Every finding on record at Bath Manor Special Care Centre

Based on observation, interview, and record review, the facility failed to ensure adequate and timely incontinence care was provided. This affected one resident (#53) of three observed for incontinence care. The facility census was 111.Findings include: Review of Resident #53's medical records revealed an admission date of 08/04/25. Diagnoses included muscle weakness, need for personal care assistance, and morbid obesity.Review of the care plan dated 08/05/25 revealed Resident #53 had self care deficits. Interventions included to utilize two staff members for assistance with toileting and personal hygiene. Resident #53 had requested no male caregivers for personal care. Interventions included only females to provide personal care.Observation of incontinence care on 12/22/25 at 7:52 A.M. for Resident #53 with Certified Nursing Assistant (CNA) #283 revealed Resident #53 was incontinent of a large amount of stale smelling urine that had soaked through two incontinence briefs and her linens and had required an entire bed change. Interview with Resident #53 at time of observation revealed she had not been changed since approximately 6:00 P.M. the previous evening [12/21/25]. Interview with CNA #283 at the time of observation revealed Resident #53 had requested no male care and stated there had been times when no female CNA's were available to change Resident #53. CNA #283 confirmed Resident #53 had been heavily soiled when she had started her shift at 6:00 A.M. and had not been provided with timely incontinence care. This deficiency represents non-compliance investigated under Complaint Number 2691818.

Based on observation, record review, interviews, and facility policy review, the facility failed to maintain acceptable infection control practices during medication administration to prevent the spread of infection. This affected one resident (#16) and had the potential to affect eight (8) residents (#19, #23, #25, #35, #77, #100, and #118) residing on 100 hall and 300 hall who were identified by the facility to require blood glucose monitoring. The facility census was 113.Findings include: Review of the medical record for Resident #16 revealed an admission date of 06/14/23. Diagnoses included but were not limited to type 2 diabetes mellitus (DM), suicidal ideations, delusional disorders, and vascular dementia. Review of the Minimum Data Set (MDS) 3.0 Signficant Change in Status assessment dated [DATE] revealed Resident #16 had impaired cognition.Review of the physician's orders for December 2025 for Resident #16 revealed an order to monitor blood glucose levels twice a day (BID) at 5:00 A.M. and at 4:00 P.M.Observation of blood glucose monitoring on 12/09/25 at 6:03 A.M. revealed Licensed Practical Nurse (LPN) #119 entered Resident #16's room to obtain the resident's blood glucose level and placed the glucometer (a meter to check blood sugar reading) on the resident's over bed tray with no barrier or disinfecting first. The over the bed tray was visibly dirty and contained an open bottle of pop with a straw in it, an opened bag of chips, and a tissue. In addition, after exiting the room LPN #119 did not clean the blood sugar glucometer, which is shared between other residents and placed it back in the medication cart and proceeded to lock the cart.Interview on 12/09/25 at 6:08 A.M. with LPN #119 confirmed she placed the glucometer on the resident's over the bed tray without placing a barrier first or disinfecting. LPN #119 reported she didn't know she had to do that. LPN #119 confirmed she did not clean the glucometer after use on Resident #16. She reported she was in a hurry. LPN #119 confirmed she used the glucometer on other residents on the 100 and 300 hall.Interview on 12/09/25 at 7:36 A.M. with Mobile Director of Nursing (DON) confirmed a barrier is to be placed under the glucometer and the glucometer, which is used on other residents, is to be cleaned before and after each blood sugar check. Review of facility policy, Glucometer/Point of Care Blood Testing and Disinfection Procedure, revised 11/19/25, revealed procedure to wipe meter using friction with recommended type of germicidal disinfectant wipe and to place glucometer on clean surface or place a clean barrier on surface that glucometer is placed/rests on. Review of facility User instruction Manual for Assure Prism Blood Glucose Monitoring System. revealed on page 38, the meter should be cleaned and disinfected after use on each patient and the disinfection procedure is needed to prevent transmission of blood-borne pathogens. This deficiency represents an incidental finding of non-compliance identified during the complaint investigation completed on 12/11/25.

Based on kitchen observation, staff interview, and facility policy review, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all residents receiving meals from the kitchen. The facility identified six Residents (#30, #57, #60, #75, #119, and #269) as receiving nothing by mouth (NPO). The facility census was 112. Findings include: Observations on 05/05/25 (Monday) at 9:03 A.M. of the facility kitchen with Food and Nutrition Services Director (FNSD) #633 revealed in the reach-in refrigerator near the steam table there was two undated or labeled salads and approximately 10 bagged sandwiches without labels or dates. FNSD #633 indicated they usually disposed of salads and sandwiches after the weekend. There was dried food splatter on the preparation table for the food processor and a container of applesauce and a spoon on floor under the table. Observation of the kitchen hood revealed the metal grates and fire suppression system had a coating of built-up dust. FNSD #633 indicated there was an outside company who cleaned the kitchen hood every three months. The microwave had dried food splatter on the top panel. There was a whisk on the floor under the steamer. Observation inside the walk-in refrigerator revealed a container of milk with expiration date of 05/01/25. The floors of the walk-in refrigerator under storage racks were dirty with debris and dried milk on the left side of the walk-in refrigerator. There were boxes stacked to the ceiling on the storage racks. There was an undated salad covered with plastic wrap. FNSD #633 indicated staff had last cleaned the floor of the walk-in refrigerator about a month prior. Observation inside the walk-in freezer revealed ice buildup on boxes of fish, mashed potatoes, and egg rolls. There was additional ice buildup on the ceiling of the freezer. There were boxes stacked to the ceiling in the freezer. Observation inside the dry storage room revealed a box of powdered thickener was open to air and a one cup measuring cup in the box resting on the product. Interview on 05/05/25 with FNSD #633 confirmed findings at time of observation during kitchen tour. Review of the facility policy Kitchen Sanitation and Cleaning Schedules Policy dated 05/24/18 revealed food and nutrition services staff would maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. Review of the facility policy Storage of Refrigerated Foods Policy dated 03/09/25 revealed all refrigerated items must be stored at least six inches above the floor and 18 inches from the ceiling and sprinkler heads.

Based on record review, observation, and interview, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented as required. This had the potential to affect all residents residing in the facility. Facility census was 112. Findings include: Review of Resident #269 medical record revealed the resident was admitted on [DATE] with diagnoses of Parkinsonism, primary pulmonary hypertension, protein-calorie malnutrition, acute respiratory failure, other rheumatic mitral valve diseases, pressure ulcer stage 4, history of malignant neoplasm of prostate, dysphagia and muscle weakness. Further review of the medical record revealed an order dated 04/18/25 for enhanced barrier precautions (EBP). Observation on 05/07/25 at 11:34 A.M. revealed a sign outside Resident #269's room for Enhanced Barrier Precautions with instructions stating Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use, and Wound Care. Observation on 05/07/25 at 11:34 A.M. revealed Rehab #910 and Rehab #909 in Resident #269's room assisting the resident with repositioning in his wheelchair. Rehab #910 and Rehab #909 were not wearing PPE. Interview on 05/07/25 at 11:35 A.M. with Rehab #910 and Rehab #909 revealed they heard Resident #269 yelling out and they both ran into resident's room to assist him without donning PPE. Rehab #910 and Rehab #909 confirmed they should have donned PPE prior to assisting Resident #269. Review of the facility Transmission-Based Precautions and Isolation Policy with a revision date of 03/20/25 revealed EBP were indicated for high contact care actives for residents with chronic wounds and indwelling devices such as central lines, urinary catheters, and trachs and for all those colonized or infected with a Multidrug-resistant bacteria (MDRO) currently targeted by the Centers for Disease Control. Review of the facility Transmission-Based Precautions and Isolation Policy with a revision date of 03/20/25 revealed EBP were indicated for high contact care actives for residents with chronic wounds and indwelling devices such as central lines, urinary catheters, and trachs and for all those colonized or infected with a Multidrug-resistant bacteria (MDRO) currently targeted by the Centers for Disease Control.

Based on observation and interview, the facility failed to ensure clean linen rooms and common shower rooms were maintained in a clean and sanitary manner. This affected 25 (#43, #33, #220, #24, #15, #48, #400, #219, #45, #78, #51, #97, #220, #225, #107, #44, #79, #221, #112, #113, #80, #269, #270, #114, and #63) of 112 facility residents. Findings include: Environmental tour on 05/12/25 from 2:06 P.M. to 2:37 P.M. with Maintenance Assistant (MA) #806 and Housekeeping and Laundry Supervisor (HLS) #620 revealed the floor of the 300-unit clean linen room was covered with old, dried spills, scuffs marks, paper scraps, straw covers, large dust bunnies, and multiple Chetos. Observation of the 300 hall shower room revealed a toilet, sink, shower area, bathtub, storage cabinet, bedside commode, and a shower bed. A tee shirt was on the floor. A cigarette butt, pillow without pillow case, two plastic parts of a bedside commode, a fitted sheet that was wet with a large reddish brown stain and when lifted a strong urine odor was noted, a multicolored sweater, three wet wash cloths, a bottle of body wash, deodorant, and a bottle of peri wash were inside the bathtub and beneath the items was loose black debris and dried unidentifiable liquid spills. HLS #620 and MA #806 indicated the bath tub was not functional and never used. Interview with Certified Nurse Aide (CNA) #808 on 05/12/25 at approximately 2:15 P.M. revealed after showering a resident in the 300 unit shower room she had to return the resident to her room quickly. CNA #808 threw the fitted bed sheet, wash cloths, body wash, deodorant and peri wash in the bathtub and then went on break. CNA #808 said she had planned to come back to clean. She indicated the bathtub was not used. Further observation revealed the shower room floor was not wet to indicate a resident was recently showered, nor was the room filled with humidity. Interview on 05/13/25 at 8:40 A.M. with CNA #654 revealed housekeeping was responsible for cleaning the shower rooms. CNA #654 thought the shower rooms were cleaned twice daily but was not sure. Interview on 05/13/25 at 8:45 A.M. with Housekeeper #625 revealed she was assigned to clean the 300 unit. Housekeeper #625 normally started at the front of the unit and worked her way through to the shower room. The shower room was cleaned everyday, sometimes twice a day if needed. Housekeeper #625 said she rechecked the shower room throughout the day; however, yesterday (05/12/15) she had not made it back to check a second time. Housekeeper #625 was unsure whose responsibility it was to ensure the bath tub was cleaned and maintained in a sanitary manner so she completed the task. Interview on 05/13/25 at 8:58 A.M. with Regional Registered Nurse #900 revealed there was not a specific policy and procedure or job description related to keeping the shower rooms in a clean and sanitary manner. Because the bathtub in the shower room on the 300 hall had not been functional for several years the staff were using it as a storage area. The CNAs were responsible for cleaning and sanitizing the areas of the shower room which were used. All residents residents on the 300 unit used the shower room. Review of the facility census dated 05/12/25 revealed Residents #43, #33, #220, #24, #15, #48, #400, #219, #45, #78, #51, #97, #220, #225, #107, #44, #79, #221, #112, #113, #80, #269, #270, #114, and #63 resided on the 300 halls. This deficiency represents non-compliance investigated under Complaint Number OH00162078.

Based on observation, record review, and interview, the facility failed to ensure a resident was provided with a dignified dining experience. This affected one (#220) resident of one resident reviewed for dignity. The facility census was 112. Findings include: Review of the medical record for Resident #220 revealed an admitted [DATE] with diagnoses that included congestive heart failure, mild protein-calorie malnutrition, and dysphagia. Review of the care plan dated 04/10/25 revealed Resident #220 had a self-care deficit with interventions that included, but not limited to, assistance from staff. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #220 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated she was alert and oriented to person pace, and time. Observation and interview on 05/06/25 at 8:30 A.M. revealed Resident #220 was lying in bed with her over-the-bed table positioned above her with her breakfast meal. Resident #220's breakfast meal consisted of pancakes and crumbled sausage. MDS Registered Nurse (RN) #709 was observed standing over Resident #220, scooping up crumbled sausage on a spoon and feeding her. Interview with MDS RN #709, at the time of the observation, revealed she walked by Resident #220's room and saw she needed to eat. MDS RN #709 revealed Resident #220 was just sitting there and usually had someone sitting, cueing, and encouraging her during meals. MDS RN #709 confirmed she was standing up and over Resident #220 feeding her and the policy was to sit down while assisting with meals. This deficiency represents non-compliance investigated under Complaint Number OH00165140, OH00165044, and OH00162078.

Based on record review, interviews, and facility policy review, the facility failed to ensure quarterly statements for resident funds accounts were mailed to the individuals who were identified as the guardian or primary financial contact for residents. This affected three residents (#33, #71,#93) out of six residents reviewed for resident funds. The facility identified 50 residents (#1 to #3 , #5, #6, #9, #11, #15 to #19, #21, #24, #26 to #28, #30 to #33, #35, #37, #39, #40, #42, #46, #47, #49 to #55, #61, #62, #64, #68, #69, #71, #72, #81, #82, #86, #89, #93, #94 , and #121) as having a personal funds account. The facility census was 112. Findings include: 1. Review of the medical record for Resident #33 revealed an admitted [DATE] and the mother of Resident #33 was listed as the primary power attorney for healthcare and the primary financial contact. Review of the Resident Fund Management Service Authorization Agreement to Handle Resident Funds, revealed on 10/25/19, the mother had signed to set up a resident fund account for Resident #33. The document indicated with a signature, the person was authorizing the facility to establish an insured interest-bearing account and the person signing the document would receive a statement at least quarterly. Review of the facility document Trial Balance, dated 05/07/25, revealed Resident #33 had a resident fund account with a balance of $73.27. Review of Resident #33's quarterly statements for the period of 10/01/24 through 12/31/24 and for the period of 01/01/25 through 03/31/25 revealed the resident had a balance of $73.27 for both periods. The resident fund statement was addressed to Resident #33 at the facility's address of 2330 [NAME] Road, Akron, Ohio, 44333. Interview on 05/05/25 at 3:24 P.M. with the mother of Resident #33 revealed she had not received quarterly statements and she had no clue what was in his personal fund account. Interview on 05/12/25 at 9:03 A.M. with Business Office Manager (BOM) #715 revealed the facility used a third party to mail out the residents' quarterly statements, and the statements were mailed to the address at the top of the quarterly statements. BOM #715 confirmed Resident #33's quarterly statements were not mailed to the primary financial contact for Resident #33. 2. Review of medical record for Resident #71 revealed an admitted [DATE] and the daughter of Resident #71 was listed as the primary financial contact. Review of the Resident Fund Management Service Authorization Agreement to Handle Resident Funds, revealed on 09/24/21, the daughter had signed to set up a resident Qualified Income Trust (QIT), a special form of trust designed to help people receive long-term benefits under Medicaid , fund account for Resident #71, and on 06/09/22 the daughter had signed to set up a resident personal fund account for Resident #71. The document indicated with a signature, the person was authorizing the facility to establish an insured interest-bearing account and the person signing the document would receive a statement at least quarterly. Review of facility document Trial Balance, dated 05/07/25, revealed Resident #71 had a QIT account with a balance of $21,574.62 and a resident fund account balance of $151.28. Review of Resident #71's quarterly statements for the period of 01/01/25 through 03/31/25 revealed the resident's QIT account had a balance of $21,574.24 and the resident's personal fund account had a balance of $151.28. Both of the resident's fund statements were addressed to Resident #71 at the facility's address at 2330 [NAME] Road, Akron, Ohio, 44333. Interview on 05/08/25 at 11:53 A.M. with the daughter of Resident #71 revealed she was not receiving any quarterly statements. Interview on 05/12/25 at 9:03 A.M. with Business Office Manager (BOM) #715 revealed the facility used a third party to mail out the residents' quarterly statements, and the statements were mailed to the address at the top of the quarterly statements. BOM #715 confirmed Resident #33's quarterly statements were not mailed to primary financial contact for Resident #71. 3. Review of medical record for Resident #93 revealed an admitted [DATE] and the resident had a guardian. Review of the Resident Fund Management Service Authorization Agreement to Handle Resident Funds, revealed on 11/25/24, the guardian had signed to set up a resident fund account for Resident #93. The document indicated with a signature, the person was authorizing the facility to establish an insured interest-bearing account and the person signing the document would receive a statement at least quarterly. Review of facility document Trial Balance, dated 05/07/25, indicated Resident #93 had a resident fund account with a balance of $3642.01. Review of Resident #93's quarterly statements for the period of 11/07/24 through 12/31/24 revealed the resident had a balance of $50.00 and for the period of 01/01/25 through 03/31/25 had a balance of $200.00. The resident fund statement was addressed to Resident #93 at the facility's address at 2330 [NAME] Road, Akron, Ohio, 44333. Interview on 05/12/25 at 9:03 A.M. with Business Office Manager (BOM) #715 revealed the facility used a third party to mail out the residents' quarterly statements, and the statements were mailed to the address at the top of the quarterly statements. BOM #715 confirmed Resident #33's quarterly statements were not mailed to the guardian of Resident #93. Review of the facility policy Resident Fund Management (RFMS) Policy, revised 10/13/21, revealed quarterly trust statements would be mailed by a third party and statement addresses were to be correct.

Based on record review, interviews, and facility policy review, the facility failed to provide notice to Resident #94 when his resident funds account reached $200 less than the Supplemental Security Income (SSI) resource limit for one person and failed to ensure Resident #226's account funds were dispersed timely after expiration. This affected two residents (#94 and #226) of six residents reviewed for resident funds. The facility census was 112 residents. Findings include: 1. Review of the medical record for Resident #94 revealed an admitted [DATE] and Medicaid was a payor source. The resident was the primary financial contact and was cognitively intact. Review of Resident #94's resident fund account's quarterly statement for the period of [DATE] through [DATE] revealed a balance of $8,266.94 and for the period of [DATE] through [DATE] revealed a balance of $8,087.63. Review of the facility's document Trial Balance, dated [DATE], revealed Resident #94 had a current balance of $3,797.16. There was no documented proof Resident #94 had received a spend down notification. Interview on [DATE] at 12:31 P.M. with Resident #94 revealed he did not know he had an account, and did not know how much he had in the account. Interview on [DATE] at 9:03 A.M. with Business Office Manager (BOM) #715 confirmed there was no documented proof spenddown letters had been sent to Resident #94, and when asked why there was no documented proof spenddown letters had been sent, BOM #715 stated during that time she had been busy covering the admissions position along with her own position as the BOM. Review of the facility policy Resident Fund Management (RFMS) Policy, revised [DATE], revealed the business office was to notify all Medicaid residents when the asset limit was approaching. 2. Review of the medical record for Resident #226 revealed an admitted [DATE] and an expiration date of [DATE]. Review of the facility document Resident Statement revealed Resident #226's account was closed on [DATE] and had a balance of $1,192.86 dollars in the account when the account was closed. Review of a check, numbered 10055474 and dated [DATE], written to the funeral home in the amount of $1,1192.86 for Resident #226's funeral expenses revealed the check was written over three months after the resident had expired. Interview on [DATE] at 11:52 A.M. with BOM #715 and Regional Director #950 confirmed the date on the check and the check had not been sent out timely. Review of the facility policy Resident Fund Management (RFMS) Policy, revised [DATE], revealed trust accounts for expired residents were to be closed and funds dispersed timely.

Based on observations, record review, interviews, and facility policy review, the facility failed to develop a person- centered care plan related to the consumption of alcohol. This affected one (#44) of one resident reviewed for alcohol consumption. The facility census was 112. Findings include: Review of the medical record for Resident #44 revealed he was admitted to the facility on [DATE] with diagnoses that included chronic diastolic congestive heart failure, cellulitis of left lower limb, and acute kidney failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 14 that indicated he was alert and oriented to person, place, and time. Review of the MDS assessment also revealed Resident #44 required some assistance from staff for Activities of Daily Living (ADLs). Review of Resident #44's current physician orders revealed no orders for alcohol consumption. Review of Resident #44's current care plan revealed no plan/interventions related to alcohol consumption. Observation on 05/06/25 at 8:35 A.M. revealed the Administrator looking inside Resident #44's compact refrigerator located inside his room. The Administrator was observed removing two 6.8 ounce bottles of [NAME] Bootlegger Ice Lemonade canned cocktails which contained 12 percent (%) alcohol. The Administrator was then observed informing Resident #44 he had no care plan or orders in place to consume or have alcohol stored in his room. The Administrator was then observed placing the alcohol bottles back into the refrigerator and exiting Resident #44's room. Interview and observation on 05/06/25 at 8:46 A.M. revealed Resident #44 had two 6.8 ounce bottles of [NAME] Bootlegger Ice Lemonade canned cocktails which contained 12 percent (%) alcohol located in his compact refrigerator. Resident #44 revealed his friend purchased the alcohol for his consumption. The Administrator entered Resident #44's room during this observation and interview and confirmed the above findings. The Administrator stated Resident #44 did not have a order or care plan in place to consume or store alcohol beverages in his room. Interview on 05/06/25 at 4:25 P.M. with Regional Registered Nurse (RRN) #900 revealed Resident #44 had two bottles of hard liquor removed from his room compact refrigerator. Review of the facility document titled Alcoholic Beverage Use revised 08/11/20, revealed residents could have alcoholic beverages if prescribed by their provider, could be obtained by family, and must be administered by a licensed nurse only. Further review of the policy revealed residents were not allowed to keep alcoholic beverages in their room.

Based on observation, resident record review, resident interview, staff interview, and facility policy review, the facility failed to ensure oxygen tubing was changed and an order was in place for administering oxygen. This affected one (#221) of one resident for respiratory care. The facility census was 112. Findings include: Review of the medical record for Resident #221 revealed an admitted d of 04/28/25 with diagnoses that included peripheral vascular disease, type 2 diabetes, and congestive heart failure. Review of the progress note dated 04/29/25 timed 2:03 P.M. revealed Resident #221 had oxygen established in the home. Review of Resident #221's current physician orders revealed no orders for oxygen. Review of Resident #221's care plan dated 04/30/25 revealed no current interventions related to oxygen administration. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #221 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated he was alert and oriented to person, place, and time. Further review of the MDS assessment revealed Resident #221 required some assistance for activities of daily living (ADLs). Observation and interview on 05/05/25 at 12:11 P.M. revealed Resident #221 seated in his wheelchair with oxygen in place and being administered via nasal cannula. The oxygen tubing and nasal cannula was undated. Resident #221 revealed his oxygen and nasal cannula tubing had not been changed. Observation and interview on 05/05/25 at 12:15 P.M. with Licensed Practical Nurse (LPN) #638 revealed Resident #221 was on oxygen via nasal cannula as needed. LPN #638 revealed she did not know when the last time the tubing and nasal cannula was changed. LPN #638 confirmed there were no current orders in place for Resident #221's oxygen administration. Review of Resident #221's Medication Administration Record from 04/28/25 to 05/13/25 revealed the first documentation the oxygen concentrator and filter were cleaned and oxygen tubing changed was 05/09/25. Review of the facility policy Oxygen Administration (All Routes) revised 07/30/24, revealed the facility would verify the provider order and then assemble equipment. Further review of the policy revealed the facility would change tubing, mask and cannula weekly and document.

Based on observation, resident record review, resident interview, staff interview, and facility policy review, the facility failed to ensure all drugs and biologicals were properly secured and permit only authorized personnel to have access. This affected one (#221) of one resident reviewed for self-administration of medications. The facility census was 112. Findings include: Review of the medical record for Resident #221 revealed an admitted d of 04/28/25 with diagnoses that included peripheral vascular disease, type 2 diabetes, and congestive heart failure. Further review of Resident #221's medical record revealed there was no assessment indicating Resident #221 was safe to self-administer medication. Review of the progress note dated 04/29/25 timed 11:08 A.M. revealed Resident #221 had multiple scattered tinea areas on bilateral arms with discoloration. Review of the care plan dated 04/30/25 revealed Resident #221 had tinea corporis located on the left and right posterior forearm. Review of the physician orders dated 04/30/25 revealed Resident #221 had an order for clotrimazole one percent cream to be applied twice a day to bilateral forearms. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #221 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated he was alert and oriented to person, place, and time. Further review of the MDS assessment revealed Resident #221 required some assistance for activities of daily living (ADLs). Observation and interview on 05/05/25 at 12:11 P.M. revealed two tubes of clotrimazole one percent cream located on Resident #221's bedside table. Resident #221 revealed he had ringworm on both arms and he applied the cream himself. Interview on 05/05/25 at 12:15 P.M. with Licensed Practical Nurse (LPN) #638 revealed Resident #221 had ringworm and the facility applied cream daily. LPN #638 confirmed Resident #221 did not have a self-administration assessment or order to apply the antifungal cream himself. At the time of the interview, LPN #638 entered Resident #221's room as he was rubbing the cream into his forearm. LPN #638 revealed the cream located on the bedside table was the prescribed medication for his ringworm. LPN #638 was observed putting on gloves and removing two tubes of clotrimazole one percent cream from Resident #221's room. Review of the facility policy Self-Administration of Medications revised 06/01/24, revealed the facility, in conjunction with the interdisciplinary care team was to assess and determine, with respect to each resident, whether self-administration of medication was safe and clinically appropriate, based on the resident's functionality and health condition. The facility was to ensure that orders for self-administration listed the specific medication(s) the resident could self administer.

Based on record review, interview, review of the Emergency Medical Services (EMS) Prehospital Care Report and review of the facility policy, the facility failed to timely notify the Guardian of Resident #18 when a significant change in condition occurred. This affected one resident (#18) of three residents reviewed for notification of changes. The facility census was 109. Findings include: Record review for Resident #18 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease with early onset, schizophrenia, mood disorder, impulse disorder, restlessness and agitation, and need for assistance with personal care. Record review revealed Resident #18 had a Legal Guardian. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 was severely cognitively impaired, dependent upon staff for transfers, used a wheelchair, and was dependent for mobility. Review of the progress note for Resident #18 dated 12/27/24 at 2:29 A.M. completed by Licensed Practical Nurse (LPN) #499 included during the P.M. medication pass, Resident #18 became unresponsive. The TeleMedicine (TeleMed) (use of technology to remotely deliver medical services) Certified Nurse Practitioner (CNP) wanted Resident #18 sent out to the hospital. The paramedics arrived, and Resident #18 needed Narcan (medication to treat narcotic overdose). Resident #18 became responsive. TeleMed was notified and ordered neuro checks per facility protocol. Resident #18 became unresponsive again and was aroused in five minutes. Contacted TeleMed again, and they ordered every 15 min checks and to hold any narcotics until seen by the doctor. Will notify the Director of Nursing (DON) and family in the A.M. Review of the undated written statement created by LPN #499 included she (LPN #499) started the shift on 12/26/24 at 7:00 P.M. During the medication pass for residents she went to Resident #18's room to give him his medications. Resident #18 seemed like he was asleep. LPN #499 began to say Resident 18's name multiple times and put the head of the bed up. Resident #18 opened his eyes and closed them again. LPN #499 started to say his name again and rubbed his chest, doing a sternal rub. LPN #499 sat Resident #18 up more and told him she had his medications. Resident #18 said, Huh and opened his mouth and took his medication. LPN #499 revealed Resident #18 still did not seem right, and she contacted TeleMed and was instructed to send Resident #18 to the emergency room . EMS arrived and assessed Resident #18's pupils and said, They are pinpointed; he needs Narcan. Resident #18 came to in five to ten seconds after receiving the Narcan and started to be himself again. LPN #499 revealed she never told EMS not to take Resident #18 to the hospital. They said since he was back to himself, there was no reason to take him to the hospital. LPN #499 revealed EMS instructed to keep an eye out or if it happened again to administer Narcan because of the half-life of Narcan. Documentation included EMS left, Resident #18 was checked every 30 minutes. Around 12:00 A.M. the Certified Nurse Aide (CNA) reported Resident #18 was not himself again. Both staff were saying his name, and he ended up waking up. TeleMed was contacted, gave an order for the Narcan but because the resident was awake was told not to give it and monitor resident every 15 minutes. LPN #499 revealed she did not notify the family that late at night, she informed them in the morning. Review of the Fire Department #606's Prehospital Care Report with the call dated 12/26/24 at 8:48 P.M. completed by Emergency Medical Technician (EMT) #605 revealed the unit was on scene on 12/26/24 at 9:02 P.M. related to an emergent response. The resident's name was (Resident #18). Primary Impression: Poisoning by drug/meds/biol substance, accidental. Narrative included, the unit was dispatched for an unknown problem. Upon arrival, Resident #18 was lying in bed with a pulse and breathing. Staff stated they were unable to wake him. They gave him pain medication around 8:00 P.M. and when they went to check on him, he was unresponsive. Resident #18 had pinpoint pupils. Staff grabbed Narcan and wanted to administer. Staff administered two milligrams (mg) Narcan. Resident #18 woke up one minute later. Staff stated he was now acting normal, they did not want him to go to the hospital, and they would monitor him. Staff refused transport. Resident #18 was nonverbal. Review of the Refusal form included: Resident #18 refusal of service; Resident #18 advised of medical treatment and evaluation needed and further harm may result without medical treatment. Depart 12/26/24 at 9:24 P.M. The phone interview on 01/22/24 at 4:42 P.M. with the Guardian of Resident #18 revealed she was upset that the facility did not notify her on 12/26/24 when Resident #18 was found to be unresponsive, was administered Narcan and the decision was made by someone not to send him to the hospital. The Guardian revealed the signature on the refusal form was Resident#18's signature. The Guardian revealed the paramedics did not know Resident #18 had a guardian. The facility did though, and they should have called her. The Guardian revealed the nurse called her on 12/27/24 at 6:00 A.M. and revealed she was upset because she would have sent Resident #18 to the hospital after receiving the Narcan to see what was in his system. An interview on 01/23/25 at 2:52 P.M. with the Director of Nursing (DON) revealed the Guardian for Resident #18 should have been notified of the change in condition as soon as possible. Review of the policy titled, Resident Change in Condition Policy revised 11/10/20 revealed the provider/family/responsible party will be notified as soon as practicably possible. This deficiency represents non-compliance investigated under Complaint Number OH00161054.

Based on observation, interview, record review and review of the facility policy, the facility failed to provide A.M. care to include washing face and hands and oral care for Residents #76 and #106. This affected two residents (#76 and #106) of three residents reviewed for activities of daily living (ADL). The facility census was 109. Findings include: 1. Record review for Resident #76 revealed an admitted [DATE]. Diagnoses included spastic hemiplegic cerebral palsy, multiple sclerosis, cervical disc disorder, blindness in the left eye, muscle weakness and need for assistance with personal care. Review of the care plan dated 10/28/24 revealed Resident #76 had an ADL self-care and mobility deficit related to multiple sclerosis, weakness, debility, cerebral palsy, and impaired mobility. Interventions included assistance with hygiene/bathing hygiene, dressing, grooming, toileting, feeding, and oral care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76 was cognitively intact. Resident #76 required substantial/maximal assistance from staff with oral hygiene, bathing, and personal hygiene. Resident #76 used a wheelchair and was dependent upon staff for chair/bed transfers. Observation on 01/22/25 at 10:04 A.M. of Certified Nursing Assistant (CNA) #457 providing A.M. care for Resident #76 revealed CNA #457 did not wash or offer to wash Resident #76's face or hands and did not provide or offer to provide Resident #76 with oral care. CNA #457 confirmed she completed all A.M. care for Resident #76 and exited the room. Observation revealed Resident #76 had visible residual food particles left in his mouth, and his face was oily. Resident #76 revealed the staff never provided him with oral care. Resident #76 revealed he would like his mouth cleansed and rinsed and it would be nice to get his face washed in the morning. CNA #457 returned to Resident #76's room per the surveyor's request and confirmed mouth care was not completed, food residual was left in Resident #76's mouth, and Resident #76 did not have his face or hands washed at all this A.M. 2. Record review for Resident #106 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), muscle weakness, muscle wasting and atrophy, malignant neoplasm of cervix uteri, and the need for assistance with personal care. Review of the care plan dated 05/13/24 revealed Resident #106 had a self-care deficit related to weakness, impaired mobility, COPD, depression, and cancer. Interventions included bathing/hygiene with assistance from one to two staff. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #106 was moderately cognitively impaired. Resident #106 required partial/moderate assistance with oral hygiene and was dependent upon staff for personal hygiene. Observation on 01/22/25 at 10:39 A.M. revealed Resident #106 was sitting up in bed. Resident #106's hair had a big knot and was disheveled in the back. Resident #106 revealed she was not assisted with or provided oral care this A.M. and did not have her hair combed. Resident #106 revealed it would be nice to have those things done every morning. Interview on 01/22/25 at 10:43 A.M. with CNA #457 confirmed she had already completed A.M. care with Resident #106. CNA #457 verified she did not brush or offer to brush Resident #106's hair and did not provide or offer to provide oral care for Resident #106 before, during, or after A.M. care. Interview on 01/22/25 at 11:27 A.M. with the Director of Nursing (DON) revealed during A.M. care, CNAs were expected to do head-to-to-tee care, which included washing residents' face, cleaning the resident's body and providing oral care. Review of the facility policy titled, Morning Care/AM Care revised 06/15/20 revealed morning care will be offered each day to promote resident comfort, cleanliness, grooming and general wellbeing. The procedure included assisting with/provide oral hygiene, provide nail care, and brush/comb hair. This deficiency represents non-compliance investigated under Complaint Number OH00161110.

Based on observation, interview, record review and review of the Emergency Medical Service (EMS) Prehospital Care Report, the facility failed to provide appropriate care and services to Resident #18, who had a significant change in condition with an altered mental status, difficult to arouse, and periods of unconsciousness. Resident #18 was administered by mouth routine medications to include psychotropic medications while being difficult to arouse and prior to notifying the physician of the change in condition. Once contacted, the physician requested Resident #18 to be transported to the emergency room . Resident #18 was not transported to the hospital emergency room per direction of the physician, Resident #18 was administered Narcan for a potential drug overdose then resided at the facility. There were no labs obtained to determine the cause for the potential drug overdose nor was the pharmacy utilized to review medications related to the potential drug overdose. This affected one resident (#18) of one resident reviewed for a potential drug overdose. The facility census was 109. Findings include: Record review for Resident #18 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease with early onset, schizophrenia, mood disorder, impulse disorder, restlessness and agitation, and need for assistance with personal care. Record review revealed Resident #18 had a Legal Guardian. Resident #18 had no known allergies. Review of the care plan dated 07/15/24 revealed Resident #18 had behavioral symptoms not directed to others verbal/vocal symptoms like screaming, disruptive sounds, and refused to be shaved. Interventions included when the resident yells out, ask the resident if he needs anything. Provide encouragement and calmness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 was severely cognitively impaired, had no hallucinations or delusions, no verbal or physical behaviors exhibited no rejection of care and no wandering in the seven-day assessment reference period. Resident #18 required set up or clean up assist with eating, dependent upon staff for toileting hygiene, bathing, dressing, and personal hygiene. Resident #18 required substantial/maximal assistance for bed mobility, dependent for transfers, used a wheelchair and was dependent upon staff for mobility. Review of the physician orders for Resident #18 revealed changes in medications for December 2024 included on 12/09/24 Risperidone (antipsychotic) was increased from 0.5 milligrams (mg) two times a day to one mg two times a day (7:00 A.M. to 11:00 A.M. and 7:00 P.M. to 11:00 P.M.) and on 12/19/24 Ativan 0.5 mg (antianxiety) was increased from 0.5 mg every day to 0.5 mg three times a day (6:00 A.M., 2:00 P.M. and 9:00 P.M.). Additional orders included Divalproex capsule delayed release (DR) sprinkles 125 mg (anticonvulsant) give two capsules in the A.M. ordered 04/18/24 and Divalproex capsule DR sprinkles 125 mg give four capsules night shift ordered 07/12/24. Review of the progress note dated 12/09/24 at 12:26 P.M. completed by LPN #428 revealed new order to increase risperidone to one mg two times a day. The progress note did not express the reason for the increase in Risperidone. Review of the progress note dated 12/19/24 at 3:07 P.M. completed by Licensed Practical Nurse (LPN) #465, Resident #18 continues to yell when needing things. Yells when wanting food/fluids. Yells when wanting trash thrown out after eating snack; gets staff attention by yelling then will verbalize a need or request. Certified Nurse Practitioner (CNP) gives new order to increase Ativan to three times a day (TID). Review of the progress notes from 11/01/24 through 12/25/24 revealed Resident #18 had no episodes of being difficult to arouse or unconscious. Review of the Medication Administration Record (MAR) for Resident #18 for December 2024 revealed on 12/26/24, Resident #18 received all the scheduled doses of medication. No additional medications were administered. On 12/26/24, the evening administration of medications, LPN #499 administered Carvedilol 3.125 mg (used to treat high blood pressure), Divalproex DR sprinkles 125 mg four capsules, Gabapentin 100 mg (used to treat epilepsy), Ativan 0.5 mg, Tamsulosin 0.4 mg (used to treat enlarged prostate), Risperidone 1 mg and Spironolactone 25 mg (used to treat high blood pressure). Review of the progress note dated 12/27/24 at 2:29 A.M. completed by LPN #499 included during P.M. medication pass Resident #18 became unresponsive. TeleMedicine (TeleMed) (use of technology to remotely deliver medical services) CNP wanted Resident #18 sent out to the hospital, paramedics arrived, and Resident #18 needed Narcan (medication to treat narcotic overdose). Resident #18 became responsive, and TeleMed was notified and ordered neuro checks per facility protocol. LPN #499 and Certified Nursing Assistant (CNA) checked on Resident #18 every 30 minutes to an hour. At 12:30 A.M. Resident #18 became unresponsive again and was aroused in five minutes. LPN #499 contacted TeleMed again, and they ordered every 15-minute checks and vital signs (VS) for an hour and hold any narcotics until the resident was seen by the doctor. LPN #499 notify the Director of Nursing (DON) and family (guardian) in the morning. Review of the progress note for Resident #18 dated 12/27/24 at 6:14 A.M. completed by LPN #499 revealed resident #18's Guardian and the DON were notified. Record review for Resident #18 revealed after the 12/26/24-12/27/24 episode, Resident #18 had no further episodes of change in mental status from the baseline. Review of the untimed Witness Statement dated 12/31/24 completed by LPN #427 included on 12/26/24 she gave Resident #18 his afternoon medication. Resident #18 was in his wheelchair, and he was alert, pleasant, and at his baseline. Review of the untimed Witness Statement dated 12/26/24 completed by LPN #304 revealed on 12/26/24 she worked the 3:00 P.M. to 7:00 P.M. shift. Resident #18 was actively yelling and talking the entire time. The CNA put Resident #18 to bed around 6:00 P.M., and Resident #18 was actively responding. Review of the typed statement dated 12/31/24 at 2:32 P.M. completed by LPN #336 revealed on 12/26/24 at the end of medication pass, the nurse (LPN #499) came and got her and stated Resident #18 was not waking up but breathing. Upon assessment, Resident #18 was lethargic and hard to wake up. LPN #499 was saying his name and rubbing his chest. He would respond a little then go right back to sleep. LPN #336 instructed LPN #499 to call the doctor and let them decide what to do next. LPN #499 called the doctor, and they said to send the resident to the emergency room for evaluation. EMS arrived, and the nurse (LPN #499) came out and said she needed Narcan for EMS to give to the resident. LPN #336 revealed she obtained the Narcan through the stock medication supplies, gave it to the nurse (LPN #499) who then handed it to EMS in the hallway. LPN #336 revealed she did not go back into the resident while the Narcan was being administered. The nurse (LPN #499) came out of the resident's room and said he was back to normal. EMS told the nurse (LPN #499) that if he went unresponsive again to give him another dose if the Narcan. Review of the undated written statement created by LPN #499 included LPN #499 started the shift on 12/26/24 at 7:00 P.M. During the medication pass for residents she went to Resident #18's room to give him his medications. Resident #18 seemed like he was asleep. LPN #499 began to say Resident 18's name multiple times and put the head of the bed up. Resident #18 opened his eyes and closed them again. LPN #499 started to say his name again and rubbed his chest doing a sternal rub. LPN #499 sat Resident #18 up more and told him she had his medications. Resident #18 said, Huh and opened his mouth and took his medication. LPN #499 revealed she did watch Resident #18 swallow his medication and revealed, But (Resident #18) still did not seem right to me so I asked another nurse (LPN #336) who knew (Resident #18) longer than me to come and look at him. She agreed with me that (Resident #18) did not seem like himself. LPN #499 revealed after taking Resident #18's vital signs, she contacted TeleMed and was instructed to send Resident #18 to the emergency room . EMS arrived and assessed Resident #18's pupils and said, They are pinpointed; he needs Narcan. EMS reviewed the medications Resident #18 was given. Another facility nurse (LPN #336) obtained the Narcan from the stock medications, and EMS administered the Narcan to Resident #18. Resident #18 came to in five to ten seconds after receiving the Narcan and started to be himself again. LPN #499 revealed she never told EMS not to take Resident #18 to the hospital. They said since he was back to himself, there was no reason to take him to the hospital. LPN #499 revealed EMS instructed staff to keep an eye out or that if it happened again, to administer Narcan because of the half-life of Narcan. EMS left; Resident #18 was checked every 30 minutes. Around 12:00 A.M., the CNA reported Resident #18 was not himself again. Both staff were saying his name, and he ended up waking up. TeleMed was contacted, gave an order for the Narcan but because the resident was awake was told not to give it and monitor resident every 15 minutes. LPN #499 revealed she charted Resident 18's medical record at around 2:00 A.M., did not notify the family (Guardian) that late at night, so she informed them in the morning. Review of the Fire Department #606's Prehospital Care Report with the call dated 12/26/24 at 8:48 P.M. completed by Emergency Medical Technician (EMT) #605 revealed the unit was on scene on 12/26/24 at 9:02 P.M. related to an emergent response. The resident's name was (Resident #18). Primary Impression: Poisoning by drug/meds/biol substance, accidental. Narrative included the unit was dispatched for an unknown problem. Upon arrival, Resident #18 was lying in bed with a pulse and breathing. Staff stated they were unable to wake him. They gave him pain medication around 8:00 P.M. and when they went to check on him, he was unresponsive. Resident #18 had pinpoint pupils. Staff grabbed Narcan and wanted to administer. Staff administered two milligrams (mg) Narcan. Resident #18 woke up one minute later. Staff stated he was now acting normal, they did not want him to go to the hospital, and they would monitor him. Staff refused transport. Resident #18 was nonverbal. Review of the Refusal form included: Resident #18 refusal of service; Resident #18 advised of medical treatment and evaluation needed and further harm may result without medical treatment. Depart 12/26/24 at 9:24 P.M. Phone call placed to the Fire Department #606 on 01/22/25 at 10:55 A.M. and a request was made to have the Fire Chief or EMT #605 return the call. Interview on 01/22/25 at 1:00 P.M. with CNP #600 revealed she visited Resident #18 on 12/27/24 in the morning due to his unresponsiveness the evening prior. CNP #600 revealed on 12/27/24 when she visited him, he was the same as prior to the episode on 12/26/24. There was no change; he was completely at baseline. CNP #600 revealed she would not have given Resident #18 the medication on the evening of 12/26/24 if he was not responding. CNP #600 revealed she was unsure why Resident #18 was not sent to the emergency room (ER). CNP #600 revealed she worked with an insurance group that visited the residents at the facility routinely. When she saw Resident #18 on 12/27/24, she thought the other CNP had already ordered his drug screen. She then found out later that the other CNP did not order the labs because she thought CNP #600 ordered them. Ultimately the drug screen was not ordered timely to determine if Resident #18 had an overdose of medications/drugs on 12/26/24. Phone call made on 01/22/25 at 2:31 P.M. to the Fire Department #606. Spoke with EMS Administrator Assistant #607 who revealed she spoke with Fire Chief who will return the surveyor call today or tomorrow. Interview and observation on 01/23/25 at 7:45 A.M. with LPN #343 revealed she was Resident #18's nurse for approximately two years. Resident #18 never had an episode where he was unresponsive or even lethargic. Resident #18 had a difficult time communicating, so he normally yelled or screamed when he wanted something until he got it and then he would stop. Medications Risperidone and Ativan were increased due to the yelling behaviors. Observation of medication administration revealed LPN #343 crushed all Resident #18's medications including the Divalproex DR capsules. LPN #343 opened the two Divalproex capsules, 125 mg each, and placed the sprinkles that were inside the capsules into a small clear pouch with the remainder of the 7:00 A.M. medications and crushed all the medications together in one pouch to a fine powder using a pill crusher. LPN #343 then placed the powder in applesauce and administered the medications to Resident #18. Review of the patient information leaflet for Divalproex DR capsules revealed the capsules should be swallowed whole and should not be crushed or chewed, the capsule can be opened and sprinkled on food. Interview and record review of Resident #18's medications on 01/23/25 at 10:00 A.M. with the facility Pharmacist Consultant #602 revealed monthly reviews were completed on each resident reviewing all medications. For Resident #18, there were no indications in the physician orders that the medications were being crushed. The Divalproex DR could be opened and added to food, but the sprinkles should not be crushed or chewed. The medication was used for schizophrenia. The idea is to extend the absorption time to the next dose which if they were crushed or chewed, would not happen. Reviewed all other medications with Pharmacist Consultant #602 who revealed there were no other concerns with the ordered medications. Pharmacist Consultant #602 revealed he would not expect that reaction with Divalproex DR even if it was crushed due to he was taking it for so long. Ativan would have an immediate action which was started three times a day on 12/19/24. The Risperidone increase on 12/09/24 may take a few days but would not expect the unresponsive episode one time. The Narcan was like a drug test, it would not be effective if it was not an overdose causing Resident #18 to be unresponsive then suddenly wake up with the administration of Narcan, he had to have something in his system for the Narcan to block that would allow him to wake up. Pharmacist Consultant #602 revealed the facility never requested him to review the medications due to possible overdose. Interview on 01/23/24 at 10:31 A.M. with LPN #370 revealed she worked on 12/25/24 night shift. She stayed over the morning of 12/26/24 until 9:00 A.M. due to a call off. LPN #370 revealed she gave Resident #18 all his morning medications on 12/26/24 as ordered. There was nothing unusual with Resident #18. His behavior was baseline. At 9:00 A.M. she handed the keys off to Unit Manager LPN #427 and left the facility. Phone interview on 01/23/25 at 11:15 A.M. with LPN #499 revealed on 12/26/24 she started her shift at 7:00 P.M. She got a report from the previous nurse and started her medication pass. LPN #499 stated, When I got to him, (Resident #18) he was unresponsive; I gave a sternum rub, sat him up, said (Resident #18's name) I got your meds. He said huh, so I gave them to him. There was no report of a med error, so then I called TeleMed, got an order to send him out. Two EMT's came, the paramedic checked his vital signs and said his eyes were pinpointed; he needed Narcan. The other nurse went to get the Narcan then EMS administered it. (Resident #18) woke up right after and was himself; he started screaming. I told the paramedic that it was normal for him. The paramedic said if he was normal, there was no need to go to the ER. LPN #499 revealed she did not know who signed the form to refuse transport, no one signed anything while she was there. Resident #18 became lethargic again but was responsive. The physician said to monitor him. Phone call made on 01/23/25 at 12:09 P.M. to the Fire Department #606. Spoke with EMS Administrator Assistant #607 who revealed she spoke with Fire Chief who is waiting for a response from the attorneys before he will return the surveyor's call. An interview on 01/23/25 at 2:52 P.M. with the DON revealed she reviewed the incident on 12/26/24 -12/27/24 with Resident #18. She asked LPN #499 why she would give medications to a drowsy or sleepy resident. LPN #499 revealed when she did a sternal rub, he said huh, so she felt it was okay to give him his medications. The DON revealed she reviewed the narcotic forms throughout the whole facility, and there were no discrepancies. The DON confirmed the facility never consulted with the pharmacy to assist in determining the change in condition on 12/26/24 for Resident #18 that required Narcan administration. The DON also confirmed that a drug screen was not done timely to determine the change in condition on 12/26/24 for Resident #18 that required Narcan administration. As of 01/27/25, no call was received from Fire Department #606. This deficiency represents noncompliance investigated under Complaint Number OH00161054.

Based on interview, record review and review of the Emergency Medical Services (EMS) Prehospital Care Report, the facility failed to involve pharmacy services related to a possible overdose involving Resident #18 who was administered Narcan. This affected one resident (#18) of three residents reviewed for a potential overdose. The facility census was 109. Findings include: Record review for Resident #18 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease with early onset, schizophrenia, mood disorder, impulse disorder, restlessness and agitation, and need for assistance with personal care. Record review revealed Resident #18 had a Legal Guardian. Resident #18 had no known allergies. Review of the care plan dated 07/15/24 revealed Resident #18 had behavioral symptoms not directed to others verbal/vocal symptoms like screaming, disruptive sounds, and refused to be shaved. Interventions included when the resident yells out, ask the resident if he needs anything. Provide encouragement and calmness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 was severely cognitively impaired, had no hallucinations or delusions, no verbal or physical behaviors exhibited no rejection of care and no wandering in the seven-day assessment reference period. Resident #18 required set up or clean up assist with eating, dependent upon staff for toileting hygiene, bathing, dressing, and personal hygiene. Resident #18 required substantial/maximal assistance for bed mobility, dependent for transfers, used a wheelchair and was dependent upon staff for mobility. Review of the physician orders for Resident #18 revealed changes in medications for December 2024 included on 12/09/24 Risperidone (antipsychotic) was increased from 0.5 milligrams (mg) two times a day to one mg two times a day (7:00 A.M. to 11:00 A.M. and 7:00 P.M. to 11:00 P.M.) and on 12/19/24 Ativan 0.5 mg (antianxiety) was increased from 0.5 mg every day to 0.5 mg three times a day (6:00 A.M., 2:00 P.M. and 9:00 P.M.). Additional orders included Divalproex capsule delayed release (DR) sprinkles 125 mg (anticonvulsant) give two capsules in the A.M. ordered 04/18/24 and Divalproex capsule DR sprinkles 125 mg give four capsules night shift ordered 07/12/24. Review of the progress note dated 12/09/24 at 12:26 P.M. completed by LPN #428 revealed new order to increase risperidone to one mg two times a day. The progress note did not express the reason for the increase in Risperidone. Review of the progress note dated 12/19/24 at 3:07 P.M. completed by Licensed Practical Nurse (LPN) #465, Resident #18 continues to yell when needing things. Yells when wanting food/fluids. Yells when wanting trash thrown out after eating snack; gets staff attention by yelling then will verbalize a need or request. Certified Nurse Practitioner (CNP) gives new order to increase Ativan to three times a day (TID). Review of the progress notes from 11/01/24 through 12/25/24 revealed Resident #18 had no episodes of being difficult to arouse or unconscious. Record review for Resident #18 revealed after 12/26/24 episode, Resident #18 had no further episodes of change in mental status from the baseline. Review of the undated written statement created by LPN #499 included LPN #499 started the shift on 12/26/24 at 7:00 P.M. During the medication pass for residents she went to Resident #18's room to give him his medications. Resident #18 seemed like he was asleep. LPN #499 began to say Resident 18's name multiple times and put the head of the bed up. Resident #18 opened his eyes and closed them again. LPN #499 started to say his name again and rubbed his chest doing a sternal rub. LPN #499 sat Resident #18 up more and told him she had his medications. Resident #18 said, Huh and opened his mouth and took his medication. LPN #499 revealed she did watch Resident #18 swallow his medication and revealed, But (Resident #18) still did not seem right to me so I asked another nurse (LPN #336) who knew (Resident #18) longer than me to come and look at him. She agreed with me that (Resident #18) did not seem like himself. LPN #499 revealed after taking Resident #18's vital signs, she contacted TeleMed and was instructed to send Resident #18 to the emergency room . EMS arrived and assessed Resident #18's pupils and said, They are pinpointed; he needs Narcan. EMS reviewed the medications Resident #18 was given. Another facility nurse (LPN #336) obtained the Narcan from the stock medications, and EMS administered the Narcan to Resident #18. Resident #18 came to in five to ten seconds after receiving the Narcan and started to be himself again. LPN #499 revealed she never told EMS not to take Resident #18 to the hospital. They said since he was back to himself, there was no reason to take him to the hospital. LPN #499 revealed EMS instructed staff to keep an eye out or that if it happened again, to administer Narcan because of the half-life of Narcan. EMS left; Resident #18 was checked every 30 minutes. Around 12:00 A.M., the CNA reported Resident #18 was not himself again. Both staff were saying his name, and he ended up waking up. TeleMed was contacted, gave an order for the Narcan but because the resident was awake was told not to give it and monitor resident every 15 minutes. LPN #499 revealed she charted Resident 18's medical record at around 2:00 A.M., did not notify the family (Guardian) that late at night, so she informed them in the morning. Review of the Fire Department #606's Prehospital Care Report with the call dated 12/26/24 at 8:48 P.M. completed by Emergency Medical Technician (EMT) #605 revealed the unit was on scene on 12/26/24 at 9:02 P.M. related to an emergent response. The resident's name was (Resident #18). Primary Impression: Poisoning by drug/meds/biol substance, accidental. Narrative included the unit was dispatched for an unknown problem. Upon arrival, Resident #18 was lying in bed with a pulse and breathing. Staff stated they were unable to wake him. They gave him pain medication around 8:00 P.M. and when they went to check on him, he was unresponsive. Resident #18 had pinpoint pupils. Staff grabbed Narcan and wanted to administer. Staff administered two milligrams (mg) Narcan. Resident #18 woke up one minute later. Staff stated he was now acting normal, they did not want him to go to the hospital, and they would monitor him. Staff refused transport. Resident #18 was nonverbal. Review of the Refusal form included: Resident #18 refusal of service; Resident #18 advised of medical treatment and evaluation needed and further harm may result without medical treatment. Depart 12/26/24 at 9:24 P.M. Interview on 01/22/25 at 1:00 P.M. with CNP #600 revealed she visited Resident #18 on 12/27/24 in the morning due to his unresponsiveness the evening prior. CNP #600 revealed on 12/27/24 when she visited him, he was the same as prior to the episode on 12/26/24. There was no change; he was completely at baseline. CNP #600 revealed she would not have given Resident #18 the medication on the evening of 12/26/24 if he was not responding. CNP #600 revealed she was unsure why Resident #18 was not sent to the emergency room (ER). CNP #600 revealed she worked with an insurance group that visited the residents at the facility routinely. When she saw Resident #18 on 12/27/24, she thought the other CNP had already ordered his drug screen. She then found out later that the other CNP did not order the labs because she thought CNP #600 ordered them. Ultimately the drug screen was not ordered timely to determine if Resident #18 had an overdose of medications/drugs on 12/26/24. Interview and observation on 01/23/25 at 7:45 A.M. with LPN #343 revealed she was Resident #18's nurse for approximately two years. Resident #18 never had an episode where he was unresponsive or even lethargic. Resident #18 had a difficult time communicating, so he normally yelled or screamed when he wanted something until he got it and then he would stop. Medications Risperidone and Ativan were increased due to the yelling behaviors. Observation of medication administration revealed LPN #343 crushed all Resident #18's medications including the Divalproex DR capsules. LPN #343 opened the two Divalproex capsules, 125 mg each, and placed the sprinkles that were inside the capsules into a small clear pouch with the remainder of the 7:00 A.M. medications and crushed all the medications together in one pouch to a fine powder using a pill crusher. LPN #343 then placed the powder in applesauce and administered the medications to Resident #18. Review of the patient information leaflet for Divalproex DR capsules revealed the capsules should be swallowed whole and should not be crushed or chewed, the capsule can be opened and sprinkled on food. Interview and record review of Resident #18's medications on 01/23/25 at 10:00 A.M. with the facility Pharmacist Consultant #602 revealed monthly reviews were completed on each resident reviewing all medications. For Resident #18, there were no indications in the physician orders that the medications were being crushed. The Divalproex DR could be opened and added to food, but the sprinkles should not be crushed or chewed. The medication was used for schizophrenia. The idea is to extend the absorption time to the next dose which if they were crushed or chewed, would not happen. Reviewed all other medications with Pharmacist Consultant #602 who revealed there were no other concerns with the ordered medications. Pharmacist Consultant #602 revealed he would not expect that reaction with Divalproex DR even if it was crushed due to he was taking it for so long. Ativan would have an immediate action which was started three times a day on 12/19/24. The Risperidone increase on 12/09/24 may take a few days but would not expect the unresponsive episode one time. The Narcan was like a drug test, it would not be effective if it was not an overdose causing Resident #18 to be unresponsive then suddenly wake up with the administration of Narcan, he had to have something in his system for the Narcan to block that would allow him to wake up. Pharmacist Consultant #602 revealed the facility never requested him to review the medications due to possible overdose. An interview on 01/23/25 at 2:52 P.M. with the DON revealed she reviewed the incident on 12/26/24 -12/27/24 with Resident #18. The DON confirmed the facility never consulted with the pharmacy to assist in determining the change in condition on 12/26/24 for Resident #18 that required Narcan administration. The DON also confirmed a drug screen was not done timely to determine the change in condition on 12/26/24 for Resident #18 that required Narcan administration. This deficiency was an incidental finding identified during the complaint investigation.

Based on record review, observation, interview and review of the facility policy, the facility failed to ensure blood sugars were assessed prior to meal for Residents #82 and #112 as ordered by the physician to ensure accurate dosage of the sliding scale insulin and failed to ensure Resident #18's medication was administered correctly, (not to be crushed). This affected three residents (#82, #112, and #18) of four residents reviewed for medication administration. The facility census was 109. Findings include: 1. Record review for Resident #82 revealed an admitted [DATE]. Diagnosis included type two diabetes mellitus. Review of the Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #82 was cognitively intact. Resident #82 used a wheelchair for mobility and was dependent upon staff for transfers. Active diagnosis included diabetes mellitus. Review of the physician order dated 01/19/25 for Resident #82 included insulin lispro solution 100 units (u) per milliliter (ml) subcutaneously per sliding scale with meals scheduled at 8:00 A.M., 12:00 P.M. and 5:00 P.M. If blood sugar is 111 to 150, give one u; If blood sugar is 151 to 200, give three u; If blood sugar is 201 to 250, give six u; If blood sugar is 251 to 300, give nine u; If blood sugar is 301 to 350, give 12 u; If blood sugar is 351 to 400, give 15 u. Observation of medication administration on 01/22/25 at 8:42 A.M. with Licensed Practical Nurse (LPN) #418 administering medications to Resident #82 revealed Resident #82 was sitting up in his bed and confirmed he had completed his breakfast meal. Resident #82 revealed he had bacon, waffles, syrup, and juice. LPN #418 assessed Resident #82's blood sugar via fingerstick glucometer. Resident #82 revealed his concern to the nurse that he already ate all that food, that will push the blood sugar high. LPN #418 revealed it was okay, and she would check it anyway. Observation revealed Resident #82's blood sugar was 120. LPN #418 administered Lispro one unit. LPN #418 confirmed Resident #82's blood sugar should have been assessed prior to eating his meals and revealed sometimes things happen, and she was unable to check residents blood sugars until after the meal. Phone interview on 01/22/25 at 4:33 P.M. with Resident #82's Primary Care Physician #609 revealed Resident #82's blood sugar was to be assessed prior to the meals to determine the correct amount of the sliding scale insulin to be given. 2. Record review for Resident #112 revealed an admitted [DATE]. Diagnoses included dependence on respirator (ventilator) and diabetes mellitus. Review of the physician order dated 07/12/24 for Resident #112 revealed Humulin R Regular U-100 Insulin 100 u/ml per sliding scale, if blood sugar is 201 to 250, give four u; If blood sugar is 251 to 300, give six u; If blood sugar is 301 to 350, give eight u; If blood sugar is 351 to 400, give 10 u; If blood sugar is 401 to 450, give 12 u before meals and at bedtime. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #112 was cognitively intact. Active diagnosis included diabetes mellitus. Observation of medication administration on 01/22/25 at 9:15 A.M. with Registered Nurse (RN) #608 administering medications to Resident #112 revealed Resident #112 ate 100 % of her breakfast. Resident #112 revealed she had biscuits and gravy, milk and Jello and confirmed she ate 100 % of her breakfast. Observation revealed RN #608 assessed Resident #112's blood sugar via fingerstick glucometer with a result of 260. Observation revealed RN #608 administered Humulin R insulin six u. Interview with RN #608 confirmed he did not check Resident #112's blood sugar until after breakfast because he was running behind. Interview on 01/22/25 at 9:34 A.M. with Resident #112 revealed some nurses check blood sugars before meals and some do it after the meals. 3. Record review for Resident #18 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease with early onset, schizophrenia, mood disorder, impulse disorder, restlessness and agitation, and need for assistance with personal care. Review of the care plan dated 07/15/24 revealed Resident #18 had behavioral symptoms not directed to others verbal/vocal symptoms like screaming, disruptive sounds, refused to be shaved. Interventions included when the resident yells out, ask the resident if he needs anything. Provide encouragement and calmness. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #18 was severely cognitively impaired, had no hallucinations or delusions, no verbal or physical behaviors exhibited, no rejection of care and no wandering during the seven-day assessment reference period. Resident #18 required set up or clean up assist with eating, dependent upon staff for toileting hygiene, bathing, dressing, and personal hygiene. Resident #18 required substantial/maximal assistance for bed mobility, dependent upon staff for transfers, used a wheelchair and was dependent for mobility. Resident #18 had an ostomy and was always incontinent of urine. Review of the physician orders for Resident #18 revealed changes in medications for December 2024 included on 12/09/24 Risperidone (antipsychotic) was increased from 0.5 milligrams (mg) two times a day to one mg two times a day (7:00 A.M. to 11:00 A.M. and 7:00 P.M. to 11:00 P.M.) and on 12/19/24, Ativan 0.5 mg (antianxiety) was increased from 0.5 mg every day to 0.5 mg three times a day (6:00 A.M., 2:00 P.M. and 9:00 P.M.). Additional orders included Divalproex capsule delayed release (DR) sprinkles 125 mg (anticonvulsant) give two capsules in the A.M., ordered 04/18/24 and Divalproex capsule DR sprinkles 125 mg give four capsules night shift, ordered 07/12/24. Observation on 01/23/25 at 7:45 A.M. with LPN #343 revealed she was Resident #18's nurse for approximately two years. Resident #18 had a difficult time communicating, so he normally yelled or screamed when he wanted something until he got it then he would stop. Resident #18's medications Risperidone and Ativan were increased due to behaviors. Observation of medication administration revealed LPN #343 crushed all Resident #18's medications including the Divalproex DR capsules. LPN #343 opened the two Divalproex DR capsules, 125 mg each, and placed the sprinkles that were inside the capsules into a small clear pouch with the remainder of the medications and crushed all the medications together in one pouch to a fine powder using a pill crusher. LPN #343 then placed the powder in applesauce and administered the medications to Resident #18. LPN #343 confirmed she crushed Resident #18's medications including the Divalproex DR sprinkles. Review of the patient information leaflet for Divalproex DR capsules (Depakote) revealed Divalproex DR capsules should be swallowed whole and should not be crushed or chewed, the capsule can be opened and sprinkled on food. Interview and record review of Resident #18's medications on 01/23/25 at 10:00 A.M. with the facility Pharmacist Consultant #602 revealed Resident #18 had no indications in the physician orders that the medications were being crushed. The Divalproex DR capsules could be opened and added to food, but the sprinkles should not be crushed or chewed. The medication was used for schizophrenia. The idea is to extend the absorption time to be effective longer, which if they were crushed or chewed, would not happen. Review of the facility policy titled, General dose Preparation and Medication Administration revised 01/01/13 revealed facility staff should crush oral medications only in accordance with pharmacy guidelines as set forth in Appendix 16: common oral dosage forms that should not be crushed and/or facility policy. Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time. The deficiency was an incidental finding identified during the complaint investigation.

Based on observation, interview, record review, review of the label directions on the cleaning wipes and review of the facility policy, the facility failed to ensure infection control practices were maintained while assessing Residents #82 and #112's blood glucose levels via fingerstick. This affected two residents (#82 and #112) and had the potential to affect an additional 19 residents (#1, #7, #13, #14, #17, #21, #31, #49, #50, #53, #63, #65, #66, #69, #74, #80, #91, #94, and #97) identified by the facility as receiving blood glucose levels via fingerstick. The facility census was 109. Findings include: 1. Record review for Resident #82 revealed an admitted [DATE]. Diagnosis included type two diabetes mellitus. Review of the physician order dated 01/19/25 for Resident #82 included insulin lispro solution 100 units (u) per milliliter (ml) subcutaneously per sliding scale with meals scheduled at 8:00 A.M., 12:00 P.M. and 5:00 P.M. Observation on 01/22/25 at 8:42 A.M. of a blood sugar assessment via glucometer revealed Licensed Practical Nurse (LPN) #418 took the glucometer out of the top drawer of the medication cart. The glucometer was not covered or stored in a pouch. LPN #418 did not clean the glucometer before assessing Resident #82' blood sugar via fingerstick. LPN #418 then returned the glucometer to the medication cart, wiped the glucometer off for approximately five seconds then placed the glucometer in a cup (without a cleaning wipe). LPN #418 verified she was done cleaning the glucometer. LPN #418 confirmed the glucometer was used for all residents residing in her hall that required fingerstick blood sugars. LPN #418 confirmed she worked in all areas of the facility. LPN #418 then reviewed the directions on the Sani wipes for cleaning the glucometer and confirmed she did not allow the surface on the glucometer to remain wet two minutes. 2. Record review for Resident #112 revealed an admitted [DATE]. Diagnoses included dependence on respirator (ventilator) and diabetes mellitus. Review of the physician order dated 07/12/24 for Resident #112 revealed Humulin R Regular U-100 Insulin 100 unit/ml per sliding scale before meals and at bedtime. Observation on 01/22/25 at 9:15 A.M. of a blood sugar assessment via glucometer revealed with Registered Nurse (RN) #608 took the glucometer out of the top drawer of the medication cart. The glucometer was not covered or stored in a pouch. RN #608 did not clean the glucometer before assessing Resident #112's blood sugar via fingerstick. RN #608 then returned the glucometer to the medication cart, sat the glucometer on top of the medication cart, opened the drawer and placed the glucometer directly on top of the opened box of lancets. RN #608 then closed the drawer and locked the medication cart. RN #608 confirmed he did not clean the glucometer before or after use and confirmed he sat the soiled glucometer directly on top of multiple lancets used to obtain blood from residents' fingers. RN #608 then removed the glucometer from the cart and wiped the glucometer with an alcohol wipe for approximately five seconds revealing that was how he would clean the glucometer between each use. Interview on 01/22/25 at 9:45 A.M. and review of the Sani wipes directions for cleaning glucometer's with Regional Director of Clinical Services (RDCS) #601 revealed the facility used Super Sani cloth wipes to clean all glucometer's. RDCS #601 revealed alcohol wipes were not an approved method for cleaning glucometers. Review of the label directions on the container of the Super Sani cloth wipes for cleaning hard surfaces including glucometers revealed to thoroughly wet surface. Allow the surface to remain wet for two minutes, let air dry. Review of the facility policy titled, Glucometer/Point of Care Blood Testing and Disinfection Procedure revised 12/27/23 revealed whether shared or assigned to a singular resident, blood testing meters will be disinfected between each use (before use the clinician should assume the meter is dirty and disinfect before use according to manufacturer instructions and infection prevention guidelines). This deficiency was an incidental finding identified during the complaint investigation.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, review of a facility Self-Reported Incident (SRI) and investigation, review of a police report and medical examiner information, personnel file review, review of narcotic/controlled drug sheets, review of Medscape drug reference information, facility policy review and interviews, the facility failed to ensure Resident #117 was free from a significant medication error and failed to ensure the error was reported immediately so that timely and appropriate medical intervention could be provided. This resulted in Immediate Jeopardy and actual harm/death of Resident #117 when on [DATE] at approximately 6:56 A.M. LPN #381 administered Resident #56's medications that included Methadone (medication used to treat opioid use disorder) 40 milligrams (mg) and likely hydromorphone (potent opioid used to treat severe and chronic pain) eight mg to Resident #117. LPN #381 did not report the medication error and therefore no medical intervention was initiated. On [DATE] at approximately 7:15 P.M. Resident #117 was found unresponsive in a common area and resuscitative measures were initiated but ultimately unsuccessful. Resident #117 was pronounced deceased on [DATE] at 8:15 P.M. On [DATE] at approximately 9:15 P.M. LPN #381 confessed to LPN #365 she had made the medication error. However, LPN #381 later denied making the medication error upon facility investigation. On [DATE] at 2:06 P.M. a telephone interview with the Medical Examiner revealed Resident #117's initial blood work screening (postmortem) was positive for Methadone and opiates, which the resident was not ordered to receive. This affected one resident (#117) of six residents reviewed for medication administration and one resident (#117) of three residents reviewed for death. The facility census was 112. On [DATE] at 9:57 A.M. the Administrator and Regional Registered Nurse (RRN) #408 were notified Immediate Jeopardy began on [DATE] at approximately 6:56 A.M. when LPN #381 administered Resident #56's medications that included Methadone 40 mg to Resident #117. LPN #381 did not report the medication error and therefore no medical intervention was immediately initiated. On [DATE] at approximately 7:15 P.M. Resident #117 was found unresponsive in a common area and resuscitative measures were initiated. Resident #117 was pronounced deceased on [DATE] at 8:15 P.M. On [DATE] at approximately 9:15 P.M. LPN #381 confessed to LPN #365 she had made the medication error. On [DATE] at 2:06 P.M. a telephone interview with the Medical Examiner revealed Resident #117's initial blood work screening showed Methadone and opiates in Resident #117's system indicative of the medication error occurring. The Immediate Jeopardy was removed and the deficient practice corrected on [DATE] when the facility implemented the following corrective actions: On [DATE] Resident #117 passed away at the facility. On [DATE] at approximately 12:00 P.M., LPN #414 reported to the Administrator a medication error rumor involving narcotics was being spread throughout the facility. It was alleged on [DATE] LPN #381 gave medication, including narcotics, that belonged to Resident #56 to Resident #117. LPN #414 reported that LPN #381 allegedly confessed this error to LPN #365. On [DATE] at approximately 1:00 P.M., LPN #381 was interviewed by the Administrator and RRN #408 regarding the medication error. LPN #381 gave a written statement denying all allegations including sharing this allegation with another nurse. LPN #381 was then suspended (on [DATE]) pending investigation. LPN #381 was subsequently terminated on [DATE] for failure to cooperate with the facility investigation. No additional/new information was obtained from LPN #381 by the facility regarding the medication error incident. On [DATE] between 12:30 P.M. and 8:30 P.M. all staff who were working at the time of the alleged incident and the following shift were interviewed by the Administrator and RRN #408. On [DATE] at approximately 1:45 P.M., LPN #365 was interviewed by the Administrator and RRN #408 and was questioned regarding knowledge of the medication error. LPN #365 provided a written statement stating she was notified of the medication error by LPN #381 on [DATE]. LPN #365 indicated she notified (by phone) Unit Manager (UM) #332 on [DATE]. LPN #365 then indicated on [DATE], she notified UM #400 in person at the facility of the alleged confession of a medication error by LPN #381 involving Resident #117. On [DATE] at approximately 2:00 P.M., RRN #408 and the Director of Nursing (DON) notified NP #410 and Physician #411 (Resident #117' primary care physician) of the alleged medication error. At the time of the notification, Nurse Partitioner (NP) #410 reported she had been aware of the alleged incident/error since [DATE] when it had been reported to her by another NP in the facility. It was noted the primary care physician had previously contacted (on [DATE]) the medical examiner with this information. On [DATE] at approximately 2:00 P.M., RRN #408 implemented a new protocol for all zeroed narcotic sheets to stay in the narcotic book until removed by unit manager and/or DON, and all empty narcotic cards were to stay in narcotic drawer until removed by unit manager and/or DON. On [DATE] at approximately 2:30 P.M., RRN #408 and the Administrator spoke with NP #410 and Physician #411 via phone and educated them of the requirement to report any allegations of abuse, neglect and misappropriation, including rumors of medication errors directly to the administrator. On [DATE] at approximately 3:00 P.M., UM #332 was interviewed by the Administrator and RRN #408. UM #332 denied hearing of the allegation prior to the time of interview. Following the interview, UM #332 was suspended pending further investigation. UM #332 returned to work on [DATE]. One on one education was provided on [DATE] by the Administrator and RRN #408 on reporting medication errors, medication administration, abuse/neglect procedures, and immediate reporting protocol to the abuse coordinator (Administrator). Education was completed again on [DATE] by the Administrator prior to returning to work. On [DATE] at approximately 3:15 P.M., UM #400 was interviewed by the Administrator and RRN #408. UM #400 denied hearing of the allegation prior to the time of interview. Following the interview, UM #400 was suspended pending further investigation. UM #400 returned to work on [DATE]. One on one education was provided on [DATE] by the Administrator regarding reporting medication errors, medication administration and abuse reporting and protocol including immediate reporting to abuse coordinator (Administrator). Education was completed again on [DATE] by the Administrator prior to returning to work. On [DATE] at approximately 4:00 P.M., RRN #408 reviewed the employee files of LPN #381, LPN #365, UM #332 and UM #400 per facility investigation protocol. On [DATE] at approximately 5:00 P.M. an in-house audit was completed by the DON, Assistant Director of Nursing (ADON) and RRN #408 for all residents receiving narcotics to ensure that medication was being received as ordered. In addition, the DON and ADON interviewed alert and oriented residents without any negative findings. The DON and ADON completed assessments on residents who were not alert and oriented, and no skin concerns or behavioral concerns were identified. RRN #408, DON and the ADON completed audits of all narcotics on each medication cart to ensure all narcotics were accounted for. On [DATE] at approximately 6:00 P.M., the DON, ADON and RRN #408 completed audits of Resident #56 and Resident #117 reviewing their controlled substance narcotic individual record and identified two controlled substance individual sheets for Methadone that were zeroed out (indicating medication card was empty) for Resident #56 and two missing Methadone narcotic sheets. Upon this finding a complete review for all residents ordered narcotics was completed for two weeks prior with no additional negative findings. The missing narcotic sheets have not been recovered as of [DATE]. On [DATE] at approximately 7:30 P.M., the DON, ADON, and RRN #408 completed a house audit on all narcotic accountability sheets to ensure there was no diversion noted and narcotic shift to shift count and individual control sheets matched the narcotic cards. On [DATE] at 12:30 P.M. and 8:30 P.M., following education to the DON and ADON by RRN #408, all nursing staff were in-serviced by the DON, ADON and RRN #408 on medication administration, abuse and neglect-with protocol to report allegations directly to abuse coordinator (Administrator), shift to shift count of narcotics, destruction of narcotics, change of condition with notification to physician and family, discontinued home medications would be verified by manager and nurse, medication errors and reporting. The in-service was followed by nurses completing a medication administration competency which was completed by the DON and nursing management. Any staff not educated in person on [DATE] were educated via phone on [DATE] with follow-up in person education conducted on the employee's next working day. Completion of the education and competencies was confirmed through review of sign-in sheets and interviews with nurses. On [DATE] between 12:30 P.M. and 8:30 P.M., the DON, ADON, and RRN #408 educated nurses on principles of medication administration per policy. The education was completed by [DATE]. Completion of the education was confirmed through review of sign-in sheets and interviews with nurses. On [DATE] from approximately 12:30 P.M. to 8:30 P.M., nurses and STNAs were educated on the abuse, neglect and misappropriation policy and reporting requirements. Staff were educated that any allegation of abuse, including rumors of medications errors must be immediately reported to the administrator. This information was also posted at the nurses' station, by the time clock and in break rooms. On [DATE] at 2:00 P.M. and 8:30 P.M., after RRN #408 educated the DON and ADON, the DON, ADON and RRN #408 educated all licensed nurses of the new protocol all zero on narc sheets needing to stay on book until removed by unit manager and/or DON; all empty narc cards must stay in narc drawer until removed by unit manager and/or DON. Education was completed by [DATE]. Completion of the education was confirmed through review of sign-in sheets and interviews with nurses. On [DATE] Alert signs with reporting requirements including the telephone number for the Administrator were placed at nurse's stations, time clock and break room. On [DATE] a Self-Reported Incident was submitted to the State agency involving Resident #117. On [DATE] at approximately 4:00 P.M., the facility Corporate Medical Director (MD) #418 was notified of the alleged medication error with no additional recommendations provided. MD #418 indicated to follow facility protocols. On [DATE] the facility implemented a plan for the DON/designee to audit narcotic medications to ensure the narcotic counts were correct three times per week for three weeks and then randomly. Audits would remain in place until at least [DATE]. On [DATE] the facility implemented a plan for the DON/designee to ensure medication administration compliance by observing medication administration with two nurses three times per week for three weeks and then randomly. Audits would remain in place until at least [DATE]. On [DATE] the facility implemented a plan to ensure compliance with the zeroed narcotic control sheets by collecting empty narcotic cards with narcotic sheets from the medication carts three times per week ongoing. This process would be an ongoing protocol. On [DATE] the facility implemented a plan for the DON/Designee to ensure compliance of reporting medication errors by interviewing two nurses three times per week for three weeks and then randomly. Interviews would be ongoing. The facility implemented a plan for all negative findings to be reviewed during Quality Assurance Performance Improvement (QAPI) meetings to determine if additional audits were necessary. A QAPI meeting was held on [DATE] in person with staff that were present in the facility and via phone for those not present in facility. A QAPI meeting was held on [DATE] in person with staff that were present in the facility and via phone for those not present in facility. The QAPI committee attending the meetings included the Administrator, DON, ADON, RRN #408, Corporate MD #418, Regional Director of Operations, Physician #411, NP #410, Social Services Designee (SSD) #419, Human Resources (HR) #420, and Unit managers #332, #400 and #402. On [DATE] at approximately 3:30 P.M., the State Agency Surveyor notified RRN #408 and the Administrator of Resident #117's preliminary toxicology results (obtained from the coroner) which indicated Methadone and opioid were present. Information obtained from the coroner revealed a final report would not be available for four to 12 weeks. The Administrator contacted the Police, and the police officer indicated the investigation would be handled by the Board of Pharmacy. The DON and RRN #408 notified Physician #411 and MD #418 of the preliminary results. On [DATE] at 8:38 A.M. telephone interview with the Administrator and on [DATE] at 9:24 A.M. telephone interview with the Administrator and RRN #408 revealed while the facility was continuing to attempt to obtain additional information internally related to this incident involving Resident #117 following the communication of the preliminary toxicology report, they were dependent on external investigations being conducted by other agencies as well which were ongoing as of this date. On [DATE] the facility made a follow-up call and left a message with the Board of Pharmacy to confirm their on-going investigation and to obtain any available updates. The facility also revealed they would be adding an addendum to the previously submitted SRI with the updated information from the coroner and also to reflect that Resident #117 had passed away on [DATE]. Findings include: Review of Resident #117's closed medical records revealed an admitted [DATE] with diagnoses including cerebral palsy, developmental disorder of speech and language and cognitive deficits. Record review revealed the resident passed away in the facility on [DATE]. Review of Resident #117's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #117 was rarely understood. Resident #117 was dependent (on staff) for bed mobility, eating, toileting and personal hygiene. Review of Resident #117's care plan dated [DATE] revealed Resident #117 had impaired cognition related to cerebral palsy and difficulty communicating. Interventions included making eye contact with Resident #117 and being patient. Resident #117 was at risk for seizures. Interventions included administering medications as ordered. Review of Resident #117's physician orders for [DATE] revealed medication including Clonazepam (a benzodiazepine used to treat seizures, panic disorder and anxiety) one mg three times a day to be administered at 6:00 A.M., 2:00 P.M. and 10:00 P.M., Oxcarbazepine (seizure medication) 600 mg three times a day to be administered at 6:00 A.M., 2:00 P.M. and 10:00 P.M., and Zonisamide (seizure medication) 200 mg, three times a day to be administered at 6:00 A.M., 2:00 P.M. and 10:00 P.M. Review of Resident #117's Medication Administration Record (MAR) for [DATE] revealed LPN #381 documented Resident #117's Clonazepam, Oxcarbazepine, and Zonisamide were administered at 6:54 A.M. Review of Resident #117's progress note dated [DATE] timed 10:17 P.M. authored by LPN #310 revealed Resident #117 was found unresponsive. Resident #117 was moved to the ground, Cardiopulmonary Resuscitation (CPR) was performed, and emergency medical services (EMS) were called. CPR was unsuccessful and EMS pronounced Resident #117 deceased . Review of the facility Code Blue (an emergency code that indicates a resident is in critical condition and needs immediate medical care. It is usually used to describe a resident who is in cardiac or respiratory arrest) investigation dated [DATE] revealed Resident #117 was found unresponsive in the TV room at 7:15 P.M. CPR was initiated. EMS were called and arrived at 7:25 P.M. Resident #117 was pronounced deceased at 8:15 P.M. by EMS. Review of LPN #374's statement dated [DATE] revealed she administered Resident #117's medications around 3:,d+[DATE]:30 P.M. and Resident #117 was alert. Review of the MAR dated [DATE] revealed medications scheduled for 2:00 P.M. were documented as administered including Clonazepam 1mg (benzodiazepine), Oxcarbazepine 600 mg and Zonisamide 200 mg. These were the same medications scheduled for 6:00 A.M. Review of a police report dated [DATE] revealed the police responded to the emergency medical services call. The report indicated Resident #117 was deceased and no foul play was detected. Review of a facility self-reported incident (SRI) initiated on [DATE] revealed the facility reported an allegation of Neglect/Mistreatment/Abuse involving Resident #117. The date of occurrence was identified as [DATE] at 12:00 P.M. and included LPN #414 reported to the Administrator a rumor that LPN #381 had made a medication error with the resident. The SRI noted Resident #117 was no longer in the facility, but failed to include this was due to the resident passing away on [DATE]. In addition, the SRI failed to include any information related to the medication error actually occurring on [DATE]. Review of the facility's final disposition revealed the facility interviewed staff and residents but were unable to determine a medication error had occurred. The SRI included LPN #381 was suspended during the investigation. Facility staff were educated on proper medication administration and reporting of medication errors. Review of the facility investigation regarding the death of Resident #117 which was initiated on [DATE] revealed a statement authored by LPN #365 indicating on [DATE], LPN #381 arrived at LPN #365's home sometime after 9:15 P.M. LPN #381 told LPN #365 Resident #117 had passed away and on the morning of [DATE] during her morning medication pass she had given Resident #117 another resident's medications that had included narcotics. LPN #381 told LPN #365 she had not reported the medication error to anyone. After LPN #381 left LPN #365's home, LPN #365 made several attempts to contact staff that were on call including the DON, UM/LPN #332 and UM/LPN #400. UM/LPN #332 contacted LPN #365 and was made aware of what LPN #381 had reported to LPN #365. UM/LPN #332 told LPN #365 she would contact the DON. The statement also indicated on the morning of [DATE], LPN #365 spoke with UM/LPN #400 and explained the reasons for her calls and text messages on [DATE] and UM/LPN #400 stated she had not been made aware of the situation. Review of LPN #381's statement dated [DATE] revealed she could not recall giving any wrong medications and Resident #117 was fine when she had left. Review of LPN #374's statement dated [DATE] revealed on the morning of [DATE] while sitting at the nurses' station she was speaking with LPN #309 about Resident #117's death. While speaking with LPN #309, LPN #309 stated a night shift nurse (LPN #381) admitted to a fell ow night shift nurse (LPN #365) that she made a mistake and gave Resident #117, Resident #56's medications. The statement indicated LPN #309 told her the DON was aware of the situation and was handling it. Review of LPN #321's statement dated [DATE] revealed she was told and had overheard LPN #381 had administered the wrong medications to Resident #117. Review of LPN #414's statement dated [DATE] revealed LPN #321 said Resident #117 died due to a medication error made when LPN #381 administered Resident #56's medications to Resident #117 and did not report the error. Review of LPN #323's statement dated [DATE] revealed she observed Resident #117 in a common dining area at lunchtime on [DATE]. Resident #117 did not appear to be his chipper self. Resident #117 normally became excited and gave out high [NAME] when staff/visitors approached. Resident #117 did not respond to LPN #323, he just continued to eat his meal. LPN #323 saw Resident #117 later in a common area (time not identified in statement) and Resident #117 appeared to be taking a nap, LPN #323 indicated time went by and an aide said, Oh my God, I think he's dead. LPN #323 performed chest compressions until EMS arrived. Review of the Administrator's statement dated [DATE] revealed on [DATE], LPN #414 informed her of a rumor regarding a medication error for Resident #117. LPN #414 stated LPN #381 had administered Resident #56's medications to Resident #117; LPN #381 had confessed to LPN #365. The Administrator interviewed LPN #381 who denied making a medication error. The Administrator also interviewed LPN #365 who stated LPN #381 had confessed to making the medication error. LPN #365 stated after LPN #381 had left her home, she called UM/LPN #332 to report the incident. LPN #365 further stated she reported the incident to UM/LPN #400 on the morning of [DATE]. The Administrator interviewed UM/LPN #332 and UM/LPN #400, and both denied they had been notified of the medication error. Review of Resident #56's medical record revealed an admitted [DATE] with diagnoses including alcoholic hepatitis, anxiety, and altered mental status. Review of Resident #56's care plan dated [DATE] revealed Resident #56 had self-care deficits related to pain, weakness and terminal illness. Resident #56 had a history of substance abuse. Interventions included if Resident #56 was symptomatic for substance abuse, hold medications and obtain urine/blood samples for drug testing. Review of Resident #56's MDS assessment dated [DATE] revealed Resident #56 had intact cognition. Review of Resident #56's physician orders for [DATE] revealed medications including Clonazepam one mg to be administered at 6:00 A.M., 2:00 P.M. and 10:00 P.M., Methadone 40 mg, every eight hours to be administered at 6:00 A.M., 2:00 P.M. and 10:00 P.M., and Hydromorphone eight mg every three hours as needed for pain. Review of Resident #56's MAR for [DATE] revealed LPN #381 documented Resident #56's Clonazepam, and Methadone were administered at 7:00 A.M. Review of Resident #56's narcotic sheet for Hydromorphone revealed LPN #381 documented the medication was signed out on [DATE] at 6:00 A.M. However, the Hydromorphone was not documented on the MAR as being administered at that time. Review of Medscape drug reference information revealed the dosage of Methadone for opioid-naive patients was 2.5 mg by mouth every eight to 12 hours; titrate slowly with dose increases no more frequent than every three to five days. Warnings included accidental exposure of even one dose, especially in children could result in a fatal overdose. Monitor for hypotension during dose initiation; use with caution in patients with hypovolemia, cardiovascular disease, or drugs which may significantly increase hypotensive effects. Concomitant use of opioids with benzodiazepines or other central nervous system depressants, including alcohol may result in profound sedation, respiratory depression, coma, and death. Onset of action when taken by mouth 0.5 to 1 hour. Duration four to eight hours; repeated administration, ,d+[DATE] hours; overdosage, ,d+[DATE] hours. Interview on [DATE] at 8:00 A.M. with LPN #309 revealed she was aware of LPN #381 making a medication error involving Resident #117 and UM/LPN #332 was also aware of the situation. LPN #309 stated she had reported concerns regarding LPN #381 being unsafe including LPN #381 pre-pouring resident medications, leaving medications in resident rooms and not crushing residents' medications that were supposed to be crushed. LPN #309 stated Resident #117 was mostly nonverbal and spent most of his time in the common area playing with his toys. Resident #117 was known to high five everyone who walked past and he was chipper all the time. LPN #309 stated LPN #323 reported LPN #381 to the nursing board on [DATE] because she believed management did not do anything regarding the medication error (that occurred on [DATE]). LPN #309 reported the situation to NP #409 on [DATE] who reported it to Resident #117's NP (NP #410) on the same date. NP #410 then contacted Resident #117's physician and the Board of Pharmacy on [DATE]. Interview on [DATE] at 8:55 A.M. with the Administrator and RRN #408 revealed the Board of Pharmacy arrived at the facility on [DATE] and requested Resident #117's Medication Administration Record (MAR) and physician orders. However, they stated the Board of Pharmacy did not disclose why they requested Resident #117's information. The Administrator stated on [DATE] she was informed by LPN #414 of rumors that LPN #381 had administered Resident #56's medications to Resident #117 (on [DATE]) and they initiated an investigation at that time. Interview on [DATE] at 10:12 A.M. with LPN #414 revealed on [DATE] he had reported to the Administrator a rumor he had heard regarding LPN #381 admitting to LPN #365 she had administered Resident #56's medications to Resident #117. Telephone interview on [DATE] at 10:50 A.M. with NP #410 revealed on [DATE] she was contacted by NP #409 who reported she was told LPN #381 administered Resident #56's medications to Resident #117 (on [DATE]). NP #410 stated she was told the facility was aware of the situation. NP #410 did not talk to the administrative staff about what she was told regarding the error, but stated she contacted the physician and the Board of Pharmacy on [DATE]. On [DATE] at 12:36 P.M. an attempt to interview LPN #381 was unsuccessful. LPN #381 stated she was sleeping and would return the call. Interview on [DATE] at 2:04 P.M. with LPN #365 revealed on the evening on [DATE], LPN #381 arrived at her home sometime after 9:15 P.M. LPN #381 told her (on [DATE]) she had given Resident #117 Resident #65's Methadone and had not reported the error. LPN #365 stated after LPN #381 had left her home she called the DON, UM/LPN #332 and UM/LPN #400. UM/LPN #332 returned her call approximately 30 minutes later and she informed her what LPN #381 had stated. UM/LPN #332 said she would contact the DON. LPN #365 stated on the morning of [DATE] she informed UM/LPN #400. Interview on [DATE] at 2:30 P.M. with LPN #323 revealed she had been aware LPN #381 admitted to LPN #365 she administered Resident #56's medications to Resident #117. LPN #323 was present on [DATE] from 7:00 A.M. to 7:00 P.M. and saw Resident #117 in a common area around lunchtime and he appeared lethargic and more tired than normal. Resident #117 normally gave high [NAME] and often yelled out to staff and residents. At approximately 7:00 P.M. LPN #323 was notified Resident #117 was unresponsive and she assisted with placing Resident #117 on the ground and performed CPR. Resident #117 had no pulse, was cold and his fingertips were blue. LPN #323 stated she had previously expressed concerns to the DON regarding LPN #381 being unsafe and stated she did not believe the management team took any action. LPN #323 said LPN #381 pre-poured resident medications and did not act like an actual nurse. During an interview on [DATE] at 3:05 P.M. with UM/LPN #332 she denied she was notified of a potential medication error or that LPN #381 confessed she made an error after Resident #117's death. UM/LPN #332 said she was not aware of the possible error involving LPN #381 until [DATE]. Telephone interview on [DATE] at 3:17 P.M. with LPN #374 revealed she was present on [DATE] from 7:00 A.M. to 7:00 P.M. and was assigned to Resident #117. LPN #374 stated she administered Resident #117's medications between 3:,d+[DATE]:30 P.M. and Resident #117 appeared to be more tired than normal. After LPN #374 left the facility at approximately 7:00 P.M. she received a phone call from LPN #310 who stated Resident #117 was unresponsive. LPN #374 returned to the facility as the paramedics were arriving. LPN #374 stated she became aware of a medication error approximately one week later and had been informed that management was aware. LPN #374 did not report what she had been told to administrative staff. Telephone interview on [DATE] at 3:26 P.M. with LPN #321 revealed she was informed LPN #381 administered Resident #56's medications to Resident #117 on the morning of [DATE]. LPN #321 was told when LPN #381 returned to the medication cart after administering medications to Resident #117 she saw Resident #117's medications were still in his cup (they had been pre-poured) and LPN #381 could not locate Resident #56's medications. LPN #321 stated on [DATE] LPN #381 admitted to LPN #365 she had administered Resident #56's medications to Resident #117. LPN #321 was told LPN #365 made management aware after LPN #381 left her home after confessing to the error. Interview on [DATE] at 6:22 A.M. with LPN #310 revealed she was Resident #117's nurse on the evening of [DATE] from 7:00 P.M. to 7:00 A.M. Shortly after LPN #310 began the shift she was alerted by Certified Nursing Assistant (CNA) #311 that Resident #117 was unresponsive. LPN #310 immediately placed Resident #117 on the ground and initiated a Code Blue. LPN #310 performed CPR until the paramedics arrived. The LPN revealed Resident #117 was already cold and blue when CPR was initiated. LPN #310 stated she had been made aware of the medication error a few days later. Interview on [DATE] at 8:38 A.M. with the Administrator and RRN #408 revealed during the Board of Pharmacy's investigation it was determined narcotic sheets for Resident #56's Methadone were missing from this time period including from [DATE]. During an interview on [DATE] at 10:06 A.M. with the DON, the DON indicated she was not aware of the medication error until [DATE]. Telephone interview on [DATE] at 12:32 P.M. with Physician #411 revealed he was notified on the evening of [DATE] that Resident #117 had passed away. Physician #411 was not aware of any potential medication error or any other concern regarding the resident's death and signed the resident's death certificate with the cause of death being related to the resident's diagnosis of cerebral palsy. On [DATE], NP #410 informed him of the possibility of a medication error and that NP #410 had contacted the Board of Pharmacy. Physician #411 contacted the medical examiner's office. The medical examiner's office indicated they would obtain blood, urine and fluid samples to test. Physician #411 stated if the results came back positive for opioids he could change the cause of death on the death certificate. Telephone interview on [DATE] at 12:40 P.M. with LPN #365 revealed she had text messages which she sent to the DON, UM/LPN #332 and UM/LPN #400 on [DATE] from 10:33 P.M. to 10:34 P.M. The messages indicated Call me ASAP. UM/LPN #332 returned her call at 10:59 P.M. and LPN #365 reported what LPN #381 had confessed. UM/LPN #332 told her she would contact the DON. Observation and an attempted interview on [DATE] at 1:34 P.M. revealed Resident #56 was in bed and appeared to be out of it. Resident #56 fell asleep while being asked questions. Interview on [DATE] at 1:40 P.M. with Resident #34 revealed approximately three to four months ago LPN #381 entered her room to administer her evening medications. Resident #34 questioned LPN #381 about the medications because the number of pills was more than she normally receiv [TRUNCATED]

Based on record review, interview, observation of photographic evidence, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure communication and coordination of services with the dialysis center regarding the care of Resident #119's dialysis catheter. This affected one resident (#119) of four residents reviewed and observed for dialysis catheter care. The facility census was 112. Findings include: Review of Resident #119's closed medical records revealed an admitted [DATE] and a discharge date of [DATE]. Resident #119 had a diagnosis of chronic kidney disease and was dialysis dependent. Resident #119 expired on [DATE]. Review of Resident #119's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #119 had impaired cognition. Review of Resident #119's care plan dated [DATE] revealed Resident #119 required dialysis. Interventions included providing access site care as ordered and monitor and report signs of infection. Review of Resident #119's physician orders for [DATE] revealed an order to monitor dialysis access site for signs of infection, intact dressing and bleeding, and notify physician as needed. There were no physician orders to change the dialysis catheter dressing. Telephone interview on [DATE] at 11:20 A.M. with Resident #119's son revealed Resident #119 was admitted to the hospital's Intensive Care Unit on [DATE] and diagnosed with an infection from his dialysis catheter that spread to his heart valves. Resident #119's son stated he arrived at the hospital on [DATE] and observed the dressing over Resident #119's dialysis catheter it was soiled and dated [DATE]. Resident #119's son took a picture of the dressing over the dialysis catheter insertion site and sent the picture to the Ombudsman's office. At the time of the interview Resident #119's son provided the photograph. Observation of the photograph revealed the photo was dated [DATE] and timed 1:27 P.M. The photograph showed a viably soiled transparent dressing with gauze border covering a central venous access device located on Resident #119's right upper chest. The dressing was dated [DATE] in black marker and had dried dark red/maroon colored drainage on the border and underneath the transparent dressing was a pool of dark red drainage around the insertion site. Interview on [DATE] at 11:21 A.M. with Licensed Practical Nurse (LPN) #392 revealed she was unsure exactly when dialysis dressings were to be changed. LPN #392 then stated I don't know, maybe every week. Interview on [DATE] at 12:26 P.M. with Dialysis Registered Nurse (RN) #413 revealed she had spoken to the Ombudsman (could not recall date) regarding Resident #119's dialysis catheter she told the Ombudsman she was not aware of any concerns related to Resident #119's dialysis catheter. RN #413 stated she had not observed any photos of the dialysis catheter or insertion site. RN #413 was shown the photograph provided by Resident #119's son and confirmed the dressing was dated [DATE]. RN #413 was unable to provide an explanation as to why the dressing had not been changed. RN #413 stated dialysis catheter dressings were usually changed on Mondays and as needed. RN #413 looked through Resident #119's dialysis treatment record and found no documentation the dressing to the dialysis catheter insertion site had been changed from [DATE] through [DATE]. RN #413 stated the facility floor nurses were supposed to monitor the dialysis site daily and report any concerns. Interview on [DATE] at 10:23 A.M. with LPN #357 revealed she had cared for Resident #119 on [DATE] and stated Resident #119's son requested that he be sent to the hospital. LPN #357 could not recall any issues with Resident #119's dialysis catheter prior to Resident #119 being sent to the hospital. LPN #357 confirmed she had signed the Treatment Administration Record (TAR) on [DATE] indicating she had assessed Resident #119's dialysis catheter site, however she could not recall if the dialysis dressing had been dated or appeared soiled. Interview on [DATE] at 9:36 A.M. with Regional Registered Nurse (RRN) #408 revealed dialysis dressings should be changed every seven days and as needed. RRN #408 stated the nursing staff was to monitor dialysis dressings and sites daily and to report any concerns to the dialysis nurses. Review of Resident #119's death certificate revealed the resident passed away on [DATE] with causes of death listed as septic shock, bacteremia (blood infection), endocarditis (infection of the hearts inner lining, usually caused by bacteria that enters the bloodstream and collects on the heart valves), and infected dialysis catheter. Review of facility policy titled Central, Venous Catheter Care revised [DATE] revealed trained and qualified dialysis care personnel were to change dressings every seven days. Review of facility policy titled Hemodialysis Care revised [DATE] revealed if a dressing was ordered over the site, monitor and change as needed. Review of CDC guidelines for the prevention of Intravascular Catheter related infections revealed the following. VII. Catheter-site dressing regimens A. Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site (146,210--212). Category IA B. Tunneled CVC sites that are well healed might not require dressings. Category II C. If the patient is diaphoretic, or if the site is bleeding or oozing, a gauze dressing is preferable to a transparent, semi-permeable dressing (146,210--212). Category II D. Replace catheter-site dressing if the dressing becomes damp, loosened, or visibly soiled (146,210). Category IB E. Change dressings at least weekly for adult and adolescent patients depending on the circumstances of the individual patient (211). Category II F. Do not use topical antibiotic ointment or creams on insertion sites (except when using dialysis catheters) because of their potential to promote fungal infections and antimicrobial resistance (107,213). Category IA (See Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters, in Adult and Pediatric Patients, Section II.I.) G. Do not submerge the catheter under water. Showering should be permitted if precautions can be taken to reduce the likelihood of introducing organisms into the catheter (e.g., if the catheter and connecting device are protected with an impermeable cover during the shower (214,215). Category II This deficiency represents non-compliance investigated under Complaint Number OH00158341.

Based on medical record review, interview, and review of the facility policy, the facility failed to ensure timely notification of death of the legal guardian for Resident #119. This affected one resident (#119) of three residents who were reviewed for notification of significant incidents or changes in condition. The facility census was 118. Findings include: Review of the closed medical record for Resident #119 revealed an admitted [DATE] with diagnoses including acute and chronic respiratory failure, extended spectrum beta lactamase (ESBL) resistance, hypothyroidism, major depressive disorder, end stage renal disease, thrombocytopenia, severe protein-calorie malnutrition, dysphagia, myxedema coma, dysphagia, and abnormalities of gait and mobility. Further review of the medical record revealed a discharge date of [DATE] after expiring in the facility. Review of the significant change Minimum Data Set (MDS) assessment completed on [DATE] revealed Resident #119's cognitive function was severely impaired, and she was receiving Hospice care. Review of the face sheet revealed Resident #119 had a legal guardian. Further review of the face sheet revealed the legal guardian was the responsible party, and the face sheet listed the name, address, telephone number, and email address for the legal guardian. The face sheet also listed a spouse as an emergency contact. Review of the admission documents revealed a court document which appointed guardianship of Resident #119's person and estate to the listed legal guardian on the face sheet as of [DATE]. The court document specified the appointed legal guardian had the power to perform all duties of a guardian, indefinitely. Review of the progress notes revealed a progress note date [DATE] timed 9:06 P.M. indicating Resident #119 passed away at 8:45 P.M., the Director of Nursing (DON) was notified at 8:53 P.M., the Hospice provider was notified at 8:55 P.M., and the listed emergency contact was notified at 9:20 P.M. The note did not indicate the legal guardian was contacted. An additional progress note, dated and timed for [DATE] at 9:21 P.M. revealed the spouse of Resident #119 was notified of her death and told the facility which funeral home he wished to use. A progress note dated [DATE] at 12:28 A.M. revealed the Hospice nurse arrived at the facility at 9:51 P.M. and notified the physician that Resident #119 had expired at 8:45 P.M. There were no documented evidence indicating Resident #119's legal guardian was notified of her death on the evening or night she expired. Review of the social services progress note dated [DATE] at 10:46 A.M. revealed the legal guardian of Resident #119 called and left a message requesting the time of death and funeral home information from the facility, and Social Worker #509 returned the call and provided the requested information at that time. Telephone interview on [DATE] at 2:48 P.M. with Licensed Practical Nurse (LPN) #504 confirmed once she and LPN #633 verified the absence of vital signs, she notified Hospice and a man she referred to as either the resident's boyfriend, fiancee, or spouse., that Resident #119 had expired. When asked if the legal guardian was contacted, said she was trying to figure out who she was supposed to notify so she called the person listed as an emergency contact, who was also listed as the spouse. During the interview, LPN #504 confirmed she did not know that Resident #119 had a legal guardian or that the daughter was involved in Resident #119's care and should have been listed as the family contact. Interview on [DATE] at 3:44 P.M. with the legal guardian for Resident #119 confirmed the facility did not notify her of Resident #119's passing on the date of her death. During the interview, the legal guardian confirmed she was responsible for all medical and financial decisions and was to be informed of any changes, including death. The legal guardian further confirmed she should have been called, regardless of whether it was after what was normal business hours, and that her answering service would have taken the message and forwarded it to her so she could have informed the resident's family. At the time of the interview, the legal guardian stated Resident #119, and her spouse had been estranged for quite some time, since before she was admitted to the facility, and that it was the resident's daughter who remained involved in Resident #119's care and with whom she communicated. The legal guardian further confirmed Resident #119's daughter visited her mother in the facility frequently and was devastated she was not afforded the opportunity to come to the facility before her mother's body was released to the funeral home (because the legal guardian was not informed timely), despite Resident #119's passing away during what the legal guardian referred to as normal waking hours. Review of the facility policy titled Resident Change in Condition Policy, [DATE], revealed the Physician/Provider, family, and the residents responsible party were to be notified of a significant change in condition. This deficiency represents non-compliance investigated under Master Complaint Number OH00157657.

Based on observation, interview, record review, facility Self-Reported Incident review, hospital record review, and review of the facility policy the facility failed to ensure a comprehensive fall risk assessment with individualized interventions was in place for Resident #83 and failed to timely assess and properly treat the resident after a fall. Actual harm occurred on 04/29/24 when Resident #83, who was at risk for falls did not have individualized interventions in place to address the risk, fell in her room and was not thoroughly assessed before being returned to bed. This resulted in the resident experiencing severe pain to her leg and a delay in immediate treatment. The resident was subsequently transferred to the emergency room for treatment of a femur fracture requiring surgical repair. This affected one resident (#83) of three residents reviewed for falls. The facility census was 122. Findings include: Review of Resident #83's medical record revealed an admitted [DATE] and a readmitted [DATE]. Resident #83's diagnoses included displaced intertrochanteric fracture of the right femur, type two diabetes mellitus without complications, rhabdomyolysis and bipolar disorder, current episode depressed, mild or moderate severity. Review of Resident #83's handwritten Preadmission Fall Review dated 04/10/24 included yes was checked for mental status, but the document did not specify as indicated if Resident #83 was confused, had delirium, had altered level of consciousness, disorganized thinking, memory or cognitive impairment, or poor safety awareness. Mobility was checked, but the document did not specify as indicated if Resident #83 had ataxia, unsteady, shuffling gait, ambulated with assistance of one person, had balance impairment or was unable to transfer, ambulate. The Preadmission Fall Review further included if yes was checked for either category of mental status or mobility the resident was considered high risk and appropriate interventions should be implemented. A preliminary review of pre-admission medical information revealed factors that might place the resident at a greater risk for falls. Please note the following interventions made by therapy and nursing in an attempt to decrease the risk of falls. The area stating what the risk factors were was not completed. Immediate Fall Prevention Interventions circled were bed in lowest position. Review of Resident #83's handwritten Therapy-to-Nursing Communication Form dated 04/12/24 revealed the front of the form was not completed, and the back of the form had a [NAME] Fall Risk Questionnaire which was completed, but unsigned. The Questionnaire included Resident #83 had a fall or near fall in the past year. Resident #83 felt uneasy or unsteady when walking down the aisle of a supermarket or in an area congested with other people. Resident #83 took medication for depression, anxiety, nerves, sleep or pain. Review of Resident #83's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #83 was cognitively intact. The assessment also noted Resident #83 had a fall within the last month of her admission to the facility. Review of Resident #83's care plan (initiated 04/10/24) included Resident #83 was at risk for falls related to impaired balance, muscle weakness, med use, debility, and impaired mobility. Resident #83 would minimize risk for falls and minimize injuries related to falls with a target date of 12/01/24. However, there were not fall interventions identified to address the fall risk. On 04/23/24 an intervention stated a fall risk evaluation would be completed to identify and minimize initial risk factors for falls and injury. There was no evidence individualized interventions were implemented including bed in lowest position until 04/29/24 (the date of Resident #83's injury of unknown origin). Interventions documented on 04/29/24 included encourage Resident #83 to keep bed in low position; fall risk assessment per routine and as needed; maintain call light within reach; reinforce need to call for assistance. When attempt was made to click on each intervention on 04/29/24 to review the history of the intervention, there were no historical interventions identified to review. Review of Resident #83's progress notes and care plan dated 04/10/24 through 04/29/24 did not reveal evidence Resident #83's bed was in the lowest position. Review of Resident #83's medical record including progress notes from 04/10/24 through 04/29/24 did not reveal a fall risk evaluation was completed. Review of Resident #83's care plan dated 04/23/24 included Resident #83 was at risk for deterioration in ADLs due to immobility, fall risk, diagnosis process, medications, and incontinence. The goal indicated Resident #83 would not deteriorate in ADLs as evidenced by maintaining ability to eat after set up. Interventions included to provide assistance for all ADLs. Review of Resident #83's progress notes dated 04/29/24 at 8:00 A.M. revealed Resident #83 was complaining of right lower extremity (RLE) pain. New order obtained from Certified Nurse Practitioner (CNP), and responsible party notified. There was no documentation describing what was causing the pain or the appearance of Resident #83's right lower extremity at this time. Review of Resident #83's physician's orders dated 04/29/24 at 9:26 A.M. revealed an order for a stat x-ray right femur 1-2 view, and stat x-ray right hip 1-2 view. Review of Resident #83's Physical Therapy Missed Visit Details dated 04/29/24 revealed nursing hold due to Resident #83 had complaints of hip pain after possible fall. X-rays ordered. Review of Resident #83's progress notes dated 04/29/24 at 3:15 P.M. revealed Resident #83 was noted to have pain in the right lower extremity, and was painful to touch. Resident #83's Nurse Practitioner (NP), NP #339, was notified and x-rays were ordered. Resulted with comminuted mild displaced femoral fracture. NP gave order to transfer Resident #83 to the local hospital orthopedic department for further evaluation. Responsible party notified. Review of an Event Report initiated 04/29/24 at 3:10 P.M. and completed 05/21/24 at 4:56 P.M. included Resident #83 had a fracture of the right femur and the location where the event occurred was unknown. Resident #83 complained of pain in right lower extremity, painful to touch, Resident #83's Nurse Practitioner (NP), NP #339, was notified and gave orders for an x-ray. Resident #83's x-ray results were comminuted (fracture producing multiple bone splinters) mild displaced femoral fracture. When Resident #83 was asked what happened she stated she fell at home. Resident #83 was transported to the hospital emergency room . The report indicated Resident #83 was oriented to person, and was ambulatory with assistance. The event was not witnessed. Further review of the Event Report included the facility completed a thorough investigation and was not able to determine the cause of the fracture. Resident #83 was alert and oriented times two with confusion. Resident #83 stated she had a fall at her apartment prior to coming to the facility. Resident #83 had a history of noncompliance with ambulating without assistance and fall prior to admission at home and also in hospital. After interviewing all staff and residents no abuse or fall was suspected. Resident #83 had the ability to self-transfer, ambulate and get herself off the floor. Resident #83 was receiving therapy services (PT, OT, and ST) and was ambulating in therapy up to 100 feet. Review of a facility self-reported incident (SRI), tracking number 246928, dated 04/29/24 revealed the facility reported Resident #83 had an injury of unknown source. The SRI included Resident #83 did not provide meaningful information when interviewed. The Administrator was notified Resident #83 had a fracture of unknown origin. Resident #83 complained of RLE pain and when interviewed she stated she fell at home. The facility obtained an x-ray which showed a fracture. The nurse practitioner (NP) gave orders to transport Resident #83 to the emergency room for further evaluation from orthopedics. The facility was obtaining hospital notes prior to nursing home admission to see if Resident #83's fracture was prior and RLE complaint of pain was present. Resident #83 had an extensive social history, APS involvement, unsafe and unsanitary living conditions. Resident #83 had a Brief Interview for Mental Status of 14 (cognitively intact), and stated she fell at home but the facility was not aware of fracture prior to admission. Resident #83 received surgery to repair the fracture and would return to the facility. The SRI revealed all nurses and State tested Nursing Assistants (STNAs) assigned to care for Resident #83 were interviewed and all staff denied Resident #83 fell as well as any other events taking place. The facility believed the incident happened at home (prior to the 04/10/24 admission) as Resident #83 described or while at the hospital prior to admission to the facility. Review of the staffing schedule revealed on 04/28/24 at 10:00 P.M. through 04/29/24 at 6:00 A.M. there were nine STNA staff, including four male STNA's. STNA #257 was assigned to care for Resident #83. Review of Licensed Practical Nurse (LPN) #341's Witness Statement dated 05/29/24 (meant 04/29/24) revealed after report and counting (medications) an unidentified aide asked her to come to Resident #83's room and look at her related to complaints of pain while the aide was dressing her. LPN #341 stated upon assessment she observed internal rotation to the right foot and Resident #83 complained of RLE pain. LPN #341 contacted the on call and obtained orders for an x-ray. Review of a Witness Statement written by the Director of Nursing (DON) included on the morning of 04/29/24 an unidentified floor nurse noted Resident #83 voiced complaints of pain in the lower back and right hip. Upon assessment Resident #83's right hip was painful to touch. When asked what happened Resident #83 stated she had a fall at home prior to coming to the facility. The DON asked if she had a fall at the facility at any time Resident #83 stated no. The NP was notified, and orders were given to get an x-ray due to pain. Review of Resident #83's Ortho Consult at the hospital on 04/29/24 at 9:35 P.M. included Resident #83 presented with right hip pain after a fall from standing at her facility (contradictory account of the accident from the facility injury of unknown origin report and investigation). Resident #83 was unable to get up and had to call for help. Resident #83 denied new significant pain other than right hip. Resident #83 denied head trauma and loss of consciousness. Resident #83 was awake and oriented times three (person, place, time), and her mood and affect were calm and appropriate to the situation. Resident #83 was in bed and unable to ambulate secondary to known injury. Resident #83's right lower extremity was shortened and externally rotated. Resident #83's x-ray of the right hip dated 04/29/24 revealed she had a four part intertrochanteric femur fracture. No other acute fracture or dislocation. X-ray results of the right femur were pending. Plan for surgery (OR) for right hip cephalomedullary nailing (CMN) on 04/30/24. Review of Resident #83's progress notes dated 04/30/24 at 12:01 P.M. included Resident #83 was admitted to the local hospital and was scheduled for surgery this morning per NP #339. Review of Resident #83's Discharge Summary for her hospital admitted d 04/29/24 through 05/08/24 included Resident #83 had a right intertrochanteric femur fracture, status post (s/p) CMN on 04/30/24. Review of Resident #83's physician progress note dated 05/13/24 written by NP #339 included on 04/29/24 Resident #83 was sent to the emergency room after a fall with RLE pain, an x-ray showed right intertrochanteric femur fracture. Resident #83 underwent CMN on 04/30/24. Resident #83 returned to the facility for rehab. Observation on 05/29/24 at 5:04 P.M. revealed Resident #83 was lying in bed, the lights were dim and observation of her window blinds revealed a couple slats were broken and large pieces of the blinds were missing. During an interview with Resident #83 on 05/29/24 at 5:04 P.M. the resident revealed she fractured her hip. Resident #83 stated (on 04/29/24) she got out of bed, she was standing and went to hang her clothing on a chair and fell down. Resident #83 stated she broke her blinds when she fell . The resident stated she laid on the floor and knew she broke something when she fell . Resident #83 stated a guy came into her room, picked her up, was not gentle, put her in bed and he really hurt her as he was putting her in bed. Resident #83 stated her fall happened between 12:00 A.M. and 1:00 A.M. Resident #83 stated she did not remember anyone coming in her room after that, her call button was not in her reach and she could not activate it to call for help. Resident #83 indicated she did not know how long she laid on the floor before the guy came in and put her to bed. Resident #83 stated later in the day the paramedics were called and she was taken to the hospital. During a follow-up interview with Resident #83 on 05/30/24 at 9:54 A.M., the resident revealed she had told the staff about her fall at the facility (on 04/29/24), how she was standing in her room, turned around and fell , and the aide picked her up and roughly put her in bed. Resident #83 stated she did not tell the staff she fell at home. Resident #83 again stated after the aide put her back in bed no one came in to see how she was, and that surprised her because she thought a nurse would come in to see if she was okay. Resident #83 stated she was in a lot of pain and her hip hurt so bad. Resident #83 indicated she was trying to remember what the male aides name was, but she could not remember. An interview with STNA #257 on 05/30/24 at 3:30 P.M. revealed she was assigned to care for Resident #83 on 04/29/24 but she could not recall an incident with Resident #83 on 04/29/24 and did not know anything about Resident #83's injury. Interview on 06/03/24 at 11:55 A.M. with Minimum Data Set (MDS) Nurse #237 revealed the facility recently changed companies for Residents Electronic Health Records (EHR), and the date of the change was 04/08/24. MDS Nurse #237 revealed Resident #83 was admitted two days after the facility changed companies. MDS #237 confirmed she edited Resident #83's care plan on 04/29/24, but stated she could not remember the details surrounding the edit. MDS Nurse #237 stated some of the problems and interventions were copied and pasted from the old EHR company to the care plans of the new EHR during the transition. The MDS Nurse stated she could not remember if she copied and pasted the problem and intervention for falls into Resident #83's care plan on 04/29/24, but said it was likely because when the interventions were clicked on in the care plan a history could not be seen. Interview on 06/03/24 at 2:39 P.M. with LPN #341 revealed on 04/29/24 she worked day shift and arrived for work at 7:00 A.M. LPN #341 stated she got report, counted and was preparing for the med pass when an unidentified aide yelled for her to go to Resident #83's room because she was having pain. LPN #341 stated Resident #83 was having pain and it was obvious her leg did not look normal, it was turned in and did not look right. LPN #341 indicated she barely touched Resident #83 leg and the touch caused severe pain. LPN #341 stated she called the nurse who worked night shift, but the nurse had no knowledge of any incident regarding Resident #83, and said nothing was reported to her. LPN #341 stated she told NP #339 there was definitely something wrong with Resident #83's leg and obtained an order for an x-ray. LPN #341 stated she asked Resident #83 what happened and Resident #83 said at around 2:00 A.M. she fell and was on the floor and a guy that helped everyone helped her up, but she did not know his name. LPN #341 stated she told Unit Manager (UM) #200 that Resident #83 fell , was on the floor and a male aide helped her off the floor and put her back to bed. When asked why she did not include Resident #83 had a fall, was found on the floor and helped back to bed by a male aide in her witness statement regarding the incident, LPN #341 stated she was told to write a statement of what she found when she got to Resident #83's room, so she only put that and not what Resident #83 told her. LPN #341 stated that was why she did not write anything else about Resident #83's fall and assistance back to bed by a male aide. Interview on 06/03/24 at 2:44 P.M. with Unit Manager (UM) #200 revealed UM #200 stated from her understanding Resident #83 was in bed and said her leg was hurting. UM #200 indicated a couple STNAs were asked what happened but they could not say. UM #200 stated Resident #83 was reaching for her pants, she heard Resident #83 was on the floor and an aide helped her up. UM #200 stated she did not interview Resident #83, only observed her leg. UM #200 stated Resident #83 required extensive assistance and could not ambulate safely by self. Interview on 06/03/24 at 2:55 P.M. with STNA #203 and #228 revealed they took care of Resident #83 and were familiar with her. STNA #228 stated Resident #83 liked to stay up until around 1:00 A.M. then she would put her call light on for them to assist her into bed. STNA #228 stated Resident #83 had to be reminded to use the call light and she would try to get up on her own if she did not have the call light close by. STNA #228 stated before Resident #83's incident on 04/29/24 Resident #83's leg was not painful to touch or turned in. STNA #228 stated he wrote a witness statement stating he had no knowledge of Resident #83's incident. STNA #203 stated he was not asked about the incident or told to write a witness statement because Resident #83 was not his resident. Interview on 06/03/24 at 3:00 P.M. with STNA #228 revealed he was not usually assigned to care for Resident #83, but the STNA's on the nursing unit worked together as a team and would help each other out with the assignments. STNA #228 stated he knew Resident #83 well and often went in her room to assist with her needs. STNA #228 stated he could not recall an incident on 04/29/24 and had no knowledge of a fall. Interview on 06/03/24 at 3:36 P.M. with the DON revealed on 04/29/24 she was driving to the facility and she was called by UM #200 regarding Resident #83 and UM #200 was going to assess her. The DON stated NP #339 was in the facility, saw Resident #83 and ordered x-rays. The DON indicated the x-rays showed Resident #83 had a fracture and NP #339 gave orders for Resident #83 to be transported to the hospital for evaluation. The DON stated the facility started an investigation for injury of unknown origin, and stated she interviewed Resident #83 multiple times. The DON indicated Resident #83 stated she fell at her apartment, not at the facility. The DON stated no one told her Resident #83 fell at the facility or that Resident #83 said she fell and a male helped her back to bed. The DON indicated Resident #83 had a history of falls before she was admitted to the facility. Interview on 06/03/24 at 4:41 P.M. with NP #339 revealed she received a call on 04/29/24 at around 8:00 A.M. by a nurse who just came on shift. NP #339 stated the nurse told her Resident #83 had fallen overnight, was having a lot of pain, and her leg did not look right. NP #339 stated she requested an x-ray and the x-ray showed Resident #83 had a fracture. NP #339 indicated she did not talk to Resident #83 about her fall because she not in the facility that day. NP #339 stated Resident #83's fall was around 3:00 A.M., somebody picked her up and put her back to bed, the facility did an investigation about that but she was not sure of the outcome. NP #339 stated Resident #83 had frequent falls at home, but she did not recall having any information about a fracture at home before she was admitted to the facility. NP #339 stated in her previous visits with Resident #83 before the fall on 04/29/24 she did not remember her leg being internally rotated or painful to the touch. NP #339 stated she read the hospital records and Resident #83's assessment when she arrived to the ED, and the assessment was not what Resident #83 had prior to her fall. NP #339 stated her leg did not look like that prior to the fall on 04/29/24. Interview on 06/04/24 at 9:35 A.M. with Regional Director of Clinical Services (RDCS) #342 revealed the RDCS did not believe the facility had evidence Resident #83 fell and hurt her hip. RDCS #342 stated Resident #83 had pain, the DON called her, and a self-reported incident was opened for an Injury of Unknown Origin. RDCS #342 stated the DON said she did not know how Resident #83 fell , an investigation was conducted, everyone was interviewed, and no one admitted to picking Resident #83 off the floor and putting her back to bed. RDCS #342 stated she did not know how Resident #83 fell and got herself back to bed. When Resident #83 returned to the facility they made sure all interventions were in place and the facility ruled out abuse. RDCS #342 indicated she talked to the therapy department staff and was told Resident #83 was ambulatory and could walk 100 feet. RDCS #342 stated she did not know what truly happened. RDCS #342 confirmed Resident #83 did not have a fall risk evaluation completed when she was admitted to the facility. RDCS #342 indicated the handwritten Preadmission Assessment was completed by therapy and was usually completed by nursing or therapy or both. Review of the facility policy titled Fall Prevention and Management, references were State Operations Manual 2017 and included residents would be assessed for fall risks on admission, quarterly, after any fall and as needed. If risks were identified, preventative measures would be put in place and care planned. All falls would be reviewed and investigated. Providers would be consulted regarding risks and interventions, feedback, and any further approaches. This deficiency represents non-compliance investigated under Complaint Number OH00154506, OH00153567, and OH00154128.

Based on record review, interview, and review of the National Pressure Ulcer Advisory Panel information, the facility failed to ensure interventions were in place to prevent the development of avoidable in-house pressure ulcers, failed to ensure treatments were provided as ordered and failed to prevent the deterioration of pressure ulcers for Resident #122 and Resident #23. This affected two residents (Residents #122 and #23) of three residents reviewed for pressure ulcers. Actual Harm occurred when Resident #122 developed an in-house avoidable unstageable pressure ulcer to the right ear and a suspected deep tissue injury (SDTI) to the left heel, and also when the resident's coccyx pressure ulcer deteriorated. Actual Harm also occurred when Resident #23's excoriation to the coccyx deteriorated to an avoidable SDTI and a Stage II pressure ulcer. Findings include: 1. Review of the closed record for Resident #122 revealed the resident was admitted to the facility 10/13/17 with [DIAGNOSES REDACTED]. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer to buttock (coccyx), cerebral infarction, and [MEDICAL CONDITION]. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severe cognitive impairment with delusions. The resident required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Additionally, the resident required extensive assistance of one staff for eating. She had an indwelling Foley catheter and was always incontinent of bowel. Resident #122 was at risk for pressure ulcer development. Review of a skin check dated 10/13/17 revealed the resident was admitted with a scab to the right front shoulder, a scab to the right elbow, scab to the right trochanter (hip), scab to the left elbow, unstageable pressure ulcer to the coccyx pressure wound, and a bruise to the first joint of the left great. Review of the NPUAP revealed an unstageable wound is described as an 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 III or Stage IV pressure injury will be revealed. Review of the weekly wound assessment dated [DATE] revealed the unstageable pressure ulcer to the coccyx measured 4.0 centimeters (cm) in length by 4.0 cm in width by 0.25 cm in depth. The wound bed had slough (yellow devitalized tissue that can be stringy or thick and adherent on the wound bed) tissue, no drainage, and a faint odor. The peri-wound (area surrounding the wound) was pink. The resident stated her pain level was seven, on a scale of zero to ten. Review of the weekly skin assessment dated [DATE] revealed the unstageable pressure ulcer to the coccyx had deteriorated to 7.0 cm in length by 7.0 cm in width by 1.0 cm in depth with undermining of 4.0 cm at 12 o'clock, 4.5 cm at three o'clock, 2.0 cm at six o'clock, and 2.0 cm at nine o'clock. The wound bed had slough, purulent drainage (this type of drainage can be green, yellow, brown, or white in color and is a thick liquid, almost always indicates an infection), and no odor. The peri-wound was black necrotic tissue. The wound was documented incorrectly as a Stage IV pressure ulcer. Review of the weekly skin assessment dated [DATE] revealed an unstageable suspected deep tissue injury (SDTI), not present on the admission assessment to the left heel measuring 1.5 cm in length by 2.0 cm in width by 0.0 cm in depth. The note indicated a new order was received to pad and protect with an abdominal (ABD) pad and wrap with Kerlix (gauze wrap). Review of the medical record revealed the new treatment order to the left heel was not transcribed, and the treatment was not initiated. Review of the weekly skin assessment dated [DATE] also revealed a new unstageable area to the right ear measuring 1.5 cm in length by 0.5 cm in width. The depth was unable to be determined due to it was covered with slough tissue. Review of the weekly skin assessment dated [DATE] revealed the pressure ulcer to the coccyx continued to deteriorate measuring 7.5 cm in length by 7.5 cm in width by 2.0 cm in depth with undermining of 2.5 cm at 12 o'clock, 0.5 cm at three o'clock, 1.0 cm at six o'clock, and 1.0 cm at nine o'clock. The wound bed was covered in slough tissue, a moderate amount of purulent drainage, and moderate odor. The peri-wound was black necrotic tissue. Review of the weekly wound assessment dated [DATE] revealed the in-house acquired left heel SDTI increased in size measuring 2.5 cm in length by 6.0 cm in width. The note stated that a treatment to pad and protect the wound was in place. Review of the medical record revealed the treatment to the left heel was still not transcribed and had not been initiated. Review of the weekly wound assessment dated [DATE] revealed the in-house acquired unstageable pressure ulcer had increased in size now measuring 1.7 cm in length by 0.7 cm in width. The depth was unable to be determined due to it was covered in slough tissue. Review of the weekly wound assessment dated [DATE] revealed the pressure ulcer to the coccyx continued to deteriorate measuring 7.5 cm in length by 7.0 cm in width by 1.5 cm in depth with undermining on 2.5 cm at 12 o'clock, 5.5 cm at three o'clock, and 5.0 cm at nine o'clock. The wound bed was covered in slough tissue with a moderate amount of purulent drainage. The peri-wound remained black necrotic tissue. Review of the weekly wound assessment dated [DATE] revealed the in-house acquired SDTI to the left heel measured 2.0 cm in length by 4.0 cm in width. The note stated that a treatment to pad and protect the wound was in place. Review of the medical record revealed the treatment to the left heel was still not transcribed and had not been initiated. Review of the weekly wound assessment dated [DATE] revealed the in-house acquired unstageable pressure ulcer to the right ear measured 1.0 cm in length by 0.3 cm in width. The depth was unable to be determined due to it was covered in slough tissue. Interview on 11/09/17 at 10:35 A.M. with licensed practical nurse (LPN) #203 revealed she verified Resident #122 developed an unstageable pressure ulcer to her right ear and a SDTI to the left heel in-house. She verified the treatment order to the resident's left heel was never written, and the treatment was never initiated. Interview on 11/09/17 at 11:30 A.M. with the family member of Resident #122 revealed the family decided to take the resident home with home health care on 11/04/17 due to the poor care she was receiving after they realized how much her wounds had deteriorated. The family memeber stated she had asked to see the resident's wounds several times and was always told they are fine. Additionally, she stated the pressure ulcer on her coccyx was approximately the size of her fingernail when they brought her to the facility and now you can put your fist in it after only three weeks. 2. Review of the medical record for Resident #23 revealed the resident was admitted to the facility 06/27/17 with [DIAGNOSES REDACTED]. Review of the admission MDS 3.0 assessment dated [DATE] revealed severe cognitive impairment with no behaviors. The resident was totally dependent of two staff for bed mobility, transfers, dressing, toilet use, hygiene, and bathing. He was dependent of one staff for eating. Additionally, the resident had a feeding tube and had an indwelling Foley catheter and was always incontinent of bowel. The resident had no pressure ulcers, but was at risk for pressure ulcer development. Review of the medical record revealed the resident was discharged to the hospital on [DATE] and returned to the facility 09/29/17. Review of the skin check dated 09/29/17 stated the resident had mild excoriation to the coccyx and bilateral buttocks. Review of the skin check dated 09/30/17 stated the resident had reddened coccyx and buttocks. Review of the skin check dated 10/03/17 stated the resident had reddened coccyx and buttocks. Review of the weekly wound assessment dated [DATE] revealed the resident had an in-house acquired SDTI to the coccyx and an in-house acquired Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) pressure ulcer to the coccyx (within the unstageable area). The wound measured 6.0 cm in length by 7.0 cm in width by 0.1 cm in depth. The peri-wound was reddened. Review of the NPUAP describes a Stage II pressure ulcer as a partial-thickness skin loss with exposed dermis. Review of the weekly wound assessment dated [DATE] revealed the in-house acquired pressure area to the coccyx now measured 4.5 cm in length by 2.5 cm in width by 0.1 cm in depth. The wound bed was noted to be red. Review of the weekly wound assessment dated [DATE] revealed the in-house acquired pressure area to the coccyx now measured 5.0 cm in length by 6.0 cm in width by 0.1 cm in depth. The peri-wound was noted to be red. There were scattered open areas within that measurement. The wound was a SDTI with a Stage II pressure ulcer to the left of the coccyx. Review of the weekly wound assessment dated [DATE] revealed the in-house acquired pressure area to the coccyx was deteriorating, now measured 5.5 cm in length by 8.0 cm in width by 0.1 cm in depth. The entire area was not open, had scattered open areas across the buttocks and coccyx region. Diarrhea was hindering resolution. Review of the weekly wound assessment dated [DATE] revealed the in-house acquired wound now measured 6.5 cm in length by 7.5 cm in width by 0.1 cm in depth. The peri-wound was reddened. Review of the weekly wound note dated 11/08/17 revealed the in-house acquired pressure ulcer had further deteriorated measuring 8.5 cm in length by 7.5 cm in width. The depth was now unable to be determined due to the wound bed was covered in slough tissue. Interview on 11/09/17 at 4:55 A.M. with State tested nurse aide (STNA) #400 revealed the resident's care was not always able to be completed due to short staffing. She stated she had between 18 and 22 residents on her assignment and all but four of them required extensive assistance or were dependent with activities of daily living (ADLs). Interview on 11/09/17 at 5:15 A.M. with STNA #404 revealed resident care was not always able to be completed as it should be due to short staffing. Interview on 11/09/17 at 6:00 A.M. with STNA #403 revealed the scheduler frequently puts STNAs on the assignment that were not scheduled to work. This STNA also revealed the facility used a lot of agency staff and they do not turn, reposition, and change the residents as they were supposed to. Interview on 11/09/17 at 10:35 A.M. with LPN #203 verified Resident #23 developed an unstageable wound in-house which had deteriorated since it was discovered on 10/04/17. This surveyor was unable to observe the dressing change to Resident #23 as it was not scheduled to be completed during the survey. This deficiency substantiates Complaint Number OH 422.