19. Review of [MEDICAL TREATMENT] monitoring sheets for Resident #41 for (MONTH) 2019 revealed the resident was out of the facility for [MEDICAL TREATMENT] on 03/02/19, 03/05/19, 03/07/19, 03/09/19 and 03/12/19. Review of Resident #41's MARs for (MONTH) 2019 revealed the resident did not receive the scheduled morning doses of [MEDICATION NAME] on 03/05/19 or 03/12/19; did not receive folic acid on 03/05/19 or 03/09/19; did not receive renal vitamin on 03/05/19 or 03/09/19; did not receive vitamin D3 on 03/05/19, 03/09/19 or 03/12/19; did not receive [MEDICATION NAME] on 03/05/19, 03/09/19 or 03/12/19; did not receive NAME] on 03/05/19, 03/09/19 or 03/12/19; did not receive sevelamer [MEDICATION NAME] on 03/05/19, 03/07/19, 03/09/19 and 03/12/19; and did not receive [MEDICATION NAME]on 03/02/19, 03/05/19, 03/07/19, 03/09/19 or 03/12/19. Interview on 03/13/19 at 1:46 P.M. with the Director of Nursing (DON) verified Resident #41's medications identified above were not administered prior to [MEDICAL TREATMENT] on the dates listed. Interview on 03/13/19 at 3:49 P.M. with Licensed Practical Nurse (LPN) #100 revealed she routinely cared for Resident #41. When asked about the administration of the resident's morning medications prior to [MEDICAL TREATMENT], LPN #100 stated most of the medications scheduled at 8:00 A.M. were vitamins and were not given. Review of the facility's [MEDICAL TREATMENT] policy, revised (MONTH) (YEAR), revealed no guidance regarding medication administration timing for residents receiving [MEDICAL TREATMENT].

Based on record review and interview, the facility failed to ensure accurate Minimum Data Set (MDS 3.0) assessments for two residents (Resident #28 and Resident #72). This affected two of 21 residents reviewed for MDS 3.0 assessments. The facility census was 96. Findings include: 1. Review of Resident #28's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. The directions for the [MEDICATION NAME] injection indicated the medication was used for DM (Diabetes Mellitus). An additional order dated 11/30/17 directed to do accu-checks (check blood sugars) twice daily for diabetes. A nutrition care plan dated 09/05/17 indicated that Resident # 28 had the potential for altered nutrition status related to type II diabetes mellitus. Review of the MDS 3.0 assessment dated [DATE] did not indicate diabetes as an active diagnosis; the prior MDS 3.0 assessments dated 10/25/17, 09/27/17, 09/13/17 and 09/06/17 also did not list diabetes as an active diagnosis. Interview on 01/25/18 at 11:47 A.M. with the Director of Nursing (DON) and the MDS Coordinator verified that Resident # 28 had diabetes and confirmed that diabetes had not been coded on Resident # 28's MDS assessment. The DON and the MDS Coordinator and were unable to provide further rationale for the error as the prior MDS Coordinator was no longer employed by the facility. 2. Review of Resident #72's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #72 Minimum Data Set ((MDS) dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of the MDS dated [DATE] revealed no documented falls with or without injury. Review of Resident #72's progress note dated 09/11/17 revealed Resident #72 was involved in an altercation with another resident and fell sideways into the wall and slid to the floor with his back against the wall. Head to toe assessment completed, injury noted. Interview on 01/25/18 at 11:02 A.M. with the Minimum Data Set (MDS) Nurse #1 verified the MDS dated [DATE] failed to indicate any resident falls during the previous two to six week period. The MDS Nurse #1 stated the 09/11/17 incident should have been included in the MDS documentation on 10/10/17.

Based on observation, interview, policy review and record review the facility failed to follow hydration plan of care for residents. This affected three of thirty six residents reviewed for accuracy of plans of care (Residents #7, #72, and #85). Findings include: 1. Review of Resident #85's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #85's Hydration Care Planned Intervention dated 01/24/17 revealed to keep water pitcher at bedside within reach filled with water and ice. Review of Resident #85's physician orders [REDACTED]. Observation on 01/23/18 at 9:49 A.M. revealed no water, pitcher or ice was observed in Resident #85's room. Interview on 01/23/18 at 5:00 P.M. with Registered Nurse (RN) # 101 confirmed no water pitcher was at Resident #85's bedside with water and ice as indicated in the resident's care plan. 2. Review of Resident #72's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #72's Hydration Care Planned Intervention dated 03/08/16 revealed to keep water pitcher at bedside within reach filled with water and ice. Review of Resident #72's physician orders [REDACTED]. Interview and observation on 01/23/18 at 5:00 P.M. with RN #101 confirmed no water pitcher was at Resident #72's bedside with water and ice as indicated in the resident's care plan. 3. Review of Resident #7's medical records revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's Hydration Care Planned Intervention dated 08/09/17 revealed to include keep the water pitcher at bedside within reach and filled with water and ice. Review of physician's orders [REDACTED]. Interview and observation on 01/23/18 at 5:00 P.M. with RN #101 confirmed Resident #7's had no water pitcher with water and ice at the resident's bedside as indicated in the resident's care plan. Review of the Hydration Policy and Procedure date May 2004 indicated each resident will be given a water pitcher upon admission unless contraindicated by the physian order or diagnoses.

Based on observation, record review, and interview the facility failed to ensure accurate medical records in the area of supplements. This affected one of three residents reviewed for nutrition (Resident #33). Findings Include: Record review of Resident #33 admitted [DATE] with [DIAGNOSES REDACTED]. Review of the physician order [REDACTED]. Minimum Data Assessment MDS dated [DATE] revealed Resident #33 was cognitive intact with no behaviors or moods present. Resident #33 required supervision for eating. Review of quarterly dietary assessment on 12/5/17 revealed trending weight loss. Interview on 01/24/18 at 1:48 P.M. with Resident #33 revealed Boost supplement was not given with her breakfast this morning and seldom receives boost with breakfast. Observation on 01/24/18 at 5:20 P.M. of Resident #33 revealed supplement was not served with dinner tray and there was no supplement served before or after meal. Observation on 01/25/18 7:22 A.M. of Resident #33 revealed supplement was not served with breakfast. Interview at this time with Resident #33 revealed the nurse provides the Boost supplement. Additional Interview on 01/25/18 at 8:18 A.M. with Resident #33 revealed the nurse did not provide Boost Supplement due to none available. Interview on 01/25/18 08:26 AM with Director of Nursing (DON) revealed the facility has Boost available for residents. Supplement are to be given then signed off at the time of administration in the Medical Record Review (MAR) with the amount consumed. Additional interview with DON on 01/25/18 at 8:32 A.M. states the nurse did realize she signed off the supplement as given but did not provide supplement. Review of January, 2018 MAR indicated [REDACTED].