Every finding on record at Ayden Healthcare of Piqua

Based on observations, staff interview, and review of the facility policy, the facility failed to ensure food was stored and prepared in a sanitary manner. This had the potential to affect all of the residents residing in the facility with the exception of one facility-identified resident (#79) who had a diet order for nothing by mouth. The facility census was 76 residents. Findings include: 1. Observation on 06/23/25 at 8:03 A.M. revealed employee drinks were stored on dry stock shelves and on top of a box of straws. Interview 06/23/25 at 8:03 A.M. with Dietary Supervisor (DS) #208 confirmed employee personal items should be stored in a way to prevent contamination and should not be stored with the residents' food items or supplies. 2. Observation on 06/23/25 at 8:04 A.M. of the dish machine revealed that it reached 155 degrees Fahrenheit (F) for the wash cycle and 174 degrees F for the final rinse. Interview with DS #208 on 06/23/25 at 8:06 A.M. confirmed the temperature for the wash cycle was 155 degrees F and the temperature for the final rinse was 174 degrees. Review of the dish machine temperature log for June 2025 revealed that the dish machine final rinse cycle reached 180 degrees only once on 06/05/25. All other final rinse temperatures were recorded as being from 170 degrees F to 179 degrees F. There were no water temperatures recorded for the following dates: 06/08/25, 06/19/25, 06/20/25, 06/21/25, and 06/22/25. Interview on 06/23/25 at 8:07 A.M. with DS #208 confirmed the majority of final rinse temperatures recorded for June 2025 did not reach 180 degrees F as required and there were missing water temperatures on the following dates: 06/08/25, 06/19/25, 06/20/25, 06/21/25, and 06/22/25. Review of the facility policy titled Cleaning Dishes/Dish Machine dated 2021 revealed for high temperature dish machines the wash temperature must be between 150 degrees F to 165 degrees F with the final rinse temperature at 180 degrees F. 3. Observation on 06/23/25 at 8:08 A.M. revealed there was an empty soda bottle stored on the clean dish rack with clean bowls stored on the bottom. Interview on 06/23/25 at 8:08 A.M. with DS#208 verified that the soda bottle belonged to an employee, and the dishes underneath were clean. 4. Observation on 06/23/25 at 8:12 A.M. of the walk-in cooler revealed it contained an unlabeled and undated peanut butter cake Interview on 06/23/25 at 8:12 A.M. with DS #208 confirmed the cake was made the day before and did not have a label or a date. Review of the facility policy titled Food Storage dated 2021 revealed all refrigerated foods should be covered, labeled, and dated and routinely monitored to assure that foods would be consumed by their safe use by dates or discarded. 5. Observation on 06/23/25 at 8:15 A.M. revealed the guard inside the ice machine had scratches in the plastic with a black residue. Interview on 06/23/25 at 8:15 A.M. with DS #208 confirmed the guard to the ice machine was scratched and had a black residue. Observation on 06/24/25 at 2:48 P.M. revealed DS #208 scrubbed the ice machine guard in the areas that had the black residue with a white cloth. Observation of the cloth revealed dark spots where it was used to clean the guard. Interview on 06/24/25 at 2:49 P.M. with DS #208 confirmed the black residue transferred onto the cloth, but she was unable to completely remove the residue from the guard to the ice machine. 6. Observation on 06/23/25 at 11:35 A.M. revealed [NAME] #377 used her gloved hands to move the lunch tray cart and then began preparing plates for the residents. [NAME] #377 touched and placed biscuits on residents' plates with the same gloved hands. Interview on 06/23/25 at 11:45 A.M. with [NAME] #377 confirmed she touched the cart with her gloved hands and did not change her gloves afterwards. [NAME] #377 confirmed she touched the biscuits with her gloved hands and that she normally used a utensil when handling food.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure members of the Interdisciplinary Team (IDT) were present at care conferences and failed to conduct care conferences as required. This affected five (Residents 16, #24, #28, #38, and #70) of five residents reviewed for care conferences. The facility census was 76 residents. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 03/17/25 with diagnoses including acute kidney failure, hypertension, dehydration, morbid obesity, and congestive heart failure. Review of the care conference summary for Resident #24 dated 03/20/25 revealed the participants included the resident and Social Service Director (SSD) #215. There were no other IDT members present. Interview on 06/24/25 03:20 P.M with SSD #215 confirmed she was the only IDT member present at Resident #24's admission care conference on 03/20/25. 5. Review of the medical record for Resident #16 revealed an admission date of 05/14/25 with diagnoses including cellulitis to left lower limb, acute thrombosis of left popliteal vein, and diabetes mellitus with a discharge date of 06/06/25. Review of a care conference summary for Resident #16 dated 05/19/25 revealed the resident and SSD #215 attended the care conference. Review of the summary revealed it did not include documentation of SSD #215's review of medications, therapies, or treatments with Resident #16. Interview on 06/25/25 at 8:32 A.M. with SSD #215 confirmed an initial care conference was conducted with Resident #16 on 05/19/25. SSD #215 confirmed the attendees to care conference included the SSD and the resident with no other members of the IDT in attendance. SSD #215 stated she discussed discharge plans with Resident #16 at the care conference on 05/19/25, but she did not review medications, treatments, or therapy services provided with the resident. Review of the facility policy titled Care Conferences revised January 2020 revealed the facility's Care Planning/IDT was responsible for the development of an individualized comprehensive plan for each resident. The policy stated care conferences would be scheduled to include the resident, resident's representative and IDT as soon as possible after admission, routinely, and with a change in condition. Members of the IDT included Registered Nurse (RN), Dietary Manager, Social Service, therapists, nursing assistants, and others as appropriate or necessary to meet the needs of the resident. 2. Review of the medical record for Resident #28 revealed an admission date of 01/14/23 with diagnoses including hemiplegia and hemiparesis following cerebral infraction, major depressive disorder, and type two diabetes mellitus. Review of the medical record for Resident #28 revealed care conferences were completed on 08/30/24 and 03/28/25. Interview on 06/25/25 at 12:15 P.M. with SSD #215 confirmed care conferences should be completed quarterly and the facility only completed two care conference in the prior year for Resident #28 on 08/30/24 and 03/28/25. 3. Review of the medical record for Resident #38 revealed an admission date of 03/22/22 with diagnoses including Huntington's disease, major depressive disorder, and anxiety disorder. Review of the medical record for Resident #38 revealed care conferences were completed on 09/06/24 and 12/13/24. Interview on 06/25/25 at 12:14 P.M. with SSD #215 confirmed only two care conferences had been completed for Resident #38 in the past year on 09/06/24 and 12/13/24. 4. Review of the medical record for Resident #70 revealed an admission date of 11/25/24 with diagnoses including metabolic encephalopathy, type two diabetes mellitus, Alzheimer's disease, and depression. Review of the medical record for Resident #70 revealed care conferences were completed on 11/29/24 and 12/10/24. Interview on 06/25/25 at 9:57 A.M. with SSD #215 confirmed only two care conferences had been completed for Resident #70 in the past year on 11/29/24 and 12/10/24.

Based on medical record review, staff interview, review of the facility policy, and review of online resources per the Centers for Disease Control and Prevention (CDC), the facility failed to administer antibiotic medications with appropriate indication for use. This affected one (Resident #13) of seven residents reviewed for medications. The facility census was 76 residents. Findings include: Review of the medical record for Resident #13 revealed an admission date of 09/26/24 with diagnoses including Alzheimer's disease, hypertension, chronic kidney disease, type two diabetes, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment for Resident #13 dated 04/03/25 revealed the resident was severely cognitively impaired. Review of physician's orders for Resident #13 revealed an order dated 09/27/24 for an antibiotic, nitrofurantoin oral capsule 50 milligrams (mg), give one capsule by mouth with meals one time a day for urinary tract infection (UTI) prevention. Review of a pharmacy recommendation for Resident #13 dated 06/18/25 revealed the resident #13 was receiving nitrofurantoin for prophylaxis of UTIs. The pharmacy report suggested there was a higher proportion of spontaneous pulmonary reactions, including fatalities, in elderly patients receiving this medication for six months or longer. The pharmacy reports also suggested an increased proportion of severe hepatic reactions, including fatalities, in elderly patients and there was a potential for renal impairment with nitrofurantoin and was also considered a high-risk medication for elderly patients according to Centers for Medicare and Medicaid Services (CMS) since safer alternatives existed. The pharmacist requested the physician to consider changing or discontinuing this medication if it was appropriate. The pharmacy recommendation was signed on 06/24/25 by the physician who agreed to discontinue the nitrofurantoin. Review of Resident #13's medical record revealed it did not include documentation per the physician regarding the rationale for the long-term use of nitrofurantoin. Interview on 06/24/25 at 3:04 P.M. with Assistant Director of Nursing (ADON) #203 confirmed Resident #13 had been on nitrofurantoin since admission on [DATE] for UTI prophylaxis, and the antibiotic order did not have an end date. ADON #203 stated nitrofurantoin was discontinued for Resident #13 per a pharmacy recommendation on 06/24/25. Interview on 06/25/25 at 9:01 A.M with ADON #203 confirmed Resident #13's record did not include documentation per the resident's physician outlining the rationale for the long-term use of nitrofurantoin. Review of the facility policy titled Antibiotic Stewardship dated August 2025 revealed the purpose of the antibiotic stewardship program was to monitor the use of antibiotics. If an antibiotic was indicated, prescribers would provide complete antibiotic orders including the following elements: drug name, dose, frequency of administration, duration of treatment with start and stop date or number of days of therapy, route of administration, indications for use. Review of online guidance per the CDC titled The Core Elements of Antibiotic Stewardship for Nursing Homes Appendix A: Policy and Practice Actions to Improve Antibiotic Use page 7 retrieved online on 07/08/25 at https://www.cdc.gov/antibiotic-use/hcp/core-elements/nursing-homes-antibiotic-stewardship.html revealed surveys of antibiotic use in nursing homes had shown UTI prophylaxis accounted for a significant proportion of antibiotic prescriptions, but very few studies supported antibiotic use for UTI prophylaxis, especially in older adults, and many studies had shown this antibiotic exposure increased the risk of side effects and resistant organisms. Therefore, efforts to educate providers on the potential harm of antibiotics for UTI prophylaxis could reduce unnecessary antibiotic exposure and improve resident outcomes.

Based on medical record review, observation, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure accurate coding of a Minimum Data Set (MDS) assessment. This affected one (Resident #54) of two residents reviewed for dental/oral status. The facility census was 76 residents. Findings include: Review of the medical record for Resident #54 revealed an admission date of 11/01/23 with diagnoses including right hemiparesis, dysphagia, hypertension, seizure disorder, and diabetes mellitus. Review of a dental note for Resident #54 dated 03/20/24 revealed the resident was seen by the dentist and 10 teeth were extracted. The note indicated the resident's remaining teeth would need to be extracted and the physician clearance form was left at the facility. Review of the annual MDS assessment for Resident #54 dated 11/07/24 revealed the resident was edentulous. Review of a dental assessment for Resident #54 dated 02/05/25 revealed the resident had some teeth in all four quadrants. Review of the MDS assessment for Resident #54 dated 04/20/25 revealed the resident had severely impaired cognition, required supervision with eating, required substantial/maximum staff assistance with oral hygiene, and no oral or dental issues. Observation on 06/24/25 at 11:44 A.M. of Resident #54 revealed several teeth noted to upper and lower jaws. Observation on 06/25/25 at 7:14 A.M. of Resident #54 with Director of Nursing (DON) revealed the resident had several teeth to upper and lower jaw. Interview on 06/25/25 at 7:15 A.M with the DON confirmed Resident #54 had several teeth to the upper and lower jaw and the facility utilized the RAI manual for guidance on coding of MDS assessments. Interview on 06/25/25 at 7:42 A.M. with MDS Nurse #205 confirmed the annual MDS for Resident #54 dated 11/07/24 indicated the resident was edentulous. MDS Nurse #205 also confirmed the facility dental assessment dated [DATE] indicated Resident #54 had teeth and was not edentulous. Review of the Long-Term Care Facility RAI 3.0 User's Manual dated October 2024 page L-1 to L-2 revealed to code a resident edentulous the resident would lack all natural teeth or parts of teeth.

Based on medical record review, observation, resident representative interview, staff interview, and review of the facility policy, the facility failed to provide routine dental services. This affected one (Resident #54) of two residents reviewed for dental services. The facility census was 76 residents. Findings include: Review of the medical record for Resident #54 revealed an admission date of 11/01/23 with diagnoses including right hemiparesis, dysphagia, hypertension, seizure disorder, and diabetes mellitus. Review of the dental note for Resident #54 dated 03/20/24 revealed the resident was seen by the dentist and had 10 teeth extracted. Further review revealed Resident #54's remaining teeth would need to be extracted, and physician clearance was left at the facility. Review of the dental note for Resident #54 dated 09/30/24 revealed the dentist was in the facility but the resident was not seen because the planned services were unable to be completed in the resident's room. Review of the dental assessment for Resident #54 dated 02/05/25 revealed the resident had some teeth in all four quadrants. Review of the Minimum Data Set (MDS) assessment for Resident #54 dated 04/20/25 revealed the resident had severely impaired cognition, required supervision with eating, and required substantial/maximum staff assistance with oral hygiene. Interview on 06/23/25 at 9:52 A.M. with Resident #54's representative confirmed the resident was supposed to have his remaining teeth pulled a long time ago so the resident could get dentures. Resident #54's Representative stated they did not know when Resident #54 was last seen by the dentist. Observation on 06/25/25 at 7:14 A.M. of Resident #54 with the Director of Nursing (DON) revealed the resident had several teeth to upper and lower jaw. Interview on 06/25/25 at 7:20 A.M. with the DON confirmed Resident #54 had some teeth pulled in 03/20/24 and was supposed to have his remaining teeth pulled after physician clearance. The DON confirmed Resident #54 had not been seen by the dentist since 03/20/24. Review of the facility policy titled Dental Services revealed the facility would arrange for routine and emergency dental services to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Routine and 24-hour emergency dental services were provided to the residents through a contract agreement with a licensed dentist that came to the facility monthly, a referral to a personal dentist, a referral to community dentist, or a referral to other health care organizations that provide dental services. A social service representative would assist residents with appointments, transportation arrangements, and reimbursement of dental services under the state plan, if eligible.

Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure medications were stored properly. This affected one (Resident #37) of the five residents observed for medication storage. The facility census was 76 residents. Findings include: Review of the medical record for Resident #37 revealed admission date of 10/24/24 with diagnoses including systemic lupus erythematosus, major depressive disorder, chronic respiratory failure with hypoxia and rheumatoid arthritis. Review of the Minimum Data Set (MDS) assessment for Resident #37 dated 03/31/25 revealed the resident was cognitively intact and required staff set-up with activities of daily living (ADLs.) Observation on 06/25/25 at 3:20 P.M. of Resident #37's room revealed the resident was seated in her chair with the bedside table directly in front of her. On the bedside table there was a bottle of over the counter (OTC) vitamins with a letter M written in black marker on the lid. Interview on 06/25/25 at 3:22 P.M. with Licensed Practical Nurse (LPN) #207 confirmed there was a bottle of OTC vitamins on the resident's bedside table which had been brought in per the resident's daughter. LPN #207 removed the medication from the bedside table and confirmed the vitamins should be stored in an area accessible only to staff. Review of the facility policy titled Medication Storage undated revealed medications should be stored in a manner that was only accessible to authorized personnel.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to develop accurate person-centered comprehensive care plans. This affected one (Resident #54) of two residents reviewed for dental/oral status. The facility census was 76 residents. Findings include: Review of the medical record for Resident #54 revealed an admission date of 11/01/23 with diagnoses including right hemiparesis, dysphagia, hypertension, seizures, and diabetes mellitus. Review of the person-centered comprehensive care plan for Resident #54 dated 11/13/23 revealed the resident was at risk for oral/dental problems related to being edentulous. Review of the annual Minimum Data Set (MDS) assessment for Resident #54 dated 11/07/24 revealed the resident was edentulous. Review of a dental assessment for Resident #54 dated 02/05/25 revealed the resident had some teeth in all four quadrants. Review of the MDS assessment for Resident #54 dated 04/20/25 revealed the resident had severely impaired cognition, required supervision with eating, required substantial/maximum staff assistance with oral hygiene, and no oral or dental issues. Observation on 06/25/25 at 7:14 A.M. of Resident #54 with Director of Nursing (DON) revealed the resident had several teeth to upper and lower jaw. Interview on 06/25/25 at 7:15 A.M with the DON confirmed Resident #54 had several teeth to the upper and lower jaw Interview on 06/25/25 at 7:42 A.M. with MDS Nurse #205 confirmed Resident #54's annual MDS dated [DATE] and person-centered comprehensive care plan indicated Resident #54 was edentulous. MDS Nurse #205 also confirmed the facility dental assessment dated [DATE] indicated Resident #54 had teeth and was not edentulous. MDS Nurse #205 confirmed the facility had not developed a comprehensive care plan regarding the resident's dental needs. Review of the policy titled Care Planning dated 04/28/22 revealed the facility's care planning/interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident.

Based on medical record review, observation, staff interview, and review of manufacturer guidelines, the facility failed to ensure staff primed insulin pen devices prior to insulin administration resulting in significant medication errors. This affected one (Resident #46) of the three residents observed for medication administration. The facility census was 76 residents. Findings include: Review of the medical record for Resident #46 revealed an admission date of 07/13/21 with diagnoses including type two diabetes mellitus, major depressive disorder, hypertension, obstructive sleep apnea, and morbid obesity. Review of the physician's orders for Resident #46 revealed an order dated 12/11/24 for insulin lispro with meals an order dated 02/06/25 for Lantus insulin in the morning. Observation on 06/25/25 at 7:55 A.M. of medication administration for Resident #46 per Licensed Practical Nurse (LPN) #345 revealed the nurse attached a new needle to a Lantus insulin pen and dialed the dose to 52 units and administered the injection to the resident. LPN #345 then attached a new needle to a lispro insulin pen and the dialed the dose to 18 units and administered the injection to the resident. LPN #345 did not prime the pens prior to administration of Lantus insulin and lispro insulin to Resident #46. Interview on 06/25/25 at 7:57 A.M. with LPN #345 confirmed she did not prime the insulin pens prior to administration to Resident #46. Review of manufacturer instructions for the Lantus insulin pen undated revealed to always perform a safety test before each injection to insure an accurate dose. To ensure the pen and needle worked properly and the pen was free of air bubbles, the nurse should take the following steps: select a dose of two units, take off the outer needle cap and keep it to remove the used needle after injection, take off the inner needle cap and discard it, hold the pen with the needle pointing upwards, tap the insulin reservoir so that any air bubbles rise up towards the needle, press the injection button all the way in, check to see if insulin comes out of the needle tip. The nurse may have to perform the safety test several times before insulin is seen. Review of manufacturer instructions for the Lispro insulin pen undated revealed the nurse should prime the pen before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensure that the insulin pen is working correctly. If the nurse did not prime before each injection it could result in the resident getting too much or too little insulin.

Based on medical record review and staff interview, the facility failed to ensure a resident Preadmission Screening and Resident Review (PASARR) evaluations were accurate and updated. This affected one (Resident #2) of the two residents reviewed for PASARR evaluations. The facility census was 76 residents. Findings include: Review of the medical record for Resident #2 revealed an admission date of 03/11/21 with diagnoses including anxiety disorder, post-traumatic stress disorder (PTSD), psychotic disorder with delusions, bipolar disorder, major depressive disorder, and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 05/07/25 revealed the resident was moderately cognitively impaired. Review of the PASARR for Resident #2 dated 03/11/21 revealed the resident had no diagnoses of mental disorders listed in section-D (indication of serious mental Illness). A box was checked no for having any of the mental disorders listed which included schizophrenia, mood disorder, delusional (paranoid) disorder, panic or other severe anxiety disorder, somatoform disorder, personality disorder, other psychotic disorder, and another mental disorder other than mental retardation that may lead to a chronic disability. Further review of Resident #2's medical record revealed no documentation of an updated PASARR being completed. The diagnosis of PTSD was added 02/21/21, the diagnosis of bipolar disorder was added 03/11/21, and the diagnosis of psychotic disorder with delusions was added 05/01/25. Interview on 06/24/25 at 3:20 P.M. with Social Services Director (SSD) #215 confirmed Resident #2's PASARR dated 03/11/22 was not accurate, and the facility had not completed an update PASARR to include the mental health diagnoses which were added for the resident.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide cares/services to dependent residents to maintain adequate personal hygiene. This affected one (Resident #6) of the three residents reviewed for activities of daily living (ADLs). The facility census was 76 residents. Findings include: Review of the medical record for Resident #6 revealed an admission date of 01/11/19 with diagnoses including chronic obstructive pulmonary disease, schizoaffective disorder-bipolar type, and depression. Review of the Minimum Data Set (MDS) assessment for Resident #6 dated 05/12/25 for the resident had severely impaired cognition and required moderate staff assistance with personal hygiene. Observation on 06/23/25 at 1:46 P.M. of Resident #6 revealed the resident had gray facial hair on her chin. Interview on 06/23/25 at 1:47 P.M. with Resident #6 confirmed she had gray facial hair on her chin and sometimes staff removed her facial hair, but they had not done so in a long time. Observation on 06/24/25 at 11:43 A.M. revealed Resident #6 had gray facial hair on her chin Interview on 06/24/25 at 11:47 A.M with Certified Nursing Assistant (CNA) #335 confirmed Resident #6 had gray facial hair on her chin. CNA #335 stated staff were expected to trim the facial hair for both men and women on shower days and as needed. Interview on 06/25/25 at 1:27 P.M. with the Director of Nursing (DON) confirmed staff were expected to provide residents with assistance with facial hair removal as needed even if the resident refused showers. Review of the facility policy titled Activities of Daily Living dated 04/28/25 revealed appropriate care and services would be provided for residents who were unable to carry out ADLs independently with the consent of the resident and in accordance with the care plan to include assistance with hygiene. Residents who were unable to carry out ADLs independently would receive services necessary to maintain good personal hygiene.

Based on medical record review and staff interview, the facility failed to schedule timely ophthalmology appointments for residents. This affected one (Resident #28) of 21 residents sampled. The facility census was 76 residents. Findings include: Review of the medical record review for Resident #28 revealed an admission date of 01/14/23 with diagnoses including hemiplegia and hemiparesis following cerebral infraction, major depressive disorder, and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #28 dated 05/22/25 revealed the resident was cognitively intact. Review of the progress note for Resident #28 dated 06/04/25 revealed the resident was examined by the facility eye doctor who gave a referral to an ophthalmologist for cataract surgery. Review of the medical record for Resident #28 dated 06/04/25 to 06/25/25 revealed it did not include documentation regarding scheduling the resident for a consultation with an ophthalmologist. Interview on 06/25/25 at 11:55 A.M. with Certified Nursing Assistant (CNA) #326 confirmed she was responsible for scheduling outside doctor appointments and transportation. CNA #326 further confirmed she was aware of Resident #28's referral for ophthalmology, but she had not contacted the ophthalmology office and had not scheduled an appointment for Resident #28.

Based on record review, staff interview, observation, review of online resources from Centers for Disease Control and Prevention (CDC), and review of facility policy, the facility failed to provide adequate infection control techniques during a resident's dressing change. This affected one (#20) resident of the three residents reviewed for infection control. The facility also failed to ensure staff properly discarded personal protective equipment (PPE) after completing a resident's dressing change who was in Enhanced Based Precautions (EBP). This had the potential to affect the 19 other residents (#01, #02, #03, #04, #05, #06, #07, #08, #09, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19) housed on the 100-hall who the facility identified as not being in EBP. The facility census was 80. Findings included: Review of record revealed Resident #20 had admission date on 03/17/25. Diagnoses included orthopedic aftercare from surgical amputation left leg below knee, acute osteomyelitis in left ankle and foot, and left leg below the knee, and acute kidney failure. Review of a physician order for Resident #20 dated 03/18/25, revealed the resident was ordered to have his coccyx wound cleansed with saline wound wash, patted dry, calcium alginate applied and covered with a superabsorbent dressing every day. Review of a Minimum Data Set (MDS) dated [DATE] revealed Resident #20 had a Brief Interview of Mental Status (BIMS) of 14 which indicated he was cognitively intact. Resident #30 required substantial to maximal assistance for activities of daily living (ADLs). Review of a physician order for Resident #20 dated 03/25/25, revealed the resident was ordered to be in Enhanced Barrier Precautions (EBP) due to pressure wounds and a wound on the right leg. Review of the plan of care dated 04/13/25, revealed Resident #20 had a pressure ulcer (a pressure ulcer is a localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) to the coccyx related to immobility. Interventions included administer medication as ordered, administer treatments as ordered, stay in EBP related to wounds, weekly treatment documentation to include measurement of each area of skin breakdowns. Review of a weekly skin assessment dated [DATE], revealed Resident #20 had a pressure ulcer on his coccyx which measured 2.1 centimeters (cm) in width by 1.1 cm in length by 0.1 in depth and categorized as a stage three pressure ulcer (full-thickness skin loss in which adipose [fat] is visible). The resident had a second wound on his left thigh related to a surgical incision which measured 8.3 cm in width by 1.2 cm in length by 0.2 cm in depth. Observation of wound care for Resident #20 on 04/29/25 from 10:58 A.M. through 11:14 A.M. with Registered Nurse (RN) #288, revealed the resident was able to turn himself to his right hip and assist with positioning. RN #288 washed her hands, applied personnel protective equipment (PPE) and gloves. RN #288 cleansed the resident's coccyx wound with four-by-four gauzes and normal saline spray. RN #288 placed the contaminated four-by-four gauzes on top of the resident's uncovered bedside table. RN #288 then took her scissors and cut the new calcium alginate dressing and applied it to the resident's wound bed. RN #288 never removed her contaminated gloves nor completed any hand hygiene before moving from a dirty area to a clean when completing the dressing change. Interview at the same time, RN #288 verified she didn't change gloves nor completed any hand hygiene when going from an area of dirty to clean wound care. RN #288 discarded the wound dressing items, removed her gloves and discarded, and exited the resident's room with her PPE (gown) in place. RN #228 placed her gown in the housekeeper's cart trash can located in the 100-hallway and RN #288 continued down the 100-hall. Interview on 04/29/25 at 11:15 A.M. with Housekeeper Director #300 verified RN #288 placed her gown in the mobile housekeeping cart trash bag after leaving Resident #20's room. A subsequent interview on 04/29/25 at 11:45 A.M. with RN #288, verified Resident #20 was in EBP. RN #288 stated she was not thinking when she exited the resident's room and discarded the PPE gown in the housekeeper's mobile cart trash bag. RN #288 stated she should have taken off her gown inside the resident's room and discarded it. Interview on 04/29/25 at 1:05 P.M. with Regional Nurse (RN) #350, revealed her expectations would be for all nurses to follow the appropriate infection control techniques. RN #350 stated she would expect a nurse to change their gloves and perform hand hygiene, when going from an area of dirty to clean, while completing dressing changes. RN #350 stated staff should not be discarding their PPE outside of a resident's rooms who were in EBP. Review of facility policy titled Enhanced Barrier Precautions dated 04/01/24, revealed the facility was required to have PPE including gowns and gloves available. PPE must be removed and discarded in the residents' room. Position a trash can inside the resident's room and near the exit for discarding PPE after removal and prior to exit of the room. Review of the facility policy titled Wound Care dated 08/2024, revealed staff shall complete wound care/ dressing changes using the appropriate infection control techniques. Remove old dressing and appropriately discard then wash and dry hands thoroughly before starting the new dressings. Review of the web site titled https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html dated 03/20/24 revealed that hand washing matters, and recommended immediately before touching a patient, before performing an aseptic task such as placing an indwelling device or handing invasive medical devices, between working on a soiled body site and a clean body site on the same patient, after touching a patient or patient's surroundings, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal.

Based on medical records, observation, staff interviews, review of employee training records, review of employee personnel files, review of manufacturer guidelines for a sit-to-stand lift, and review of facility policy, the facility failed to safely transfer a resident using a sit-to-stand lift. This affected one (#30) resident of the three residents reviewed for transfers. The facility identified three residents were dependent on staff for transfers. The facility census was 80. Findings included: Review of the medical record for Resident #30 revealed an admission date 11/25/24. Diagnoses included metabolic encephalopathy, muscle weakness, unsteadiness on feet, type two diabetes, and multiple fractures of ribs. Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was severely cognitively impaired as evidence by a Brief Interview of Mental Status (BIMS) of 02. Resident #30 was dependent on staff for transfers and required substantial to maximal assistance for other activities of daily living (ADLs). Review of the plan of care for Resident #30 dated 02/26/25, revealed the resident had ADL self-care performance deficit related to Alzheimer's and limited mobility. Interventions included transfer with assistance from staff. Observation of a transfer for Resident #30 on 04/17/25 at 11:30 A.M. with Certified Nursing Assistant (CNA) #245 and CNA #200, revealed Resident #30 was assisted to a sitting position on the side of the bed. CNA #245 then placed a yellow (medium sized for residents weighing between 121 and 165 pounds) sit-to-stand sling around the resident. The sling was situated approximately one inch under the right arm and approximately three inches under the left arm. The sling could not be secured properly across the resident's chest as there was an approximate eight-inch gap between the sides of the sling and the straps were directly on the resident's bare chest. Interview on 04/17/25 at 11:45 A.M. with CNA #245, verified the yellow sling used on Resident #30 did not fit correctly which could have led to the resident slipping out the sling during the transfer. CNA #245 verified the yellow sling was a medium and the resident required a large sling. Interview on 04/17/25 at 1:33 P.M. with Physical Therapy Assistant (PTA) #219, revealed she provided training to the staff for the sit-to-stand lift when Resident #30 was assessed for needing therapy. PTA #219 stated she demonstrated the proper techniques to the staff, then had the staff sign a form verifying they were educated. PTA #219 stated Resident #30 required a large sling for safe transfers. PTA #291 stated the yellow sling used on the resident was a medium and it was too small for Resident #30. Interview on 04/17/25 at 1:51 P.M. with CNA #200, verified Resident #30 was placed in a yellow sling which was too small and not the appropriate size for Resident #30. Interview on 04/17/25 at 4:30 P.M. with Assisted Director of Nursing (ADON) #322, revealed the staff should have used the large green sling which was to be used on residents weighing between 154 to 254 pounds. ADON #322 verified Resident #30 was 249 pounds. Review of the facility policy titled Mechanical Lift Transferring dated 08/2021, revealed two nursing staff members will be used for all mechanical lift transfers and transfers that were done smoothly and safely using the appropriate equipment. Review of a facility form titled Mechanical Sling Lift for CNA #245, revealed staff would place a sling under a resident and visually check that sling is not too large or too small. CNA #200 was checked off for properly completing a sit-to-stand lift transfer on 01/05/24. Review of a facility form titled Mechanical Sling Lift for CNA #200, revealed staff would place a sling under a resident and visually check that sling is not too large or too small. CNA #200 was checked off for properly completing a sit-to-stand lift transfer on 09/09/24. Review of employee personnel file for CNA #245, revealed a hire date of 07/13/23. The employee personnel file contained a documented titled Employee Disciplinary Program indicated STNA #245 was given a verbal counseling for improperly transferring a resident using the sit-to-stand on 03/28/25 Review of the facility document titled Sling Color and Size Guide undated, revealed adults that weighed between 154 and 254 pounds, should have the green sling utilized when being transferred via the sit-to-stand lift. Review of manufacturer instructions for the sit-to-stand lift titled SARA 3000, revealed the residents will be placed in the appropriate fitting sling for safe and effective transfer. This deficiency represents non-compliance investigated under Complaint Number OH00164223.

Based on resident interview, review of the Certification and Licensure System (CALS), medical record review, staff interview, and review of facility policy, the facility failed to investigate an allegation of inappropriate staff touching as potential resident abuse. This affected one resident (#38) of three residents reviewed for abuse. The facility census was 83. Findings include: Review of Resident #38's medical record revealed an admitted [DATE]. Diagnoses included chronic respiratory failure, morbid (severe) obesity and Type II diabetes. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #38 was cognitively intact, required set-up assistance with eating and oral hygiene, partial staff assistance with bed mobility and transfers, and substantial staff assistance with toileting hygiene, bathing, dressing, personal hygiene, and wheelchair mobility. Review of the physician orders revealed an order dated 02/22/25 for No Male Care for showers every shift for Post traumatic Stress Disorder (PTSD). Review of the care plan, dated 03/15/25, revealed Resident #38 preferred no male staff for showers, with a goal to not receive showers from male staff. Interventions included to keep a list of no male showers in the schedule book and respect resident's preference and carry them out while resident is in the facility. Interview on 03/18/25 at 11:01 A.M. with Resident #38 revealed a male Certified Nursing Assistant (CNA) had touched her inappropriately on two occasions. Further interview confirmed the male CNA was CNA #174. Resident #38 was unable to recall the date of the first incident but reported CNA #174 tickled her under her arms when she had her shirt on, which she did not like and it made her uncomfortable. Resident #38 stated she reported it at that time. Resident #38 reported that about one week ago, CNA #174 again tickled her under her arms. This time she had no shirt on. Resident #38 stated she did not like CNA #174 touching her under her arms, near her breasts, and she felt uncomfortable. Resident #38 stated she reported her concerns to the Director of Nursing (DON). The resident confirmed CNA #174 had not been back in her room but she was uncomfortable when he was around. Review of the facility submitted Self-Reported Incidents (SRIs) from 02/01/25 through 03/17/25, located in CALS, revealed no evidence the facility reported Resident #38's allegations of inappropriate staff touching. Interview on 03/18/25 at 12:09 P.M. with the Administrator verified there was no incident of inappropriate staff touching/potential abuse involving Resident #38 reported to the ODH. Interview on 03/18/25 at 1:45 P.M. with the Director of Nursing (DON) verified Resident #38 reported to her that CNA #174 had tickled her under her arms while she had clothing on, and then again when she had no clothing on. The DON further confirmed Resident #38 reported the incidents made her uncomfortable. The DON verified the incidents were not reported to the ODH and the facility did not conduct an investigation into the allegations because she did not take the resident's concerns as potential abuse. The DON stated Resident #38's request to not have a male staff assist with showers following the incidents with CNA #174 was honored and CNA #174 was moved to another unit. A follow-up interview on 03/18/25 at 1:59 P.M. with the Administrator confirmed the incidents involving Resident #38's allegations of CNA #174 touching her inappropriately were never reported to him and further verified the facility did not conduct an investigation. The Administrator stated CNA #174 was related to the DON and the DON changed CNA #174's assignment so that he no longer worked with Resident #38. Interview on 03/18/25 at 2:45 P.M. with CNA #174 confirmed he was no longer able to provide care for Resident #38, although he stated he was unsure of why. CNA #174 stated the resident asked him to scratch her back, by her arms, and that was all he did. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/24/22, revealed residents have the right to be free from abuse. It was the facility's policy to investigate all alleged violations involving abuse. This deficiency represents non-compliance investigated under Complaint Number OH00163436.

Based on medical record review, resident interview, review of the Certification and Licensure System (CALS), staff interview and review of facility policy, the facility failed to report an allegation of inappropriate staff touching as potential resident abuse to the Ohio Department of Health (ODH). This affected one resident (#38) of three residents reviewed for abuse. The facility census was 83. Findings include: Review of Resident #38's medical record revealed an admitted [DATE]. Diagnoses included chronic respiratory failure, morbid (severe) obesity and Type II diabetes. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #38 was cognitively intact, required set-up assistance with eating and oral hygiene, partial staff assistance with bed mobility and transfers, and substantial staff assistance with toileting hygiene, bathing, dressing, personal hygiene, and wheelchair mobility. Review of the physician orders revealed an order dated 02/22/25 for No Male Care for showers every shift for Post traumatic Stress Disorder (PTSD). Review of the care plan, dated 03/15/25, revealed Resident #38 preferred no male staff for showers, with a goal to not receive showers from male staff. Interventions included to keep a list of no male showers in the schedule book and respect resident's preference and carry them out while resident is in the facility. Interview on 03/18/25 at 11:01 A.M. with Resident #38 revealed a male Certified Nursing Assistant (CNA) had touched her inappropriately on two occasions. Further interview confirmed the male CNA was CNA #174. Resident #38 was unable to recall the date of the first incident but reported CNA #174 tickled her under her arms when she had her shirt on, which she did not like and it made her uncomfortable. Resident #38 stated she reported it at that time. Resident #38 reported that about one week ago, CNA #174 again tickled her under her arms. This time she had no shirt on. Resident #38 stated she did not like CNA #174 touching her under her arms, near her breasts, and she felt uncomfortable. Resident #38 stated she reported her concerns to the Director of Nursing (DON). The resident confirmed CNA #174 had not been back in her room but she was uncomfortable when he was around. Review of the facility submitted Self-Reported Incidents (SRIs) from 02/01/25 through 03/17/25, located in CALS, revealed no evidence the facility reported Resident #38's allegations of inappropriate staff touching. Interview on 03/18/25 at 12:09 P.M. with the Administrator verified there was no incident of inappropriate staff touching/potential abuse involving Resident #38 reported to the ODH. Interview on 03/18/25 at 1:45 P.M. with the Director of Nursing (DON) verified Resident #38 reported to her that CNA #174 had tickled her under her arms while she had clothing on, and then again when she had no clothing on. The DON further confirmed Resident #38 reported the incidents made her uncomfortable. The DON verified the incidents were not reported to the ODH because she did not take the resident's concerns as potential abuse. The DON stated Resident #38's request to not have a male staff assist with showers following the incidents with CNA #174 was honored and CNA #174 was moved to another unit. A follow-up interview on 03/18/25 at 1:59 P.M. with the Administrator confirmed the incidents involving Resident #38's allegations of CNA #174 touching her inappropriately were never reported to him. The Administrator stated CNA #174 was related to the DON and the DON changed CNA #174's assignment so that he no longer worked with Resident #38. Interview on 03/18/25 at 2:45 P.M. with CNA #174 confirmed he was no longer able to provide care for Resident #38, although he stated he was unsure of why. CNA #174 stated the resident asked him to scratch her back, by her arms, and that was all he did. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/24/22, revealed residents have the right to be free from abuse. Facility staff should immediately report all such allegations to the Administrator and to the ODH. This deficiency represents non-compliance investigated under Complaint Number OH00163436.

Based on medical record review, staff interview, and facility policy review, the facility failed to have physician visits and nurse practitioner visits notes signed in a timely manner. This affected three (#06, #34, and #60) of three residents reviewed for provider visits. The facility census was 84. Findings include: 1. Medical record review for Resident #06 revealed he was admitted to the facility on [DATE]. Diagnoses included myocardial infarction, diabetes mellitus, pulmonary embolism, essential primary hypertension, hyperlipidemia, respiratory failure, obstructive sleep apnea, major depressive disorder, pleural effusion chronic kidney disease, hernia, and morbid obesity. Review of the Minimum Data Set (MDS) assessment, dated 02/10/25, revealed Resident #06 was cognitively intact. Review of the progress notes for Resident #06 revealed he was assessed by the facility physician on 02/11/25; however, the document was not signed until 02/15/25. Further review revealed Resident #06 was assessed by Nurse Practitioner (NP) #500 on 02/13/25 and the document was not signed until 02/22/25. 2. Medical record review for Resident #34 revealed she was admitted to the facility on [DATE]. Diagnoses included, multiple sclerosis, hypothyroidism, neurogenic bowel, constipation, hyperlipidemia, gastro-esophageal reflux disease, osteomyelitis, and acute respiratory failure. Review of the MDS assessment, dated 01/03/25 revealed Resident #34 was cognitively intact. Review of the physician progress notes for Resident #34 revealed she was assessed by the physician on 01/06/25; however, the physician note was not signed by the physician until 01/19/25. 3. Medical record review for Resident #60 revealed she was admitted to the facility on [DATE]. Diagnoses included, cerebral infarction, diabetes mellitus, aphasia, morbid obesity, hyperlipidemia, hyperkalemia, dementia, kidney failure, metabolic acidosis, dehydration, and essential primary hypertension. Review of the MDS assessment, dated 02/10/25, revealed Resident #60 had impaired cognition. Review of the physician notes for Resident #60 revealed she was assessed by the physician on 01/28/25; however, the document was not signed by the physician until 02/07/25. Resident #60 was also assessed by the facility physician on 01/14/25 and the document was not signed until 01/17/25. Further review of the progress notes revealed Resident #60 was assessed by the facility physician on 01/06/25 and the document was not signed until 01/19/25. Interview on 02/25/25 at 3:18 P.M. with Assistant Director of Nursing (ADON) #200 stated the facility had several concerns related to the current facility Medical Director. ADON #200 stated the Medical Director gave notice to the facility that she was no longer going to work for the facility and was related to timely documentation of resident physician visits. ADON #200 confirmed Resident #06, Resident #34, and Resident #60 had provider visits that were not signed at the time of the visit. Review of the facility policy titled, Charting and Documentation, dated July 2017, revealed documentation of procedures and treatments should include specific details that include the date and time of the procedure.

Based on record review, observations, staff interviews and review of Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff followed proper infection control procedures during incontinence care. This affected one (#16) out of three residents review for infection control. The facility census was 82. Findings include: Review of medical record for Resident #16 revealed admitted [DATE]. Diagnoses include chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). The resident remained in the facility. Review of Resident #16's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview Mental Status (BIMS) score of eight out of 15 indicating impaired cognition. Resident #16 required set up for eating, maximum assistance with bed, transfers and was dependent for toileting hygiene. Resident #16 was frequently incontinent of bladder and always incontinent of bowel. Observation was made on 12/18/24 at 10:58 A.M. of incontinence care by Certified Nursing Assistants (CNA's) #104 and #105 for Resident #16. Resident #16 was assisted to her left side and CNA #104 was observed to thoroughly cleanse her of stool. Without removing her gloves, CNA #10 placed a new incontinence product under Resident #16 and encouraged her to lay on her back. CNA #105 then cleansed Resident #16's peri area. Just prior to applying the new incontinence product, CNA #104 grabbed two more wet wipes and cleaned her peri area. Interview on 12/18/24 at 11:23 A.M. with CNA #105 verified she did not remove her gloves after cleaning stool and used the soiled gloves when cleaning Resident #16's peri area. CNA #105 acknowledged she should have removed her gloves and washed her hands after cleaning stool. Review of guidelines from the CDC for Healthcare Providers for Hand Hygiene, located at https://www.cdc.gov/clean-hands/hcp/clinical-safety/?CDC_AAref_Val=https://www.cdc.gov/handhygiene/providers revealed the need to change gloves and clean hands if moving from work on a soiled body site to a clean body site. This deficiency represents non-compliance investigated under Complaint Number OH00160272.

Based on review of facility infection control records, observations, staff interviews, review of electronic mail (e-mail) correspondence, review of facility policies and procedures, review of the Center for Disease Control and Prevention CDC) guidance, and review of Ohio Department of Health's (ODH) guidance for reporting infectious diseases, the facility failed to develop and implement effective infection control policies and practices which includes a failure to ensure cleaning schedules for ice buckets were developed/implemented, failure to ensure storage areas were maintained in a sanitary manner to potentially prevent rodent/animal contamination, failure to ensure the handwashing sink in the kitchen was appropriately functioning, failure to develop written policies and procedures which included when and to who potentially communicable diseases should be reported, and failure to ensure the local health department was notified in a timely manner of a Campylobacter illness outbreak. This affected a total of nine (Resident #10, #32, #43, #45, #48, #54, #61, #65 and #66) residents who experienced gastrointestinal symptoms, five of which (Resident #10, #32, #48, #61 and #66) tested positive for Campylobacter. This had the potential to affect all 67 residents residing in the facility. The facility census was 67. Findings include: Review of the facility infection control records for a 2024 gastrointestinal outbreak revealed the onset of the outbreak was 03/12/24 and the reporting date was 04/01/24. The facility had nine (#10, #32, #43, #45, #48, #54, #61, #65 and #66) residents who experienced gastrointestinal illness including symptoms of vomiting and/or diarrhea (loose stools) from 03/12/24 through 03/31/24. On 03/12/24, Resident #66 experienced loose stools. On 03/17/24, Resident #32 experienced loose stools. On 03/18/24, Resident #10 experienced both vomiting and loose stools. On 03/22/24, Resident #45 experienced vomiting. On 03/25/24, Resident #61 experienced loose stools. On 03/27/24, Resident #65 experienced loose stools. On 03/30/24, Resident #43 experienced loose stools and Resident #48 experienced both vomiting and loose stools. On 03/31/24, Resident #54 experienced loose stools. Five (#10, #32, #48, #61 and #66) residents tested positive for Campylobacter Further review of the infection control records revealed the facility had five (Director of Nursing (DON), State tested Nursing Assistant (STNA) #220, Licensed Practical Nurse (LPN) #312, Registered Nurse #223 and #300) staff members who experienced gastrointestinal illness including symptoms of vomiting, diarrhea (loose stools), and/or nausea from 03/11/24 through 04/06/24. There were no confirmed cases of Campylobacter among the staff. Initial tour of the facility on 04/11/24 at 8:17 A.M. through 8:35 A.M. with Human Resource Director #246, revealed the kitchen had one sink with soap and hand towels for handwashing but observations revealed the sink did not have working hot water. Observations revealed there was no sign indicating the hot water was not working and/or no sign indicating where staff should wash their hands. While completing the facility tour, an interview on 04/11/24 at 8:33 A.M. with Cook #252, confirmed she was not sure how long the hot water had not been working but knows it has been at least a couple of days. Cook #252 also revealed management has been working on it. Cook #252 revealed staff has been washing their hands in the 3-sink area. Cook #252 confirmed there is no soap or hand towels in 3-sink area, but she just uses what is available in the sink area that is not working. Cook #252 also confirmed other staff members would not know which sink to use unless told because there is not a sign hung to let staff know the hot water is not working and to use the other sink. Interview on 04/11/24 at 10:47 A.M. with Cook #310 confirmed the hot water in the hand washing sink is not working and it hasn't worked for a couple weeks. Cook #310 also confirmed the last Administrator was told it was not working before he left. Cook #310 confirmed staff wash their hands in the 3-compartment sink area and the staff use the hand soap and hand towels available at the hand washing sink which is approximately eight feet away. Cook #310 confirmed the new ice buckets have only been brought to the kitchen one time since 04/08/24 to be run through the dishwasher. Cook #310 is not aware of a cleaning schedule for the ice buckets, which are used to pass ice to the residents. During an interview on 04/11/24 at 11:38 A.M., the DON confirmed the local health department was not notified of the gastrointestinal outbreak until 04/01/24, which was approximately 20 days after the outbreak began. The DON also confirmed there was no policy which specified when and to whom communicable diseases should be reported. The DON also confirmed gloves and Styrofoam cups that were stored in the garage that was contaminated with possible rodents and cat feces and these items were being used. Observations of the storage garage and interview with the DON revealed the area had been cleaned up and there was currently no evidence of rodents or cats in the area. The DON confirmed that new ice buckets have been purchased based on the recent health departments recommendations but there is not a cleaning schedule in place, but there are expectations of the night shift floor staff to take them to the kitchen and change them out nightly for clean ones. The DON confirmed a total of nine (#10, #32, #43, #45, #48, #54, #61, #65 and #66) residents who experienced gastrointestinal symptoms and five (#10, #32, #48, #61 and #66) residents tested positive for Campylobacter. The DON confirmed there were five (DON, STNA #220, LPN #312, RN #223 and #300) staff members who experienced gastrointestinal illness including symptoms of vomiting, diarrhea (loose stools), and/or nausea from 03/11/24 through 04/06/24 but there were no confirmed cases of Campylobacter among these staff members. Interview on 04/11/24 at 2:20 P.M. with LPN #326 confirmed when gloves and Styrofoam cups were needed staff would go to the garage and pull the extra from the stock. LPN #326 confirmed there were evidence in the garage, before all of the outbreak, of cats using the garage as a litter box. LPN #326 confirmed gloves would be worn to pull supplies out of the garage so not to touch any nasty items. Interview on 04/11/24 at 2:39 P.M. with STNA #220 confirmed no knowledge of who's responsible for cleaning the ice buckets on the halls. STNA #220 confirmed the ice buckets are used to pass ice to residents. STNA #220 confirmed gloves and Styrofoam cups were pulled from the garage when it was dirty and had possible animal feces everywhere. Interview on 04/11/24 at 4:11 P.M. with the Administrator confirmed he was not aware of the hot water not working in the hand washing sink in the kitchen until today. The Administrator also confirmed the staff in the kitchen were aware to wash their hands in the prep sink and there was soap available for use. The Administrator confirmed there was no sign at the hand washing sink in the kitchen to inform staff the sink was not working and to use the prep sink. The Administrator confirmed staff members who do not work in the kitchen, would not know to wash their hands elsewhere. The Administrator confirmed the hot water in the hand washing sink was fixed during the investigation. Review of the e-mail correspondence from the local health department, dated 04/01/24, revealed after reviewing the line list, the Campylobacter was the infection with the first positive case being on 03/14/24 and the local health department notification was on 04/01/24. The health department inquired about any other interventions implemented such as staff being kept from work for at least 48 hours past resolution of symptoms. Review of the facility policy titled Infection Prevention and Control Program (IPCP), revised 11/15/21, revealed the IPCP designee should report communicable diseases that are reportable to local/state public health authorities. The policy did not contain specific information regarding when and to whom potentially communicable diseases would be reported. Review of the CDC guidance titled Guideline for the Prevention and Control of Campylobacter Gastroenteritis Outbreaks in Healthcare Settings dated 07/03/23, revealed as with all outbreaks, notify appropriate local and state health departments, as required by state and local public health regulations, if an outbreak of Campylobacter is suspected. Review of ODH guidance titled, Know Your ABCs: A Quick Guide to Reportable Infectious Diseases in Ohio, effective 08/01/19 revealed Campylobacter was listed under the section Class B. Facilities should report an outbreak, unusual incident or epidemic of other diseases by the end of the next business day. This deficiency represents non-compliance investigated under Complaint Number OH00152778.

Based on medical record review, staff interviews, review of the facility Self-Reported Incidents (SRI), and policy review, the facility failed to ensure residents were free from resident-to-resident sexual abuse. This affected two (#11 and #62) out of the three residents reviewed for abuse. The facility census was 71. Findings included: 1. Review of the medical record for Resident #62 revealed an admitted [DATE] with medical diagnoses of Alzheimer's disease, legal blindness, hypertension, and adult failure to thrive. Review of the medical record for Resident #62 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #62 had moderate cognitive impairment and required supervision with eating and substantial staff assistance with toilet hygiene, bed mobility, transfers, and bathing. Review of the medical record for Resident #62 revealed a Social Service note dated 01/11/24 at 2:07 P.M. which stated an attempt was made to contact the resident's power of attorney (POA) to notify him of an incident that occurred today with a male resident. The note stated there was no answer and a message was left requesting a return call. Review of the medical record revealed no further documentation related to an incident on 01/11/24. 2. Review of the medical record for Resident #11 revealed an admitted [DATE] with medical diagnoses of Huntington's disease, mild Intellectual Disabilities, anxiety, and dysphagia. Review of the medical record for Resident #11 revealed a quarterly MDS, dated [DATE], which indicated Resident #11 is sometimes understood, able to understand information, and per staff interview alert and oriented to person, place, and time. Review of the MDS revealed Resident #11 required supervision with eating, transfers, and bed mobility and substantial staff assistance with toilet hygiene and bathing. Review of the medical record for Resident #11 revealed a nurse's note dated 01/15/24 at 8:00 P.M. which stated a staff member notified the nurse that a male resident was observed with his hands on her chest. The note stated Resident #11 was removed from the situation, assessed head to toe, and the Director of Nursing (DON) was notified. Review of the medical record for Resident #11 revealed no documentation related to the incident investigated for the SRI dated 01/11/24. 3. Review of the medical record for Resident #35 revealed an admitted [DATE] with medical diagnoses of Coal worker's pneumonoconiosis, Parkinson's disease, atherosclerotic heart disease (ASHD), and atrial fibrillation. Review of the medical record for Resident #35 revealed a quarterly MDS, dated [DATE], which indicated Resident #35 had moderate cognitive impairment and required substantial/maximum staff assistance with toileting hygiene, bathing, and bed mobility and was dependent for transfers. Review of the medical record for Resident #35 revealed a nurse's note dated 01/11/24 at 12:13 P.M. which stated the nurse was notified that Resident #35 was observed being inappropriate with other female residents. The note stated Resident #35 was observed grabbing at female resident breasts and genital area. Review of the medical record revealed a Social Service note dated 01/11/24 at 1:47 P.M. that Resident #35 was observed by care staff in the dining room grabbing at the breasts of two female residents. The note stated Resident #35 was questioned regarding his behavior and he admitted to touching Resident #11 and Resident #62's breasts but could not state why he did it. Review of the medical record for Resident #35 revealed a physician order dated 01/11/24 for resident to be always visible by staff when not in bed and to document on behaviors every shift. The medical record revealed an order dated 01/12/24 for medroxyprogesterone acetate 10 milligrams one tablet by mouth daily for sexual behaviors. Review of the medical record for Resident #35 revealed a behavior care plan dated 01/12/24 which stated Resident #35 had the potential to be physically aggressive related to history of harm to others and poor impulse control. The interventions included medications as ordered and to document behaviors. 4. Review of the medical record for Resident #75 revealed an admitted [DATE] with medical diagnoses of cerebral infarction with right hemiparesis, chronic obstructive pulmonary disease, depression, and hyperlipidemia. Review of the medical record revealed Resident #75 discharged from the facility on 01/21/24. Review of the medical record for Resident #75 revealed a quarterly MDS, 01/10/24, which indicated Resident #75 was cognitively intact and was independent with eating, bed mobility, transfers, and toilet hygiene. No behaviors were noted on the MDS. Review of the medical record for Resident #75 revealed a nurse's note dated 01/15/24 at 10:30 P.M. which stated Resident #75 was observed touching another female resident inappropriately in the dining room which was witnessed by the dietary staff. Further review of the note stated the DON and Administrator were notified and the police department was contacted. Review of the medical record revealed a nurse's note dated 01/17/24 at 10:34 A.M. which stated a police officer came to the facility to notify Resident #75 he was being charged with a crime related to the incident on 01/15/24. Review of the medical record for Resident #75 revealed a physician order dated 01/15/24 which stated if the resident must be supervised at all times by a staff member when he comes out of his room. Review of the SRI dated 01/11/24 stated Resident #35 was observed by staff to be touching Resident #11 and Resident #62's breasts over the top of their shirts while sitting in the dining room. Review of the SRI revealed an investigation was completed which included resident and staff interviews, resident assessments, and staff education. The SRI stated neither resident had any adverse effects from the incident. The SRI indicated the facility substantiated the allegation of abuse. Review of the SRI dated 01/15/24 stated Resident #75 was observed by staff with his hands down the front of Resident #11's shirt and was touching her breasts. The SRI stated an investigation was completed which included resident and staff interviews, resident assessments, police notification, and staff education on abuse. The SRI indicated the facility substantiated the allegation of abuse. Interview on 01/29/24 at 4:00 P.M. with DON confirmed the facility substantiated the allegation of sexual abuse by Resident #35 to Resident #11 and Resident #62 on 01/11/24 after a thorough investigation. DON also confirmed the facility substantiated the allegation of sexual abuse by Resident #75 to Resident #11 on 01/15/24 after a thorough investigation. Review of the facility policy titled, Abuse and Neglect, revised March 2018, stated sexual abuse was defined as non-consensual sexual contact of any type with a resident. The policy stated the residents would be assessed, the physician would be notified, and the facility management and staff would institute measures to address the needs of residents and minimize the possibility of abuse and neglect. This deficiency represents non-compliance investigated under Complaint Number OH00150359.

Based on medical record review, staff and resident interviews, and policy review, the facility failed to notify residents of room changes. This affected two (#35 and #49) out of the three residents reviewed for room changes. The facility census was 71. Findings included: 1. Review of the medical record for Resident #35 revealed an admitted [DATE] with medical diagnoses of Coal worker's pneumonoconiosis, Parkinson's disease, atherosclerotic heart disease (ASHD), and atrial fibrillation. Review of the medical record for Resident #35 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #35 had moderate cognitive impairment and required substantial/maximum staff assistance with toileting hygiene, bathing, and bed mobility and was dependent for transfers. Review of the medical record for Resident #35 revealed Resident #35 moved rooms on 11/28/23. Review of the medical record revealed no documentation to support Resident #35 was notified or approved of the room change. Interview on 01/29/24 at 3:30 P.M. with Director of Nursing (DON) confirmed the facility moved Resident #35 rooms and the medical record did not contain documentation to support Resident #35 was made aware of the room change or approved the room change. 2. Review of the medical record for Resident #49 revealed an admitted [DATE] with medical diagnoses of chronic obstructive pulmonary disease, adult failure to thrive, chronic respiratory failure, and protein calorie malnutrition. Review of the medical record for Resident #49 revealed a quarterly MDS, dated [DATE], which indicated Resident #49 was cognitively intact and was independent with eating and bed mobility and supervision with bathing, toilet hygiene, and transfers. Review of the medical record for Resident #49 revealed Resident #49 moved rooms on 12/12/23. Review of the medical record revealed no documentation to support Resident #49 was notified or approved of the room change. Interview on 01/29/24 at 8:53 A.M. with Resident #49 stated that while she was hospitalized from 12/06/23 to 12/20/23 the facility moved her stuff to a different room without notifying her. Interview on 01/29/24 at 3:30 P.M. with DON confirmed the medical record for Resident #49 did not contain documentation to support the facility notified Resident #49 of her room change on 12/12/23 while she was hospitalized from 12/06/23 to 12/20/23. Review of the facility policy titled, Transfer, Room to Room, revised December 2016, stated the facility was to orient the resident to the transfer in a form and manner that the resident can understand and included location of room, who is the new roommate, if any, who would be providing the resident's care, that visitors would be information and why the transfer is taking place. The policy stated the information should be recorded in the resident's medical record include date/time room transfer was made, names and titles of staff who assisted with the move, how the resident tolerated the move, any assessment data obtained during the room move, if the resident refused, the resident why and the intervention taken, and the signature and title of person recording the data. This deficiency represents non-compliance investigated under Complaint Number OH00149671.

Based on medical record review, physician and staff interviews, review of the facility policies and information from the National Pressure Ulcer Advisory Panel, the facility failed to accurately and timely assess a resident's nutritional status with decreased meal intakes, abnormal laboratory values, and two new in-house acquired unstageable pressure ulcers (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar). Additionally, the facility failed to provide a diet to meet the resident's estimated energy and protein needs. Actual Harm occurred to Resident #05 when the facility was providing less calories and protein than the resident's estimated energy and protein needs resulting in the resident losing 4.7 percent weight loss in one month and the two unstageable pressure ulcers deteriorating. This affected one (Resident #05) of three residents reviewed for nutrition. The facility census was 76. Findings include: Closed medical record review for Resident #05 revealed an admitted [DATE]. Diagnoses included cerebral palsy, heart disease with history of malnutrition, stroke, osteopenia, hemiplegia, and hemiparesis. Review of the admission physician orders revealed Resident #05 received a nocturnal nutritional tube feeding. On 07/22/23, the nocturnal nutritional tube feeding was discontinued, and 200 milliliter (ml) water flushes every four hours was started. This would provide a total of 800 ml water daily. Resident #05 was to be on a pureed diet with liquid nutritional supplements 240 ml three times daily. On 07/27/23, the speech therapist was treating Resident #05 and the resident's diet was upgraded to mechanical soft with nectar thickened liquids. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #05 had severely impaired cognition and required extensive assistance from staff with eating. Review of the care plan dated 07/21/23 revealed Resident #05 had the potential for alteration in nutrition/hydration related to altered texture and gastrostomy tube feeding. Interventions were to encourage good nutrition and hydration to promote healthy skin. Review of a comprehensive metabolic panel dated 08/14/23 revealed Resident #05's glucose level was low at 58 milligrams/deciliter (normal was 65 to 99) and albumin was low at 2.8 grams per deciliter (normal was 3.5 to 5.5; indicating low serum protein stores necessary for skin integrity). Review of the nutrition assessment completed by Registered Dietitian (RD) #90 dated 08/31/23 revealed Resident #05 had a decreased appetite with intakes varying from 25-75 percent. Nutritional interventions were to start nutritional ice cream supplements three times daily at meals and the liquid supplements discontinued due to poor acceptance by Resident #05. The nutrition assessment did not mention the abnormal comprehensive metabolic panel dated 08/14/23. Review of the weekly body audit dated 09/09/23 revealed Resident #05 developed two new pressure areas on the sacrum and distal buttocks that were both unstageable wounds. The previous weekly body audit dated 08/28/23 revealed Resident #05's skin was intact. Review of the nutrition assessment by RD #90 completed on 09/29/23 revealed this was first time Resident #05 was nutritionally assessed after Resident #05 developed two unstageable pressure ulcers on 09/09/23. The resident's weight was 149 pounds on 09/01/23 with no weight loss and Body Mass Index (BMI) of 27.2. There was no additional weight recorded for Resident #05 from 09/02/23 to 09/29/23. The resident was dependent on one staff assistance for feeding mechanical soft diet, nectar thickened liquids with nutritional ice cream cups at all meals, with intakes varying from 26 to 100 percent. Resident #05's unstageable pressure ulcers to the sacrum and coccyx were declining. Liquid protein supplements at 30 ml twice daily were recommended for wound support. The resident continued to receive 800 ml of water daily via the gastrostomy tube. The nutrition assessment did not include the calculations of the resident's increased calorie and protein nutritional needs due to the unstageable pressure ulcers, did not accurately reflect the resident's meal intake, and did not mention the abnormal comprehensive metabolic panel dated 08/14/23. Review of Resident #05's weight record revealed the admission weight was 146 pounds on 07/27/23, 148 pounds on 08/10/23, 149 pounds on 09/01/23, and 142 pounds on 10/03/23. On 10/03/23, Resident #05 lost seven pounds (4.6 percent) in one month. Review of the wound documentation dated 10/03/23 revealed Resident #05's two unstageable wounds were combined and Resident #05 now had one unstageable pressure ulcer. The wound measured 7.0 centimeter (cm) in length by 6.8 cm in width and unable to determine depth and the wound had declined. Review of the meal intake records, from the time the two unstageable areas were identified on 09/09/23 until 10/03/23 when Resident #05's pressure areas were deteriorating and the seven pounds weight loss to 142 pounds, revealed Resident #05 was consuming less than half of his meals for 63 of the 80 opportunities which was equivalent to 78.5 percent, 51 to 75 percent of his meal consumed for 14 of the 80 opportunities equivalent to 17.5 percent of his meals and consumed more than 75 percent of his meals only three of the 80 opportunities equivalent to about four percent of his meals. Resident #05's daily estimated nutritional needs during this period were 2,010 kcals based on 30 calories per kilogram body weight, 100 to 134 grams of protein based on 1.5 to 2.0 gram per kilogram of body weight with unstageable pressure areas, and 2,010 ml of fluid based on 30 ml per kilogram of body weight. Based on the meal intake records including meals, nutritional supplements, and snacks, the resident's average daily intake during this period provided approximately 1,200 kilocalories (kcals) (60% of his estimated energy needs) and 42 grams of protein (31 to 42 percent of his estimated protein needs) daily. Review of the nursing progress note dated 10/10/23 revealed the resident's responsible family member contacted the Director of Nursing and expressed concerns Resident #05 was not eating well and he would like the tube feeding restarted. A physician's order for Jevity 1.5 at 60 ml for 12 hours nocturnally with 200 ml water flushes every six hours was initiated on 10/10/23. On 10/10/23, Dietary Technician (Diet Tech) #84 noted the tube feeding provided 1080 calories, 46 grams of protein and a total of 1347 ml of fluid daily. On 10/12/23, Diet Tech #84 noted the resident was not tolerating anything by mouth except nectar thickened liquids and requested the tube feeding be changed to continuous Isosource 1.5 ml at 60 ml plus the water flush. On 10/12/23, Resident #05 was found unresponsive and diagnosed with a urinary tract infection, acute encephalopathy, and hyperammonemia. Telephone interview with Physician #98 on 10/24/23 at 1:30 P.M. revealed Resident #05's pressure areas were not healing, and the resident continued to decline until he was hospitalized on [DATE]. Interview with Registered Nurse (RN) #80 on 10/24/23 at 2:28 P.M. verified Resident #05 received very little nutrition via the tube feeding during his entire stay. Telephone interview with Diet Tech #84 on 10/24/23 at 4:00 P.M. verified she was notified Resident #05 had two unstageable pressure ulcers via electronic mail on 09/13/23 which was communicated to RD #90 on a shared spreadsheet. Diet Tech #84 stated she was in the facility weekly to monitor the resident's nutritional status. Telephone interview with RD #90 on 10/24/23 at 5:08 P.M. revealed she coordinated with Diet Tech #84 and completed assessments for high-risk residents with pressure ulcers, tube feedings and receiving dialysis during her one-to-three-hour monthly visits. RD #90 verified her assessment on 09/29/23 had no new calculations for Resident #05's nutritional needs with the two unstageable pressure ulcers. She verified her recommendation for liquid protein 30 ml twice daily but did not specify the nutrition the supplement would provide to the resident. RD #90 verified her note did not specify calories, protein, and fluid provided to the resident from meals, nutrition supplements and snacks he consumed by mouth. RD #90 stated the resident's seven-pound weight loss from the previous month identified on 10/03/23 was not addressed because it was not considered significant until it was five percent or more weight change. Interview with Cook #92 on 10/25/23 at 8:50 A.M. revealed she was Resident #05's niece. The resident was eating well at home and received a nocturnal tube feeding for years every night prior to his admission. During his stay at the facility, he declined with the pressure ulcers and did not eat well especially the past month. The resident went home from the hospital on 10/24/23. A second telephone interview with RD #90 on 10/26/23 at 9:30 A.M. confirmed she was not aware Resident #05 was consuming 50 percent or less at most meals from 09/09/23 through 0/03/23. RD #90 verified Resident #05 was not consuming enough nutrition to meet his estimated energy and protein needs. RD #90 verified she did not review and address the complete metabolic panel concerning the low glucose and low albumin on 08/14/23. Review of the facility policy titled Nutritional Assessment, revised 2017, revealed a nutritional assessment included the current nutritional status and risk factors for impaired nutrition was conducted for each resident by the multidisciplinary team as indicated by a change in condition that placed the resident at risk for impaired nutrition. The assessment was a process that included gathering and interpreting data, using the data to help define meaningful interventions for the resident at risk including a description of the resident's usual intake and appetite, any reduced appetite or weight loss, recent events that may have affected resident's nutritional status, laboratory results and general appearance of the resident. The need for enteral nutrition was periodically reassessed for appropriateness and effectiveness based on the resident's requirements for nutrient intake. Review of the facility policy titled Pressure Ulcers/Skin Breakdown, revised April 2018, revealed staff should attempt to maintain stable weight and provide 1.2 to 1.5 grams of protein per kilogram of body weight for residents with pressure ulcers. Review of the National Pressure Ulcer Advisor Panel (NPUAP) 2019 revealed nutrition screening should be conducted for those at risk of pressure injury and comprehensive nutrition assessments should be conducted for adults screened to be at risk for malnutrition and at risk of a pressure injury and for all adults with a pressure injury. If nutritional requirement cannot be achieved by normal dietary intake, offer calorie-and protein-fortified foods and/or nutritional supplements to the usual diets of adults at risk for pressure injury and are malnourished/at risk for malnutrition. Provide high-calorie, high protein, arginine, zinc, and antioxidant oral nutritional supplements or enteral formulas to adults with Stage II or greater pressure injury and are malnourished/at risk of malnutrition. Develop and implement individualized nutrition care plans for those with or at risk of a pressure injury and who are malnourished or at risk of malnutrition. This deficiency represents non-compliance investigated under Master Complaint Number OH00147667 and Complaint Number OH00147570.

Based on medical record review, observations, staff interview, and review of facility policy, the facility failed to provide routine oral care to a dependent resident who received tube feedings. This resulted in actual harm when Resident #27, who was dependent on staff for all aspects of care, displayed multiple areas of the lower gums that were observed to be bleeding and swollen with areas of dark brown holes on the teeth extending halfway up the teeth. Resident #27's teeth were observed to have significant yellow and gray build up on both the upper and lower natural teeth, that were yellowish gray in color. Resident #27's tongue was observed to be dry and pale pink in color. Resident #27's both upper and lower lips were discolored (a deep maroon color) with dry flaky skin. This affected one (#27) of one resident reviewed for gastronomy tube management. The facility identified two residents with a gastronomy tube. The facility census was 72. Findings include: Medical record review for Resident #27 revealed an admitted on 12/08/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #27 revealed the resident had severely impaired cognition, required total assist for bed mobility, transfers, eating and toileting, is incontinent of bowel and bladder and has natural teeth. Review of the plan of care for Resident #27 dated 06/24/19 revealed the resident has potential for oral dental health problems related to dependence on staff for care. Interventions include apply lip balm/ointment as needed, coordinate arrangements for dental care, and provide oral care as needed. Review of the dental summary report for Resident #27 revealed the resident was seen on 07/07/21 by a dental hygienist who documented resident was semi-cooperative today due to increased head movement. Hygienist documented heavy calculus with moderate plaque and recommended assistance from staff for daily hygiene. Further review of the document revealed Resident #27 was unable to be seen on 01/20/22 due to testing positive for COVID-19 and remains in isolation. Additionally, the document noted a dentist visit on 04/15/22 and documented refused. No other documentation was made related to the visit. Review of the oral/dental evaluation dated 07/06/22 for Resident #27 revealed no recent oral examination, and resident did not refuse the dentist. Further review of the assessment revealed no natural teeth or tooth fragments present, no dentures, and that resident is dependent and is brushing adequately. Further review of the medical record revealed no documentation of refusal of oral care. Review of the monthly physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #27 has a gastronomy tube placed and receives all nutritional support via enteral feedings. Observation on 08/30/22 at 9:55 A.M., revealed Resident #27 in bed with mouth open. Resident #27 opened eyes when called by name. Resident #27 was unable or unwilling to respond to verbal questions. Resident #27 was moving the head up, to the side and down constantly during observation. Resident #27 had multiple areas of the lower gums that were observed to be bleeding and swollen with areas of dark brown holes on the teeth extending halfway up the teeth. Resident #27's teeth were observed to have significant yellow and gray build up on both the upper and lower natural teeth, that were yellowish gray in color. Resident #27's tongue was observed to be dry and pale pink in color. Resident #27's both upper and lower lips were discolored (a deep maroon color) with dry flaky skin. Further observations revealed disposable toothettes (oral swab-stick) on the bedside table next to Resident #27. Interview on 08/30/22 at 10:10 A.M., with State tested Nursing Assistant (STNA) #67 assigned to Resident #27 verified she did not complete oral care this morning for the resident. STNA #67 verified the discoloration of the lips, tongue and the significant debris accumulations around all teeth. Interview on 08/30/22 at 10:15 A.M. with Licensed Practical Nurse (LPN) #52, verified Resident #27 had significant buildup of matter on all teeth both upper and lower that was discolored yellow and brown. Furthermore, LPN #52 verified Resident 27's teeth had visible areas of missing enamel on the bottom front teeth. LPN #52 verified the resident's gums were red and swollen. Interview on 08/31/22 at 12:04 P.M., with the Assistant Director of Nursing (ADON) verified the resident lips were dry and bleeding at multiple sites of the gums and the teeth had buildup of yellow and brown matter covering the bottom one third of lower teeth and on both the upper and lower jaws. Interview on 08/31/22 at 12:46 P.M. with Minimum Data Set (MDS) Licensed Practical Nurse (LPN) #15, revealed she was reviewing the care plans yesterday and added a statement in the focus that the resident was resistant at times. LPN #15 verified she has taken care of the resident in the past and the resident is resistant to any care involving the face. MDS LPN #15 verified the resident chart does not include any documentation regarding the resistant behaviors, but she has taken care of her in the past and she will pull away from the caregiver. LPN #15 further verified the MDS assessment does not include any rejection of care. LPN #15 was unable to recall what day she provided care for the resident. Observation on 08/31/22 at 1:10 P.M. of oral care provided by LPN #52, revealed the resident turning her head to the right, then down and then to the left but allowed LPN #52 to complete the task. LPN #52 stated she can complete mouth care when she is assigned to the resident about every four hours. Resident #27's lips were soft and without flaky dry maroon colored skin, tongue was moist, but still with dry tissue lifting at the edges of the tongue. There was a heavy amount of yellow brown matter covering the teeth that remains. Review of policy titled Activities of Daily Living, dated 03/2018, revealed all care and services will be provided for residents who are unable to carry out tasks independently. Additionally, the policy stated the facility will document the refusals in the resident's clinical record. This deficiency substantiates Complaint Number OH 891.

Based on review of closed and current medical records, review of an Emergency Medical Squad (EMS) report, review of a facility Self-Reported Incident (SRI), review of a facility investigation, interviews with staff and the physician, review of the facility Emergency Management Policy Guidelines, the facility failed to timely initiate Cardiopulmonary Resuscitation (CPR) and timely contact Emergency Medical Services (EMS) for one resident (#5) who was a Full Code and was found unresponsive and without vital signs. Life threatening harm and death occurred when Resident #5 did not receive timely CPR or EMS and expired at the facility. This resulted in Immediate Jeopardy for one (#5) of four residents reviewed for change in condition and death in the facility. The facility identified 49 residents residing in the facility designated with a Full Code status. The total facility census was 72 residents. On [DATE] at 2:35 P.M., the Administrator, Director of Nursing (DON) and Regional Nurse #325 were notified Immediate Jeopardy began on [DATE] at 5:30 P.M., when Resident #5 was found unresponsive. Licensed Practical Nurse (LPN) #360 was informed by State tested Nursing Assistant (STNA) #350 that Resident #5 was unresponsive, and LPN #360 subsequently checked Resident #5 and found the resident to be without a pulse and other vital signs. STNA #350 requested LPN #380 respond to Resident #5's room and LPN #380 confirmed the resident was without vital signs as well; however, neither LPN #360 nor LPN #380 began CPR. STNA #350 provided post mortem care to Resident #5. Hospice Provider #450 was notified of Resident #5's death. The medical record was not reviewed to confirm the resident's code status. Registered Nurse (RN)# 390 was in the facility and upon hearing of Resident #5's death, instructed the LPNs to check the resident medical record to verify the resident's code status. When LPN #360 checked the chart, the resident was discovered to be a Full Code. LPN #360 obtained the crash cart and proceeded to Resident #5's room to initiate CPR and 911 was called. Upon the EMS arrival at the facility, CPR was being performed on Resident #5. Resident #5 was noted by EMS services to be cold to touch, dependent lividity and rigor mortis was beginning to set in. EMS did not initiate care due to obvious signs of death. Resident #5 expired in the facility. The Immediate Jeopardy was removed on [DATE] at 7:00 A.M., when the facility implemented the following corrective actions: · On [DATE] at 6:21 P.M., CPR was initiated on Resident #5. · On [DATE] at 9:30 P.M., an ad hoc Quality Assurance meeting with the Administrator, DON and attendance by the medical director via teleconference was held and the abatement plan was reviewed and accepted. · On [DATE] at 9:55 P.M., LPN #360 was identified as an employee of a staffing agency and was educated by the Administrator regarding the facility Emergency Management Policy Guidelines. · On [DATE] at 9:55 P.M., an all staff education was initiated by the Administrator on the Emergency Management Policy Guidelines which includes the process defining the roles and responsibilities of nursing staff involved in the care of patients in an emergent situation which include physician notification with change in condition. Staff was not to work an assignment until education was completed. · On [DATE], RN #390 began reviewing all current resident's medical records to validate physician orders [REDACTED]. The audit was completed by 10:00 P.M. · On [DATE] at 8:30 A.M., Human Resource Director (HRD) #305 started an audit of all nurse's personnel files to validate an active license and CPR certification with a completion time of 11:30 A.M. · On [DATE] at 10:45 A.M., an audit of the crash cart was conducted and revealed all items were present on the cart needed to perform CPR. · On [DATE], the Unit Managers reviewed and updated current resident's care plans and Kardex with current physician ordered codes status. The audit was completed by 2:10 P.M. · On [DATE], all new employees hired will receive education on the Emergency Management Policy Guidelines which includes the process defining the roles and responsibilities of nursing staff involved in the care of patients in an emergent situation by the Administrator and/or the DON. Additionally, the center will ensure agency staff receive education on the Emergency Management guidelines which included the process and defining the roles and responsibilities of nursing staff involved in the care of the patients in an emergent situation by the DON and or Unit Manager prior to working in the facility. · On [DATE], all staff will be educated on the Emergency Management Policy Guidelines which includes the process defining the roles and responsibilities of nursing staff involved in the care of a patient in an emergent situation by the Administrator or DON or designee prior to working. Staff unable to participate in education will be removed from the schedule until such education has been completed by the DON and or Unit Manager. · On [DATE], the DON or Administrator will begin monitoring code status through the morning interdisciplinary team meeting daily for the next 14 days, then Monday through Friday on an ongoing basis. Areas of deficiency will be submitted to the Quality Assurance Committee and corrected immediately. · On [DATE], the DON will begin completing follow-up after death audits on any death in the facility and the audit will be completed Monday through Friday for thirty days. The floor nurses will call the DON with any death in the facility. · On [DATE] at 7:00 A.M., agency Nurse #397 was educated on the facility Emergency Management Policy Guidelines by HRD #305, prior to working in the facility on her next shift, [DATE] at 7:00 A.M. · On [DATE], review of the follow-up after death audit performed on [DATE] and [DATE], revealed the facility performed emergency management as per their policy for Resident #10 and #30 who expired in the facility. These are the only two deaths that occurred since Resident #5 expired. · On [DATE], the facility identified three other residents (#10, #20, and #30) who had expired in the facility in the last 60 days. The medical records were reviewed for change in condition and death and no concerns were identified. Additionally, four random resident medical records (#31, #32, #33, and #34) were reviewed and physician orders [REDACTED]. · On [DATE] and [DATE], at various times, interviews with RN #320, #360 and LPN #315, and agency LPN #340, revealed the staff have received recent emergency management training in the last few weeks that has included what to do if you find a resident who is unresponsive and without signs of life, where code status is located, and the process to follow to ensure residents are receiving prompt emergent care. The staff were able to verbalize the proper procedure. · On [DATE], review of the facility staffing schedules from [DATE] to [DATE] and the Agency Orientation Check List and Training revealed agency RN #405 worked on [DATE], evening shift, and agency LPN #410 worked on [DATE], [DATE], and [DATE]. The facility had no documented evidence of agency RN #405 and agency LPN #410 as having received training on emergency management prior to them working on the floor at the facility as per the facility's corrective action plan. Although the Immediate Jeopardy was removed on [DATE] when the facility implemented the corrective action plan including training agency staff on the facility's Emergency Management Policy Guidelines for initiating CPR on a resident with a Full Code status prior to working, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for minimal harm that is not Immediate Jeopardy) as the facility is still in the process of monitoring to ensure on-going compliance. Findings include: Review of Resident #5's closed medical record revealed an admission date of [DATE] and a re-admission date of [DATE]. Resident #5 had [DIAGNOSES REDACTED]. Review of the signed admission physician order [REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact, had no delusions, hallucinations or behaviors, was an extensive assist for bed mobility and eating but dependent on staff for all other daily care. The resident was coded as always incontinent of bowel and bladder, as being on a pain management program, as having a life expectancy of less than 6 months, and as receiving hospice services. Review of the advanced directive section of Resident #5's medical record revealed a green colored Full Code paper. The green paper documented the resident's name, FULL CODE and GO in bold letters. Also, under this section was the physician order [REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of the task information document for STNAs revealed the documentation listed the resident as a Full Code. Review of Resident #5's care plan revealed the resident was receiving hospice services for End Stage ALS and as retaining a Full Code status. Review of Hospice admission paper work dated [DATE], revealed the resident was most recently enrolled in hospice benefits with the advanced directive noted as being none. Review of the nurse's progress notes revealed the medical record lacked documented evidence of the resident expiring or the circumstances surrounding the resident's death. Review of the EMS report dated [DATE] revealed the squad was dispatched on [DATE] at 6:22 P.M., were in route at 6:24 P.M. and on the scene at 6:27 P.M. The report revealed the squad was dispatched for a resident in [MEDICAL CONDITION] at a facility. The report revealed the resident was found lying supine in bed in bedroom, with staff performing CPR. Staff stated they found the patient not breathing approximately one-half hour ago. Further assessment revealed the patient to be cold to touch, dependent lividity, and rigor mortis beginning to set in. EMS did not initiate care due to obvious signs of death. The EMS gathered patient information and returned to the station. Review of the facility SRI with an initial submission date of [DATE] and a final close date of [DATE] regarding suspicion of neglect or mistreatment was reviewed. The SRI documented the incident involved an agency LPN #360 as the perpetrator and Resident #5 as the involved resident. The investigation revealed LPN #360 found Resident #5 unresponsive and without vital signs at 5:35 P.M. The SRI indicated the LPN notified the hospice provider and first emergency contact of Resident #5's death. LPN #360 was then informed of Resident #5 being a Full Code status, emergency medical treatment was initiated and 911 was called, without a time being given in the SRI. Resident #5 was pronounced deceased at 6:30 P.M. by the EMS squad. The SRI was substantiated by the facility. Review of the undated facility investigation revealed the facility confirmed Resident #5 was found at 5:35 P.M. on [DATE], without signs of life confirmed by two LPN's. The resident's code status was not verified by the facility until 6:10 P.M. and the resident was not provided any emergency management intervention at the time of death. The facility staff became aware of Resident #5 wishing to be a Full Code at 6:10 P.M., when the medical record was checked. The facility investigation revealed CPR was not initiated until 6:21 P.M. Resident #5's death was pronounced by the squad at 6:30 P.M. Interview on [DATE] at 10:15 A.M., with RN #390, verified she was in the building when Resident #5 expired. RN #390 stated it was approximately 6:10 P.M., when she became aware the resident had expired and she told the agency nurse to check the chart regarding Resident #5's code status. RN #390 stated LPN #360 checked the chart and stated Resident #5 is a Full Code. RN #390 told LPN #360 she needed to initiate CPR. RN #390 stated LPN #360 stated Even after this long? and RN #390 replied to her yes. RN #390 stated she called 911 and hospice and told the LPN to initiate the Full Code. Interview on [DATE] at 11:33 A.M., with Physician #500, verified she was the physician for Resident #5 and she did receive a call the evening of [DATE] that the resident was found pulseless and without respirations. Physician #500 stated she asked when the resident was last seen alive and was told 25 minutes prior Resident #5 was at her base line. Physician #500 denied the facility discussing the resident's code status with her at this time. The physician did confirm she was aware the resident was under the care of hospice for her End Stage ALS, and the resident s condition was declining. Physician #500 stated the facility called back later that evening to discuss the delay in CPR for Resident #5 and she participated in an ad hoc Quality Assurance meeting via phone about the education, monitoring auditing and the process of checking code status immediately when a resident expires. Interview on [DATE] at 11:34 A.M. with STNA #350, revealed she provided care to Resident #5 on [DATE] at 5:20 P.M., she then left the room and provided care to other residents. STNA #350 stated she returned to Resident #5's room approximately 10 to 15 minutes later and Resident #5 was deceased . The STNA stated Resident #5's color was darker and when she touched Resident #5 she was still warm but when she called her name there was no response when Resident #5 would have normally had a response. STNA #350 stated she yelled for the nurse who was right outside the door performing the medication pass. STNA #350 stated the nurse came in the room, checked for a pulse, used the stethoscope and stated she is deceased . The STNA stated she was going down the hall to get another nurse because that was the normal process when someone is deceased . STNA #350 stated LPN #380 came to the room and confirmed the resident was without signs of life. STNA #350 stated neither nurse talked about code status or about initiating CPR. The STNA stated she then went to provide care for another resident. STNA #350 stated she then completed post mortem care on Resident #5 and had left Resident #5's room when she saw the nurses with the crash cart go to Resident #5's room. STNA #350 confirmed she witnessed Resident #5 receiving CPR from the nurses at the facility after she had performed post mortem care. STNA #350 stated the squad did respond to the facility after the nurses began CPR. Interview on [DATE] at 3:21 P.M. with LPN #380 was attempted with no response and a message left to return the call. No return call was received. Interview on [DATE] at 3:24 P.M. with LPN #360 was attempted with no response and a message left to return the call. No return call was received. Interviews on [DATE] and [DATE], at various times, with RN #320, RN #360, LPN #315, and agency LPN #340, revealed the staff have received recent Emergency Management Training in the last few weeks that has included what to do if you find a resident who is unresponsive and without signs of life, where code status is located and the process to follow to ensure residents are receiving prompt emergent care. The staff were able to verbalize the procedure. Interview on [DATE] at 10:00 A.M. with HRD #305 revealed a request was made for the Agency Orientation Check List for LPN's #360, #370, and #340. HRD #305 provided the Agency Orientation Check List for LPN #360 and LPN #370 dated [DATE] and for LPN #340 dated [DATE]. Interview on [DATE] at 4:00 P.M., with the DON and Regional Nurse #325, revealed it is the company policy to examine the crash cart and audit employee files for CPR certification as part of the Emergency Management Review. The DON and Regional Nurse confirmed the staff had all needed supplies to provide Resident #5 with CPR on [DATE] and all staff were current in CPR certification. Review of Resident #10, #20 and #30's medical records on [DATE] revealed the residents expired at the facility and had do not resuscitate orders which the facility honored. Review of the facility staffing schedules from [DATE] to [DATE] and the Agency Orientation Check List and Training revealed LPN #410 worked on [DATE], [DATE], and [DATE]. The facility had no documented evidence of agency LPN #410 as having received Emergency Management Training prior to working on the floor as per the facility's corrective action plan. Interview on [DATE] at 5:24 P.M. with the Administrator and HRD #305, verified the facility had no documented evidence that LPN #410 received training on the facility policy of Emergency Management and had worked [DATE], [DATE] and [DATE]. Review of the Staff Development Program Attendance Record provided by the facility for documentation of staff who had attended the Emergency Management in-service revealed there have been nine RNs, 17 LPNs, and 18 STNAs trained to date. Review of the all staff listing provided by the facility revealed the facility employs nine RNs, 20 LPNs and 31 STNAs. Review of the policy titled Emergency Management with a date of [DATE] and a revision date of ,[DATE], revealed under the section titled Emergency Response Guidelines: the first licensed nurse that arrives on the scene will evaluate the patient level of consciousness, circulation, airway and breathing. The nurse directs additional licensed nurses to review chart for living will or do not resuscitate (DNR) documentation, physician orders [REDACTED]. The nurse directs additional responders to page emergency code per center established process, e.g. Code Blue, Code 100, paging Dr. Blue, etc. Page is repeated at least two times if resident is full code. The nurse directs additional license nurses or staff member to phone emergency medical services (EMS) team requesting emergency assistance. This deficiency substantiates Complaint Number OH 357.

Based on medical record reviews, observations, review of the National Pressure Ulcer Advisory Panel (NPUAP) website, review of the facility's skin guide, and staff interviews, the facility failed to appropriately monitor and evaluate pressure ulcers for two residents (#48 and #327) of three reviewed for pressure ulcers. This resulted in actual harm when Resident #48 developed an unstageable pressure ulcer to her right heel. The facility census was 76. Findings include: 1. Review of Resident #48's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #48's significant change correction Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had severe cognitive impairment. Further review of the MDS assessment dated [DATE] revealed Resident #48 had a stage II pressure ulcer. Review of physician orders [REDACTED]. Review of Treatment Administration Records (TARs) revealed on 07/12/18, 07/19/18, 07/26/18, 08/02/18, 08/09/18, 08/23/18 and 08/30/18, weekly skin checks were not documented as being completed as ordered. Review of Resident #48's nursing progress note dated 07/26/18 revealed the resident had a right heel wound with slough (necrotic tissue) and dried drainage. Review of progress notes from, 07/01/18 through 09/05/18, revealed there was no documentation of Resident #48's pressure ulcer to her right heal, other than the nursing note dated 07/26/18. Resident #48 was documented as complaining of right foot, and lower extremity pain on 09/05/18, 09/04/18, 09/01/18, 08/28/18, 08/23/18, 08/17/18, 07/30/18, 07/26/18, 07/25/18 and 07/22/18. Review of a Hospice Summary Visit Note dated 07/31/18, revealed Resident #48 had a right heel wound measuring 1 centimeter (cm) by 0.2 cm deep. There was no documentation of the right heel wound's stage or appearance. Review of Resident #48's physician order [REDACTED]. Review of Resident #48's skin progress note dated 09/05/18 revealed a wound round was completed and the resident was noted with a pressure ulcer to her right heel measuring 1 cm x 1.2 cm, and the depth was unable to be determined. The pressure ulcer was coded as unstageable. No tunneling or undermining present, and 100% of the wound bed was covered with light tan slough. A scant amount of brown drainage with no odor was present. Review of Resident #48's pressure ulcer assessment dated [DATE], revealed the resident had an unstageable right heel pressure ulcer to her right heel which measured 1 cm x 1.2 cm, with a wound bed covered in slough. A scant amount of dark brown exudate was present without odor. Review of Resident #48's comprehensive care plan revealed that a care plan for right heel pressure ulcer was not initiated until 09/05/18. Review of the facility's Skin Practice Guide, revealed a licensed nurse provides wound treatments as ordered and documents completion on the TAR. Weekly skin alteration evaluations were to be completed weekly and documented on a Skin Alteration Record. An observation of Resident #48's right heel on 09/06/18 at 10:36 A.M., revealed an unstageable pressure ulcer which measured 1.2 cm, by 1.3 cm, with a wound bed covered in tan slough. The wound bed was deeper than the surrounding skin's depth. Interview with the Director of Nursing (DON) on 09/05/18 at 1:41 P.M. confirmed she could not find any Skin Alteration Records for Resident #48's right heel pressure ulcer. The DON confirmed she had visualized the right heel pressure ulcer on 09/05/18, and it was unstageable. The DON confirmed pressure ulcers should be staged at least weekly. Interview with the DON on 09/06/18 at 11:20 A.M., confirmed weekly skin assessments were not completed as ordered. The DON confirmed it could not be determined when Resident #48 first developed the right heel pressure ulcer, or what stage, or size it was when found. The DON confirmed documentation for Resident #48's right heel pressure ulcer was inadequate. Review of the NPUAP website revealed an unstageable pressure injury is defined as obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. 2. Review of Resident #327's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 08/29/18, revealed Resident #327 had moderate cognitive impairment. The MDS further revealed the resident had one unhealed stage two pressure ulcer. Further review of the medical record revealed Resident #327 was hospitalized [DATE] through 08/08/18, and again 08/09/18 through 08/20/18. Review of Resident #327's re-admission screening, dated 08/08/18, following a hospitalization revealed Resident #327 had a closed right heel blister, and was documented as measuring 5 cm, by 5 cm. No additional wound characteristics were documented for the heel. The re-admission screening dated 08/20/18 was silent for any right heel wound. Review of Resident #327's physician orders [REDACTED]. Review of Resident #327's nursing progress note dated 08/30/18 revealed Resident #327 had a dark purple blister to the right heel. Review of Resident #327's TARs revealed no evidence the daily skin audits were completed on 08/30/18, 08/31/18 and 09/03/18. Observation of the right heel wound was not able to be observed for Resident #327 as the resident was admitted to the hospital on [DATE], and did not return to the facility prior to the exit date of the survey. Interview on 09/06/18 at 10:35 A.M., with the DON confirmed there was no skin monitoring documented of the right heel wound in respect to wound measurements and wound characteristics. The DON also confirmed the plan of care referenced the right heel as being unstageable and body audits for Resident #327 should have been completed on a daily basis. Review of a facility provided document titled, Skin Practice Guide, with an issue date of 01/2013, revealed if a pressure ulcer is identified, a Pressure Ulcer Scale for Healing (PUSH Tool) is initiated by a member of the wound team for each identified site. A comprehensive evaluation is completed and documented in the patient's clinical record and should include location, depth, appearance of surrounding skin, presence and location of tunneling, presence and location of undermining, evidence of infection and pain. Daily skin evaluations are completed by the licensed nurse for any patient with a pressure ulcer.

Based on medical record review, observation, staff interviews, review of hospital records and review of facility policy, the facility failed to coordinate continuity of care, monitor how long a resident had a splint/cast on and seek timely medical intervention and treatment to prevent neglect after a resident returned to the facility following the application of a splint/cast for immobilization of a fractured left arm. This resulted in Immediate Jeopardy when one resident (#10) returned from the hospital with a splint/cast device in place to his left arm and there were no follow-up appointments scheduled which subsequently caused the resident to suffer avoidable serious physical harm and injuries. The splint/cast was left in place for a time period of 11 weeks allowing the mesh/stockinet under the splint/cast to embed itself into the resident ' s skin. The resident ' s skin was torn open during the removal of the splint/cast and mesh/stockinet. This affected one (#10) of four residents reviewed for neglect. The facility census was 69. On 01/12/17 at 4:35 P.M., the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Consultant #75 and LNHA #76 of another facility were notified Immediate Jeopardy began on 11/08/16, when Resident #10 returned to the facility from the hospital with a splint/cast to his left arm that was placed on 10/29/16 while at the hospital. There were no orthopedic follow-up appointments scheduled by the facility for 11 weeks. As a result, the resident suffered skin injuries due to the splint/cast digging into the upper arm of the resident and tearing of the skin to the left hand during the splint/cast removal as a result of the mesh/stockinet embedding itself into the resident ' s skin over time. Although the Immediate Jeopardy was removed on 01/11/17 when Resident #10 ' s splint/cast was removed and his arm assessed by Medical Doctor (MD) #77 and all other current residents with splint/casts due to orthopedic injury were confirmed to have an orthopedic appointment, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. The facility implemented the following corrective actions: · On 01/11/17, MD #77 removed the splint/cast from Resident #10 ' s left arm and assessed the resident ' s skin condition. · On 01/11/17, current residents with splint/casts due to orthopedic injury had an orthopedic appointment established. · On 01/11/17, skin sweeps were completed on all residents residing in the facility by the DON and Licensed Nurses #78 and #79. · On 01/11/17, Licensed Nurses were educated on the facility skin practice guide already in place to include notification of change in condition as it relates to skin alterations and pressure ulcers to include casts and splints, along with notification to physician by Nursing Managers. Those Licensed Nurses unable to participate in education will be removed from patient care until such education has been completed by the Nursing Managers. · On 01/11/17, a Quality Assurance (QA) meeting was held with attendance by the Medical Director. An additional QA meeting with attendance by the Medical Director was held via teleconference on 01/12/17 regarding these corrective actions being put in place and was accepted by the Medical Director. · On 01/11/17, the LNHA and DON began monitoring the skin program to include notification to the attending physician of changes in condition. New admissions with casts and/or slings that required orthopedic follow-up appointments would be monitored through the morning interdisciplinary team (IDT) meeting daily for the next two weeks, then Monday through Friday, ongoing. Areas of deficiency would be submitted to the QA Committee and corrected immediately. · On 01/12/17, interviews with Licensed Practical Nurse (LPN) #86, Registered Nurse (RN) #79 and #85 confirmed they had been re-educated on the facility skin practice. Findings include: Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive quarterly assessment dated [DATE] revealed Resident #10 had severe cognitive impairment, had not rejected care, no skin issues and required extensive assistance from two staff for bed mobility, hygiene, toileting and dressing. Review of Certified Nurse Practitioner (CNP) #81 ' s note dated 10/28/16 revealed Resident #10 was being seen for left arm pain due to him being rolled out of bed by State tested Nursing Assistant (STNA) #80 improperly by completing the care by herself, when the resident required the assistance of two staff members on 10/27/16. The x-ray completed after the fall was negative for a fracture at that time. The note further revealed Resident #10 had an acute contusion to his left shoulder and severe pain with passive range of motion to his left arm. CNP #81 encouraged staff to administer as needed [MEDICATION NAME] (Tylenol) and ordered [MEDICATION NAME] (narcotic pain medication) for severe pain. Review of a nursing note dated 10/29/16 revealed Resident #10 was transferred to the emergency room (ER) and admitted due to low oxygen saturation, aspiration pneumonia, and multiple abrasions. Another x-ray was obtained and Resident #10 was noted with a fractured arm. Review of the hospital note dated 10/29/16 revealed a splint/cast was applied to Resident #10 ' s left arm. There was no order for orthopedic follow-up mentioned, however it was noted the resident needed to follow-up with the facility physician. Review of the hospital discharge note dated 11/08/16 had no documentation of an orthopedic follow-up for Resident #10, only to follow up with the facility physician. Review of the admission note completed when Resident #10 returned to the facility on [DATE] revealed the resident had a splint/cast to his left arm, however there was no mention of follow-up orders or how to care for the left arm. The resident was also noted with a Vaseline gauze in place to his upper left shoulder, covering a scabbed area. MD #77 was notified and no new orders were written for an orthopedic follow-up for the fractured left arm. Review of CNP #81 and MD #77 ' s notes dated from 11/08/16 to 01/11/17 revealed the resident was seen at least four times and no new orders were written for orthopedic consultation or follow-up for Resident #10 ' s fractured left arm. Review of a nurse ' s note dated 01/11/17 revealed a full body skin assessment was completed on Resident #10 after the splint/cast was removed on 01/11/17 by the orthopedic office. The appointment was finally made by Unit Manager #78 when he was made aware Resident #10 had a splint/cast. The DON, Administrator, MD #77 and UM #78 were present. Resident #10 had a skin tear to the left posterior hand which was received during the splint/cast removal. The skin tear measured 0.8 centimeters (cm) by 1.2 cm. Resident #10 was also noted with a small healing light brown scab to his left forearm which measured 0.6 cm by 0.7 cm, a second small healing light brown scabbed area to left forearm measured 0.7 cm by 0.8 cm, a small healing light brown scab to left outer elbow measured 0.1 cm by 0.3 cm, an old healing skin tear to the left upper arm measured 1.0 cm by 6.5 cm, and a new skin tear which measured 2.3 cm by 0.3 cm. During an interview on 01/12/17 at 9:08 A.M., the DON stated on 10/29/16 Resident #10 was experiencing some low oxygen saturations and was sent out to the hospital where he was admitted and it was determined he had a fractured left arm. He returned to the facility on [DATE] and he had no orders to follow-up with an orthopedic specialist. The DON confirmed the orders from the hospital should have been clarified when he returned with a splint/cast on. She further stated Resident #10 obtained skin tears to the upper left arm and on his left hand during his fall on 10/27/16. During an interview on 01/12/17 at 10:53 A.M., MD #77 stated Resident #10 was having some respiratory issues and was sent to the hospital on [DATE] and was diagnosed with [REDACTED].#77 further stated the resident returned to the facility on [DATE] without any orthopedic orders. She stated the facility did not schedule an orthopedic consult until the first week of January 2017. She stated the initial orthopedic consult should have been conducted within the first week the splint/cast was applied. MD #77 stated, We clearly dropped the ball getting an appointment for an orthopedic follow-up. She stated the skin tear happened during the removal of the splint/cast and it took longer to remove it. During a telephone interview on 01/12/17 at 11:26 A.M., Orthopedic Physician Assistant (OPA) #83 stated Resident #10 had a posterior splint/cast applied on his left arm and it went all the way up to mid arm and down around the hand leaving the fingers exposed. She stated the fracture Resident #10 had should have had a one week orthopedic follow-up to make sure proper healing was taking place. OPA #83 further stated the cast should have been removed in three to four weeks from placement of the cast, not almost three months later. She further stated the splint/cast was digging into the upper left arm, the mesh and stockinet was imbedded into the skin and the skin had grown over it. She stated the splint/cast had to be soaked longer and during the removal Resident #10 ' s skin was pulled off. She also stated the splint/cast was digging into the resident ' s upper arm and there was a laceration to the left upper arm. She confirmed Resident #10 had no orthopedic follow-up until he was seen on 01/11/17, when the splint/cast was finally removed. During an interview on 01/12/17 at 1:09 P.M., LPN #84 stated she recently became a guardian angel (program where they make sure residents are doing well). She stated she saw Resident #10 on 01/03/17 and noticed Resident #10 had a splint/cast on his left arm. She brought this to the attention of management and they began to look into the splint/cast. During an observation on 01/12/17 at 2:41 P.M., LPN #82 completed the dressing change to Resident #10 ' s left hand. The old dressing was removed and Resident #10 had an approximately quarter sized open reddened area with a white center to the back of the left hand. He also had a scabbed area across the upper left arm. During an interview on 01/12/17 at 3:56 P.M., UM #78 stated he was told about Resident #10 ' s cast on 01/03/17. UM #78 stated he called the orthopedic office on 01/04/17 and made the resident an appointment on 01/11/17. He further stated to his knowledge that was the first available appointment. Review of the facility policy titled Patient Protection Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention dated 11/2016 revealed neglect was defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This deficiency substantiates allegations contained in complaint OH 903.

Based on clinical record review, staff interview, review of hospital records, review of fall investigation, and facility policy review, the facility failed to prevent an avoidable fall. This resulted in actual harm for one (#10) of three residents reviewed for falls when Resident #10 was rolled incorrectly in a raised bed and fell to the floor and suffered a fractured humerus (arm). The facility census was 69. Findings include: Clinical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive quarterly assessment dated [DATE] revealed Resident #10 had severe cognitive impairment, had not rejected care, no skin issues and required extensive assistance from two staff for bed mobility, hygiene, toileting and dressing. Review of the plan of care (POC) with a target date of 03/10/17 revealed Activities of Daily Living (ADL) self care deficit related to [DIAGNOSES REDACTED]. Interventions included extensive assistance of two person for bed mobility and toileting. Recently updated to read totally dependent for ADL care. Review of the nurse note dated 10/27/16 revealed Resident #10 was on the floor on his back with blood noted to the left shoulder and the left arm was excoriated like a rug burn where he had fallen against the tube feeding pole according to State tested Nursing Assistant (STNA) #80. Resident #10 had streaked bruising to his left shoulder. The Medical Doctor (MD) #77 and family were notified and the resident was sent to the emergency room (ER). He returned from the ER with no new orders and negative x-rays of the left arm at this time. Review of the fall investigation documentation dated 10/28/16 documented STNA #80 was providing care to Resident #10 who was in bed in the high position. She rolled the resident away from her and had one hand on the resident and reached to grab wipes and briefs when Resident #10 rolled off the opposite side of the bed onto the floor. During the course of the investigation it was noted STNA #80 used improper bed mobility and did not follow the policy. Review of the Certified Nurse Practitioner (CNP) note dated 10/28/16 #81 revealed Resident #10 was being seen for left arm pain, she documented an acute contusion to left shoulder and severe pain with passive range of motion to left arm. The CNP encouraged staff to administer as needed acetaminophen (Tylenol) and ordered Tramadol (narcotic pain medication) for severe pain. Review of nursing note dated 10/29/16 revealed Resident #10 was transferred to the ER due to low oxygen saturation where later he was admitted with aspiration pneumonia, fractured elbow and multiple abrasions. Review of the hospital x-ray report dated 10/29/16 revealed an acute fracture involving the medial epicondyle of the distal humerus (arm) extending to the joint. Review of the hospital noted dated 10/29/16 revealed a splint/cast was applied to the left arm. There was no order for orthopedic follow up mentioned, only to follow up with the facility physician. Review of the interdisciplinary team (IDT) note dated 10/31/16 revealed Resident #10 was a quadriplegic and unable to reposition himself in the bed and staff were educated on rolling residents toward them and not away. Review of the nursing note dated 11/08/16 revealed Resident #10 returned to the facility from the hospital and had a splint/cast intact to his left arm. Circulation checks were within normal limits and there was a Vaseline gauze to upper left shoulder scabbed area. There were no orders for an orthopedic follow up appointment. During an interview on 01/12/17 at 2:31 P.M., STNA #80 stated she went in to change Resident #10 and she rolled him away from her and kept one hand on him and when she reached over to get the wipes and brief he rolled off the opposite side of the bed. She verified she provided this care by herself and she knew Resident #10 was a two person assist for this type of care. She further stated the nurse was busy passing medications and the float STNA was in with another resident and she did not want to make Resident #10 wait so she attempted to do the care by herself. Review of the policy titled Bed Positioning dated 10/2011 revealed to verify transfer assist needed and obtain additional assistance as indicated, reach across the patient and place one hand behind the shoulder and the other behind the hip and gently roll the patient toward you. This deficiency substantiates allegation in Complaint Number OH 903.

Based on medical record reviews, staff interviews, review of manufacturer's recommendations for glucometers, review of the American Diabetes Association guidelines, and Med Scape.com (internet-based medication reference), and review of facility policies, the facility failed to provide the necessary care and services when staff did not immediately address a resident's clinical change in condition resulting in a critically low blood sugar level. This resulted in Immediate Jeopardy when Resident #89 was found moaning and making unintelligible noises, and had a critically low blood sugar level of 30 milligrams per deciliter (mg/dL). The nurse failed to monitor the resident's condition, failed to notify the physician, and failed to provide immediate treatment, resulting in the resident's death within hours of the change in condition. Additionally, twelve other residents (#13, #15, #36, #39, #49, #58, #59, #61, #77, #78, #90 and #155) were placed at risk for the likelihood of serious impairment or harm as the facility had established practices of failing to adequately monitor, report to the physician abnormal blood sugar levels, treat abnormally high and low blood sugar levels, and failing to administer insulin as ordered. This affected 13 (#13, #15, #36, #39, #49, #58, #59, #61, #77, #78, #89, #90 and #155) of 16 residents identified by the facility as having diabetes requiring finger stick blood sugar (FSBS) monitoring. The facility census was 75. On 04/21/16 at 4:21 P.M., the Administrator, Director of Nursing (DON), Nursing Unit Manager #200, Nursing Unit Manager #201, and Resident Assessment Coordinator #203, were notified Immediate Jeopardy began on 01/09/16 at approximately 5:30 A.M., when Resident #89 was observed moaning and making unintelligible noises. On 01/09/16 at 6:10 A.M., a routine FSBS was taken with a reading of 30 mg/dL. The resident was unable to swallow when offered pudding and orange juice. On 01/09/16 at 6:17 A.M., the resident was given an injection of [MEDICATION NAME] (used for the treatment of [REDACTED]. On 01/09/16 at 6:22 A.M., the FSBS remained low at 34 mg/dL. The resident continued to moan and was restless. A small amount of Glucogel (oral glucose gel) was placed in the resident's mouth. On 01/09/16 at 6:27 A.M., a repeated FSBS check revealed a decline in result at 32 mg/dL. The resident continued to moan and be restless. On 01/09/16 at 6:32 A.M., the resident's FSBS was 52 mg/dL with continued moaning and restlessness. On 01/09/16 at 6:35 A.M., a second injection of [MEDICATION NAME] was administered to the resident. On 01/09/16 at 6:40 A.M., the resident's FSBS was slightly increased at 57 mg/dL. Resident #89 was observed to continue moaning with restlessness. On 01/09/16 at 6:45 A.M., the resident's condition was unchanged with a FSBS of 61 mg/dL. No additional treatment was implemented. On 01/09/16 at 6:50 A.M., the resident's FSBS was 66 mg/dL. Again, the resident continued to moan and was restless. On 01/09/16 at 6:55 A.M., the resident's FSBS was 72 mg/dL. At that time, Resident #89 was more responsive and able to answer questions. He stated he did not feel well. His vital signs were taken and revealed a low oxygen concentration at 85% on room air and oxygen was applied. On 01/09/16 at 7:00 A.M., the resident's vital signs were taken again with the oxygen concentration at 92%. On 01/09/16 at 7:30 A.M., staff responded to the sounding of the oxygen concentrator alarm. Upon entering the room, Resident #89 was observed slumped over the right side of the bed. The resident was unresponsive, without an apical pulse or respirations. The Immediate Jeopardy was removed on 04/22/16, when all 15 residents currently residing in the facility with a [DIAGNOSES REDACTED]. · On 04/21/16, all residents with the [DIAGNOSES REDACTED]. · On 04/21/16, all residents with diabetes care plans were reviewed by licensed nurses to ensure the physician parameters in relation to notification and treatment of [REDACTED]. · On 04/21/16, licensed nurses obtained physician orders [REDACTED]. · On 04/21/16, licensed nurses obtained new orders for Glucogel and [MEDICATION NAME] to ensure all residents had orders to include the medications as needed. · On 04/21/16, licensed nurses provided notification of all new orders to residents and/or their legal representatives for their FSBS parameters and medications. · On 04/22/16, licensed nurses' transcribed orders to change FSBS from 6:00 A.M. to 7:30 A.M. per the revised facility meal time to ensure insulin coverage was administered just prior to the meal. · On 04/22/16, the facility amended breakfast times from 7:00 A.M. to 8:00 A.M. effective 04/23/16, to ensure insulin coverage was administered just prior to the meal. · On 04/22/16, the facility amended the blood glucose monitoring process to include [MEDICAL CONDITION] (high blood sugar) and [DIAGNOSES REDACTED] (low blood sugar). · On 04/22/16, in-servicing was completed by the DON for all nurses on the revised meal times. Staff will not work until this education has occurred. · On 04/22/16, in-servicing was completed by the DON for all nurses on the blood glucose monitoring process to include [MEDICAL CONDITION] and [DIAGNOSES REDACTED] signs and symptoms and treatment. Staff will not work until this education has occurred. · On 04/22/16, in-servicing was completed by the DON for all nurses on blood glucose monitoring including [MEDICAL CONDITION], [DIAGNOSES REDACTED], notification as it relates to blood sugar levels, as well as proper procedures regarding errors and omissions and the revised policy. Those nurses unable to participate in education will be removed from patient care until such education has been completed by the Nursing Managers. · On 04/22/16, the Licensed Nursing Home Administrator and/or Nurse Management will monitor blood glucose before meals and at bedtime to ensure accurate administration of insulin and notification of the attending physician per the orders including documentation in the clinical records for the next 14 days. After 14 days, the monitoring will continue Monday through Friday and will be ongoing to ensure compliance. Areas of identified deficiency will be submitted to the Quality Assurance (QA) committee and corrected immediately. · On 04/22/16, the facility's current policy titled [MEDICAL CONDITION] and [DIAGNOSES REDACTED] Treatment was amended to indicate the following: upon admission, the attending physician will be notified of patients with [DIAGNOSES REDACTED]. Upon evaluation by the attending physician, parameters will be adjusted by the physician based on the patient's overall clinical condition. · All new licensed nurses will receive education on blood glucose monitoring including [MEDICAL CONDITION], [DIAGNOSES REDACTED], and notification of changes in condition by a licensed nurse and proper procedures regarding errors and omissions. · On 04/23/16 at 2:00 P.M., a QA committee meeting was held with the Medical Director via teleconference and the plan was reviewed and accepted. · On 04/23/16, between 11:25 A.M. and 11:50 A.M., the FSBS for the 15 (#13, #15, #36, #39, #49, #53, #58, #59, #61, #77, #78, #84, #90, #93 and #155) current diabetic residents were reviewed for the 7:30 A.M. and 11:30 A.M. checks and confirmed the facility was monitoring the FSBS and providing the required notifications and treatments as ordered. · Interviews on 04/23/16, between 11:30 A.M. and 3:40 P.M., with Licensed Practical Nurses (LPN) #210, #212 and Registered Nurses (RN) #211, #213 and #214, verified education by the facility on blood glucose monitoring including [MEDICAL CONDITION], [DIAGNOSES REDACTED], and notification of changes in condition by a licensed nurse and proper procedures regarding errors and omissions. All staff were able to correctly verbalize knowledge of the policy changes. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of Resident #89's closed medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Discharge Hospital Course of Treatment form dated 12/22/15, indicated the resident was admitted to the hospital for nausea and vomiting. He has known [MEDICAL CONDITION] with an arteriovenous (AV) fistula created over a year ago but, had not been dialyzed. He was found to have a urinary tract infection for which he was treated with intravenous (IV) antibiotics. [MEDICAL TREATMENT] was initiated during his admission to the hospital. The resident's condition is stable at this point where he can be discharged to an extended care facility. FSBS at the hospital on [DATE] revealed a blood sugar of 152 mg/dL and 98 mg/dL. Review of the Admitting Physician order [REDACTED]. There were no orders for routine insulin or oral hyperglycemic medications. The resident's diet was noted as regular texture carbohydrate controlled. The admission orders [REDACTED]. There were no resident specific orders for treatment of [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was alert and oriented with no cognitive deficits. He did not demonstrate hallucinations, delusions, or behaviors. He required extensive assistance of two persons for all activities of daily living except for eating. He was assessed as being able to eat with set up of one person and supervision. He was assessed as having no difficulty with chewing or swallowing. The resident was assessed as having [MEDICAL TREATMENT] treatments prior to and during admission. The residents ' overall expectation of stay was assessed as expected to be discharged to the community. The discharge plan indicated active discharge planning is already occurring for the resident to return to the community. The resident received occupational and physical therapy during the assessment reference period. Review of the plan of care for discharge planning dated 01/08/16, revealed the resident shows potential for discharge and the resident expresses a wish for discharge. The goal was for the resident to be discharged to live with family when clinical rehabilitation goals are met. The plan of care further indicated the resident has non-insulin dependent diabetes. The goal documented the resident would be free of complications related to the disease process. The interventions included obtaining glucometer readings (finger stick blood sugars) and report abnormalities as ordered, report symptoms of [MEDICAL CONDITION] (high blood sugars) with symptoms of excessive thirst or urination, hunger, weakness, and report symptoms of [DIAGNOSES REDACTED] (low blood sugar) with symptoms of weakness, paleness, and changes in consciousness. Review of the History and Physical form dated 01/04/16, revealed the facility was to continue the resident's current medications, as the resident is stable. A new order was written to start [MEDICATION NAME] 10 units every morning routinely. Review of a neurological consult dated 01/06/16, revealed the impression was lower extremity weakness due to deconditioning as a result of renal function, diabetes, and [MEDICAL CONDITION]. The recommendations were for physical therapy for conditioning to gradually increase time out of bed to increase strength. The resident is to keep his legs elevated when sitting to decrease [MEDICAL CONDITION]. A follow up visit was requested in three to four months. Review of the nursing progress notes dated 01/09/16 at 5:30 A.M., revealed Resident #89 was observed with an acute change in clinical condition. The resident was moaning and making unintelligible noises. On 01/09/16 at 6:10 A.M., a routine FSBS was taken with a reading of 30 mg/dL. The resident was unable to swallow when offered pudding and orange juice. On 01/09/16 at 6:17 A.M., the resident was given an injection of [MEDICATION NAME] (used for the treatment of [REDACTED]. On 01/09/16 at 6:22 A.M., the FSBS remained low at 34 mg/dL. The resident continued to moan and was restless. A small amount of Glucogel (oral glucose gel) was placed in the resident's mouth. At 6:27 A.M. on 01/09/16, a FSBS was repeated and revealed a decline with the result of 32 mg/dL. The resident continued to moan and be restless. On 01/09/16 at 6:32 A.M., the resident's FSBS was 52 mg/dL with continued moaning and restlessness. On 01/09/16 at 6:35 A.M., a second injection of [MEDICATION NAME] was administered to the resident. On 01/09/16 at 6:40 A.M., the resident's FSBS was slightly increased at 57 mg/dL. Resident #89 was observed to continue moaning with restlessness. On 01/09/16 at 6:45 A.M., the resident's condition was unchanged with a FSBS of 61 mg/dL. No additional treatment was implemented. On 01/09/16 at 6:50 A.M., the resident's FSBS was 66 mg/dL. Again, the resident continued to moan and was restless. On 01/09/16 at 6:55 A.M., the resident's FSBS was 72 mg/dL. At that time, Resident #89 was more responsive and able to answer questions. He stated he did not feel well. His vital signs were then taken and revealed a low oxygen concentration at 85% on room air. Oxygen was applied. On 01/09/16 at 7:00 A.M., the resident's vital signs were taken again with the oxygen concentration at 92%. There was no FSBS repeated on 01/09/16 at 7:00 A.M. On 01/09/16 at 7:30 A.M., staff responded to the sounding of the oxygen concentrator alarm. Upon entering the room, Resident #89 was observed slumped over the right side of the bed. The resident was unresponsive, without an apical pulse or respirations. Review of the nursing progress note dated 01/09/16 from 5:30 A.M. through 7:30 A.M., revealed there was no notification of the physician or family being notified of the critically low blood sugars or the continued change in condition. Review of the nursing progress note dated 01/09/16 at 7:40 A.M., revealed the physician, family, and funeral home were notified of the resident's death. Interview on 04/21/16 at 12:16 P.M. with the Administrator, Unit Manager #200, and Unit Manager #201, verified the facility was aware of the incident with Resident #89 on 01/09/16. The Administrator stated the former DON handled the incident. The Administrator stated there was no education of the staff that she was aware of. The Administrator and Unit Manager #200 verified the facility does not have standing orders for the treatment of [REDACTED]. 2. Review of Resident #13's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Additionally, specific insulin orders included [MEDICATION NAME] (100 units/ml vial) injection 40 units to be given before breakfast, 45 units before lunch, and before dinner. A [MEDICATION NAME] (100 units/ml vial) insulin injection was also ordered for 88 units to be given twice daily at 6:00 A.M. and 6:00 P.M. Review of the MAR for February 2016, revealed FSBS results greater than 400 mg/dL on nine occasions during the month. Subsequent review of the nurse's progress notes revealed the physician was notified on two occasions of the elevated FSBS. Documentation showed the physician was notified of the FSBS of 437 mg/dL on 02/07/16 at 8:00 P.M. The physician ordered an additional 10 units of [MEDICATION NAME]to be given now. Additionally, the physician was notified of an elevated FSBS of 431 mg/dL on 02/10/16 at 11:00 A.M. The physician responded with an increase in the dose of [MEDICATION NAME] to 94 units twice daily. The MAR indicated [REDACTED].M. of 419 mg/dL, on 02/02/16 at 6:00 A.M. of 412 mg/dL and 11:00 A.M. of 420 mg/dL, on 02/08/16 at 11:00 A.M. of 431, on 02/11/16 at 4:00 P.M. of 468 mg/dL and 8:00 P.M. of 446 mg/dL. Review of the medical record revealed no documentation of the physician being notified of any of the listed FSBS out of the recommended range. A review of the MAR for February 2016 revealed six evening (8:00 P.M.) FSBS results were not recorded as required for medication administration and monitoring purposes. The dates no FSBS were recorded were as follows: 02/03/16, 02/04/16, 02/06/17, 02/17/16, 02/22/16 and 02/23/16. 3. Review of Resident #15's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #15's physician orders [REDACTED]. The parameters for the scale indicated if FSBS measures 151-200 mg/dL, inject 2 units of insulin, if FSBS reading is 201-250 mg/dL, inject 4 units of insulin, if FSBS measures 251-300 mg/dL, inject 6 units of insulin, if FSBS reading is 301-350 mg/dL, inject 8 units of insulin and, if FSBS reads greater than 350 mg/dL or less than 60 mg/dL to call the physician. Another order revealed to inject 42 units of [MEDICATION NAME] daily. Further review of the medical record revealed a third order for Humalog insulin; inject 8 units, three times daily with meals. A physician order [REDACTED]. Review of the MAR for January 2016 revealed on 01/11/16 at 9:00 P.M., the FSBS and dosage injected were missing documentation as having been obtained or administered as ordered. On 01/30/16, the 8:00 A.M. dose of [MEDICATION NAME] 42 units was missing the documentation as having been administered as ordered. Review of the MAR for February 2016 revealed on 02/08/16 at 6:00 A.M., the FSBS and dosage of insulin injected were missing documentation as having been obtained or administered as ordered. On 02/28/16, the 12:00 P.M. dose of Humalog insulin 8 units was missing the documentation as having been administered as ordered. Review of the MAR for March 2016 revealed on 03/01/16 at 6:00 A.M., the FSBS and dosage of insulin administered were missing documentation as having been obtained or administered as ordered. On 03/01/16 the 8:00 A.M., the dose of Humalog insulin 8 units was not documented as having been administered as ordered. On 03/17/16, 03/19/16, 03/23/16, 03/26/16, 03/27/16 and 03/30/16, the 6:00 A.M. dose of Humalog insulin was refused by Resident #15 with no documentation of physician notification. On 03/30/16 at 11:00 A.M., the FSBS and dosage of Humalog insulin were missing documentation as having been obtained or administered and the 5:00 P.M. FSBS revealed a result of 368 mg/dL and 8 units injected with no documentation of physician notification of the high FSBS. Review of the MAR for April 2016 revealed on 04/01/16 and 04/15/16 the 6:00 A.M. results of the FSBS or the dosage of Humalog insulin were not obtained or administered as ordered. On 04/07/16 at 11:00 A.M., the FSBS and dose of the Humalog insulin were missing documentation as having been obtained or administered as ordered. On 04/08/16 at 11:00 A.M., the FSBS and dosage of Humalog insulin were missing documentation as having been obtained or administered as ordered. On 04/09/16 at 11:00 A.M., the FSBS was 368 mg/dL, and there was no indication of the physician being notified as ordered, and the dosage of the Humalog insulin was missing the documentation as being administered as ordered. On 04/10/16 at 11:00 A.M., the FSBS was 361 mg/dL and 8 units of Humalog insulin was injected, however, there was no documentation of physician notification. On 04/14/16 at 11:00 A.M., the FSBS reading was 403 mg/dL and 8 units of insulin was injected but there was no documentation of physician notification. On 03/18/16 at 11:00 A.M., the FSBS was 351 mg/dL and 8 units were injected, however, there was no documentation of physician notification. 4. Review of Resident #36's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the April 2016 physician orders [REDACTED]. 6 units, for FSBS 301 mg/dL -350 mg/dL give 8 units, for FSBS 351 mg/dL- 400 mg/dL give 10 units, and for FSBS greater than 400 mg/dL, the physician is to be notified. Review of the April 2016 MAR indicated [REDACTED].M., the FSBS was 446 mg/dL and at 11:00 A.M. the FSBS was 488 mg/dL. The Resident was given 10 units of [MEDICATION NAME]at 6:00 A.M. and 11:00 A.M. Review of the nursing progress notes dated 04/12/16 revealed the physician was not notified of the blood sugars over 400 as per physician's orders [REDACTED].>5. Review of Resident #39's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of Resident #39's physician order [REDACTED]./dL give 12 units of insulin, and if FSBS is greater than 400 mg/dL call the physician. Review of the MAR for January 2016 revealed on 01/06/16, the 4:00 P.M. dose of 4 units Humalog insulin was missing the documentation as having been administered as ordered. On 01/09/16 at 6:00 A.M., the FSBS and the sliding scale dose were missing documentation as having been obtained or administered as ordered. On 01/22/16 at 11:00 A.M., the dose of 4 units Humalog insulin was missing the documentation as having been administered as ordered. Review of the MAR for February 2016 revealed on 02/11/16 the 6:00 A.M. dose of 2 units of Humalog insulin was missing the documentation of having been administered as ordered. On 02/13/16 and 02/14/16 the 11:00 A.M. dose of 4 units Humalog insulin were missing the documentation as having been administered as ordered. On 02/20/16 the 6:00 A.M. dose of 2 units Humalog insulin and the FSBS and sliding scale dose of Humalog insulin were both missing documentation as having been obtained or administered as ordered. On 02/25/16, the 9:00 P.M. dose of [MEDICATION NAME] 12 units was missing the documentation as having been administered as ordered. On 02/28/16, the 11:00 A.M. dose of 4 units of Humalog insulin was missing the documentation as having been administered as ordered. Review of the MAR for March 2016 revealed on 03/02/16 the 9:00 P.M. dose of [MEDICATION NAME] 12 units was missing the documentation as having been administered as ordered. On 03/16/16, the 4:00 P.M. dose of Humalog 4 units was missing the documentation as having been administered as ordered. Review of the MAR for April 2016 revealed on 04/09/16 the 4:00 P.M. dose of Humalog insulin was missing the documentation as having been administered as ordered and the FSBS was missing documentation as having been obtained. On 04/10/16, the 6:00 A.M. dose of Humalog insulin 2 units and the FSBS results were missing documentation as having been obtained or administered as ordered. On 04/10/16, the 4:00 P.M. FSBS was missing the documentation as having been obtained. On 04/16/16, the 6:00 A.M. dose of Humalog insulin 2 units was missing the documentation as having been administered as ordered. 6. Review of Resident #49's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the monthly physician orders [REDACTED]. The [MEDICATION NAME] sliding scale was to be given as follows: for FSBS 140 mg/dL - 189 mg/dL give 1 unit, for FSBS 190 mg/dL - 239 mg/dL give 2 units, for FSBS 240 mg/dL - 289 mg/dL give 3 units, for FSBS 290 mg/dL - 339 mg/dL give 4 units, for FSBS greater than 340 mg/dL or less 70 mg/dL, and to notify the physician. No coverage is to be given at 6:00 A.M. Review of the MAR for January 2016 revealed the [MEDICATION NAME]5 units ordered to be given before breakfast was held and not given for 14 days (January 07, 08, 10, 11, 12, 15, 16, 19, 21, 22, 27, 28, 29 and 30). Review of the January 2016 nursing progress notes, physician progress notes [REDACTED]. The 11:00 A.M. and the 4:00 P.M. dose of [MEDICATION NAME] 5 units insulin ordered to be given before lunch was held and not given for 10 days (January 06, 07, 10, 11, 12, 15, 19, 20, 24 and 25). Review of the January 2016 nursing progress notes, physician progress notes [REDACTED]. Review of the MAR for January 2016 revealed on 01/16/16 at 6:00 A.M., the FSBS was 68 mg/dL, and on 01/25/16 the FSBS was 68 mg/dL. Review of the nursing progress notes revealed no notification to the physician when the FSBS was less than 70 mg/dL. On 01/17/16 at 11:00 A.M., there was no documentation on the MAR indicated [REDACTED]. Review of the MAR for February 2016 revealed [MEDICATION NAME]5 units ordered to be given before breakfast was held and not given for 5 days (February 01, 03, 05, 08 and 14). Review of the February 2016 nursing progress notes, physician progress notes [REDACTED]. On 02/01/16 at 6:00 A.M., the FSBS was 67 mg/dL and on 02/14/16 at 4:00 P.M., the FSBS was 64 mg/dL. Review of the nursing progress notes revealed no notification to the physician the FSBS was less than 70 mg/dL. Review of the MAR for March 2016 revealed [MEDICATION NAME]5 units was ordered to be given before breakfast was held and not given for 18 days (March 02, 04, 05, 06, 07, 08, 09, 11, 13, 14, 15, 18, 19, 20, 21, 29, 30 and 31). Review of the March 2016 nursing progress notes, physician progress notes [REDACTED]. On 03/10/16 at 8:00 P.M., the FSBS was 346 mg/dL. Review of the nursing progress notes revealed there was no notification of the physician the FSBS was greater than 340 mg/dL. On 03/18/16 at 6:00 A.M., the FSBS was 61 mg/dL. Review of the nursing progress notes revealed there was no notification of the physician the FSBS was less than 70 mg/dL. Review of the MAR for April 2016 revealed the [MEDICATION NAME]5 units ordered to be given before breakfast was held and not given for seven days (April 01, 02, 09, 11, 12, 13 and 14). Review of the nursing progress notes, physician progress notes [REDACTED]. On 04/01/16 at 6:00 A.M., the FSBS was 67 mg/dL. Review of the nursing progress notes revealed there was no notification to the physician the FSBS was less than 70 mg/dL. 7. Review of Resident #58's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the monthly physician orders [REDACTED].M. and 4:00 P.M., and to administer [MEDICATION NAME]6 units, 3 times a day with meals and [MEDICATION NAME] 24, units at bedtime. Review of the MAR for January 2016 revealed the 6:00 A.M. administration of [MEDICATION NAME] insulin, 6 units ordered to be given before meals was held and not given for 7 days in January (January 15, 18, 19, 23, 27, 28 and 29). Review of the January 2016 nursing progress notes, physician progress notes [REDACTED]. Review of the MAR for February 2016, revealed the 6:00 A.M. [MEDICATION NAME]6, units ordered to be given before meals was held and not given for 3 days in February (February 01, 18 and 24). Review of the February 2016 nursing progress notes, physician progress notes [REDACTED]. Review of the MAR for March 2016 revealed the 6:00 A.M. [MEDICATION NAME] insulin, 6 units ordered to be given before meals was held and not given for 16 days in March (March 01, 04, 09, 11, 13, 14, 18, 19, 20, 21, 22, 23, 25, 27, 28 and 29). Review of the March 2016 nursing progress notes, physician progress notes [REDACTED]. Review of the MAR for April 2016 revealed the 6:00 A.M. [MEDICATION NAME] insulin, 6 units ordered to be given before meals was held and not given for 10 days in April (April 01, 02, 11, 12, 13, 16, 17, 18, 21 and 22). Review of the April 2016 nursing progress notes, physician progress notes [REDACTED]. 8. Review of Resident #59's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of Resident #59's physician order [REDACTED].