Every finding on record at Belpre Landing Nursing and Rehabilitation

Based on observation, record review, hospital record review and interview, the facility failed to ensure Resident #2, with a known history of hypothermia, was comprehensively monitored for a change in condition to ensure timely notification to the resident's medical provider to prevent a delay in treatment. This affected one resident (#2) of three sampled residents reviewed for quality of care. The facility census was 49.Actual Harm occurred on 01/17/26 when Resident #2 was noted to exhibit decreased consciousness and was transported to the hospital for evaluation where she was admitted with hypothermia (body temperature of 91 degrees F) and multiple infections requiring treatment in the intensive care unit and antibiotic therapy. Resident #2, who was dependent on a ventilator for breathing, dependent on staff for care, had diagnosis of multiple sclerosis and had been re-admitted to the facility (on 12/24/25) from the hospital after being treated for hypothermia (with a temperature of 93 degrees Fahrenheit (F)) related to multiple sclerosis and infection. Upon re-admission, the facility failed to have a comprehensive system in place for monitoring for signs and symptoms of hypothermia. Resident #2 had low body temperature readings on 01/14/26, no temperature assessed on 01/15/26 and a low temperature on 01/16/26 with no physician notification or evidence of increased monitoring or assessment of the resident. The resident was subsequently transferred to the hospital and treated for hypothermia.Findings include:Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including anemia, dependence on ventilator, multiple sclerosis, and functional quadriplegia. According to the National Institute of Neurological Disorders and Stroke, multiple sclerosis (MS) is a chronic neurological disorder. It's an autoimmune disorder, meaning that in MS, the immune system, which normally protects us from viruses, bacteria, and other threats; mistakenly attack healthy cells. Review of a care plan dated 04/02/25 revealed Resident #2 had an alteration in respiratory functions related to respiratory failure, tracheostomy and ventilator, history of aspiration pneumonia and mucus plugging or bronchus. Goals included to be free from respiratory distress through the review date. Interventions included to assess lung sounds per orders and nursing judgement, report abnormal breath sounds to provider, AVAP per physician order, change tracheostomy tube every 30 to 45 days and as needed (trach size six Shiley), CPT as ordered, evaluate shortness of breath for pain and discomfort when breathing and administer medications as ordered to relieve, instruct resident in pursed lip breathing technique and coughing and deep breathing techniques, maintain head of bed elevated to prevent shortness of breath, monitor vital signs as ordered and report any abnormalities to provider, nursing to monitor resident and assess for effectiveness of respiratory treatment: vitals, lung sounds, mental status, skin color, and report abnormalities to provider, nursing to assure set up of all required equipment and clean up after, provide oxygen as ordered, and provide respiratory treatment as ordered. Review of a care plan dated 04/02/25 revealed Resident #2 was at risk for infection related to nursing home stay, tracheostomy status, surgical wound, suprapubic catheter, gastrostomy (g-tube) and history of infections. The goal was to remain free of signs and symptoms of infection through the review date. Interventions included assessing signs and symptoms of infection and report to provider: redness, swelling, increased pain, purulent drainage, elevated temperature, change in color of secretions, cough, congestion, abnormal lung sounds, diarrhea, and vomiting. Review of a care plan dated 04/02/25 revealed Resident #2 had an alteration in respiratory function and required a tracheostomy and ventilator. Goals included oxygen level to be kept at desired levels set per provider through the review date. Interventions included to administer oxygen as ordered, aerosol treatments as ordered, change aerosol nebulizer set-up as ordered, change closed suction catheter system as ordered, change heated moisture exchange as ordered, change size six Shiley tracheostomy inner cannula as ordered, change trach ties as ordered, change ventilator circuit as ordered, cleanse tracheostomy site as ordered, ensure ventilator was on proper settings per orders: AC/VC via tracheostomy continuous, pressure control (PC) 22, respiratory rate (RR) 20, Inspiratory time 1.2, Positive End- Expiratory Pressure (PEEP) 6, fraction of inspired oxygen (FIO2) 32%, ventilator checks every four hours, medications as ordered, monitor lung sounds as ordered, monitor oxygen levels as ordered; and observe for signs and symptoms of dyspnea: labored respiration, low oxygen, use of accessory muscles, cyanosis, changes in mental status, and tachypnea, provide inhalers as ordered, respiratory therapist to change tracheostomy tube every 35 to 40 days and as needed, and suction trach per orders. Review of a care plan dated 10/22/25 revealed Resident #2 had an alteration in musculoskeletal status related to muscle weakness, multiple sclerosis, and functional quadriplegia. The goal was to remain free from complications related to musculoskeletal status through the review date. Interviews included to administer medications per physician orders and monitor for effectiveness/side effects, anticipate and meet needs, ensure call light was within reach and respond promptly to all requests for assistance, assist with activities of daily living (ADLs) and care as needed, educate resident and family on joint conversation techniques as indicated, monitor and document for fall risk, educate resident and care givers on safety measures to reduce risk; pain assessment per facility policy, skin assessment per facility policy, and therapy to evaluate and treat as indicated. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2's cognition was intact and she was able to make her needs known. Review of a nursing note dated 12/04/25 at 2:11 P.M. authored by Licensed Practical Nurse (LPN) #164 revealed Resident #2 was having complaints of feeling really hot, vitals were taken and her blood pressure was 168/84 (hypertensive), heart rate was 53 beats per minute (bradycardic), and temperature was 93 degrees Fahrenheit (F) (hypothermic). (Medical) Provider was notified and gave orders to transfer the resident to the hospital. 911 was contacted and resident's family updated. Report was called to the local hospital. Hypothermia is a condition that occurs when core body temperature drops below 95 degrees Fahrenheit (F). It is a medical emergency. In hypothermia, the body loses heat faster than it can produce heat, causing a dangerously low body temperature. Normal/regular body temperature is around 98.6 degrees Fahrenheit. When body temperature drops, the heart, nervous system and other organs can't work as well as they usually do. Left untreated, hypothermia can cause the heart and respiratory system to fail and eventually can lead to death Review of a nursing note dated 12/24/25 at 12:38 P.M. authored by LPN #108 revealed Resident #2 was re-admitted to the facility (from the hospital stay that started 12/04/25) via stretcher, orders were verified and assessments were completed. Vitals were obtained and Resident #2 was alert and able to communicate needs. Record review revealed on 01/14/26 at 8:19 A.M. Resident #2 temperature was documented to be 98 F. Additionally, at 4:38 P.M., she had a temperature of 97.3 F which the (electronic) system triggered as a low exceeding 97.8 F. There was no corresponding nursing note. There was no evidence the resident's condition was thoroughly assessed at this time. Record review revealed no evidence the resident's physician was notified of the low temperature reading, no evidence a comprehensive assessment of the resident was completed, and no evidence the resident's temperature was re-checked. Review of the temperature log revealed no temperature was taken for Resident #2 on 01/15/26. There was no evidence that the resident's condition was thoroughly assessed and monitored on this date. On 01/16/26 at 4:35 P.M. Resident #2's temperature was noted to be 96.4 F which the (electronic) system triggered as a low exceeding 97.8 F. There was no corresponding nursing note. There was no evidence that the resident's condition was thoroughly assessed at this time. Record review revealed no evidence the resident's physician was notified of the low temperature reading, no evidence a comprehensive assessment of the resident was completed, and no evidence the resident's temperature was re-checked. On 01/17/26 at 1:16 P.M. Resident #2's temperature was 95.7 F which the (electronic) system triggered as a low exceeding 97.8 F. A follow-up nursing note dated 01/17/26 at 1:46 P.M. by Registered Nurse (RN) #140 revealed Resident #2 was showing signs of increased confusion and repeating herself. The resident's temperature was documented to be 85.7 F, and verbal orders were received to send the resident to the emergency room for evaluation. Resident's family was notified and the resident was transported to a local hospital. Review of a nursing note dated 01/17/26 at 3:46 P.M. by Registered Nurse (RN) #140 revealed the hospital updated the facility and stated Resident #2 was being admitted and was in a warmer as her temperature was registering at 91 F. Review of a hospital note dated 01/17/26 revealed Resident #2 was admitted to the hospital with ventilator associated pneumonia ([NAME]), septic shock, and a complicated urinary tract infection with EBL producing E. Coli which were treated with antibiotics, Vancomycin (glycopeptide antibiotic used for serious Gram-positive bacterial infections) and Merrem (broad spectrum antibiotic). Additionally, Resident #2 had hypothermia with a temperature of 91. F on arrival to the emergency department which was resolved with a [NAME] (a clinical, forced-air warming device that uses a specialized blanket and heater unit to maintain a patient's normal body temperature (normothermia) during pre-operative, intraoperative, and post-operative, stages) and treatment of infection. The hospital note included hypothermia was likely in the setting of acute infection and baseline of advanced multiple sclerosis. Resident #2 returned to the facility on [DATE] after receiving treatment in the intensive care unit including antibiotic therapy. Interview on 01/22/26 at 4:32 A.M. with Respiratory Therapist (RT) #172 revealed Resident #2 had been admitted to the hospital twice in the last two months for hypothermia. RT #172 stated she learned dry lips are a sign of hypothermia. RT #172 stated Resident #2's room would be cold, but she would decline for the heat to be turned on because she felt comfortable. Interview on 01/22/26 at 12:55 P.M. with Nurse Practitioner (NP) #305 revealed at this time, she was not aware of increased monitoring for Resident #2 related to episodes of hypothermia. NP #305 stated she had not spoken with the medical director yet to see if there was anything that could be done since the hypothermia was related to multiple sclerosis but stated perhaps the staff could check the resident's vital signs more frequently, maybe once a shift. Interview on 01/28/26 at 1:26 P.M. with Certified Nursing Assistant (CNA) #158 revealed when she would provide care for Resident #2, she would notice her skin was very cold but Resident #2 always stated she was fine. CNA #158 stated there was no increased monitoring being completed officially, but stated since the two instances of hypothermia, she had been checking in more frequently on Resident #2. CNA #158 was not sure what the symptoms of hypothermia were but stated she checked vital signs and would let the nurse know if something arises. During the interview, CNA #158 identified resident vital signs are normally taken once every shift. Interview on 01/28/26 at 4:20 P.M. with Director of Nursing (DON) confirmed Resident #2 had hypothermia related to infections and multiple sclerosis. The DON confirmed the care plan said to monitor resident for elevated temperature despite the fact that her temperature drops once she has an infection due to multiple sclerosis. The DON confirmed their (electronic) system triggered multiple low temperatures for Resident #2 (as noted on the dates above) with no evidence of staff follow-up (comprehensive assessments) or notification to the physician documented. The DON stated there was increased monitoring of Resident #2's room temperature since she was re-admitted to the facility on [DATE] but could not provide evidence of increased monitoring of Resident #2's body temperature. Per the DON, resident vital signs are typically obtained once per shift. On 01/28/26 at 4:35 P.M. Resident #2 was observed in her room. The room felt cool, but not cold. During the observation, the resident did not voice any current concerns related to her care by staff. The resident stated she was comfortable at this time and did not feel too cold. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2702282.

Based on review of the facility assessment and interview, the facility failed to ensure the facility assessment was completed accurately. This had the potential to affect all residents in the facility. The facility census was 49. Findings include:Review of the facility assessment dated [DATE] revealed the facility treats a wide range of patients transitioning from hospital to home. Prior to the admission of any resident, the Director of Nursing (DON) along with the interdisciplinary team would assess the physical and psychosocial needs to determine if placement is appropriate. Prior to a new admission arriving at the facility, all care related items not currently in the facility are ordered. Special treatments that could be completed in the facility included, but were not limited to, respiratory treatments. Respiratory treatments that could be completed in the building included oxygen therapy (15), suctioning (5), tracheostomy care (0), and ventilator or respirator care (2). Further review of the facility assessment did not include information of staffing needs for residents receiving respiratory services. Interview on 01/22/26 at 4:32 A.M. with Respiratory Therapist (RT) #172 revealed there were two residents with a tracheostomy and two residents with ventilators. Interview on 01/28/26 at 1:14 P.M. with the Administrator revealed in the facility assessment, they entered the average number of residents they usually have with the care needs rather than the number of residents the facility is able to provide care for based on their needs. The Administrator stated they were able to admit ten residents with ventilators in the facility. The Administrator confirmed the facility assessment was not completed based on what services they were able to provide, but rather the average number of residents they have needing those services, and there was no specific number of staffing requirements or types listed to address the needs of those residents on a ventilator or receiving trach services. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2702282.

Based on record review, observations, interview, and policy review, the facility failed to ensure respiratory care was completed as ordered. This affected two residents (#1 and #2) of two residents reviewed for respiratory care. The facility census was 49. Findings include: 1.Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including sepsis, pneumonia, and acute and chronic respiratory failure with hypoxia. Review of a care plan dated 01/08/26 revealed Resident #1 had an alteration in respiratory function related to respiratory failure with hypoxia and hypercapnia, pneumonia, dependence on a respiratory and tracheostomy. Goals included to be free of respiratory distress through the review date, show adequate oxygen perfusion through review date, and lungs will be clear to auscultation and spO2 will be above 90% through the review date. Interventions included but were not limited to assess lung sounds per orders and nursing judgment, report abnormal breath sounds to physician; evaluate shortness of breath for pain and discomfort when breathing and administer medications as ordered to relive; maintain head of bed elevated to prevent shortness of breath; medications for secretions; monitor vital signs as per orders and report any abnormalities to the provider; nursing to monitor resident and assess for effectiveness of respiratory treatment, vital signs, lung sounds, mental status, skin color, and will report abnormalities to provider, nursing to assure set up of all required equipment and clean up after; provide oxygen as ordered; and provide respiratory treatment as ordered. Review of a care plan dated 01/09/26 revealed Resident #1 had an alteration in respiratory function and required oxygen use, tracheostomy, and ventilator. Goals included oxygen levels will be kept at desired levels set per physician through review dated. Interventions included but were not limited to administer oxygen as ordered; ensure ventilator is set on proper settings (PSV via tracheostomy: QHS 10/5, FIO230%); monitor lung sounds as ordered; monitor oxygen levels as ordered; observe for signs and symptoms of dyspnea: low oxygen, use of accessory muscles, cyanosis, changes in mental status, tachypnea; PMV as tolerated; size eight Shiley tracheostomy inner cannula; suction trach per orders; and trach care as needed. Review of orders revealed an order dated 01/12/26 to change Resident #1's heat moisture exchange (HME) daily and as needed. Review of a treatment administration record (TAR) for January 2026 revealed Resident #1's HME was changed on 01/12/26. Review of a respiratory progress note dated 01/15/26 at 6:27 P.M. by Respiratory Therapist (RT) #172 revealed Resident #1 was on four liters with a trach mask, trach and oral care completed, suction as needed, the inner cannula was changed, HME was changed, CPO was in place, a respiratory assessment was completed at this time, ventilator was on standby at bedside, all ventilator cords were plugged in and connected to the correct electrical outlet, Resident #1's call light was in reach, the resident had a full tank of oxygen with ambu bag at bedside along with extra tracheostomy (trach) supplies. Review of a treatment administration record (TAR) for January 2026 revealed Resident #1's HME was changed on 01/15/26. Review of a respiratory progress note dated 01/21/26 at 10:10 P.M. by RT #172 revealed Resident #1's trach care and oral care were completed, he was suctioned as needed, and the HME and inner cannula were changed. Resident #1's call light was within reach and per his request staff awaited nurse to administer melatonin before placing him on the ventilator. Review of a treatment administration record (TAR) for January 2026 revealed Resident #1's HME was changed on 01/21/26. There was no additional evidence of Resident #1's HME being changed daily as ordered. Review of a minimum data set (MDS) completed on 01/26/26 revealed Resident #1's cognition remained intact. Interview on 01/22/26 at 9:49 A.M. with Nurse Practitioner (NP) #305 revealed she was not familiar with what an HME was but she researched it and found an HME humidifies air so the lungs are not getting dry. Concerns related to not changing the HME include pneumonia related to bacteria or aspiration due to increased airway resistance, mucus plugging, hypothermia, pneumonia and potential respiratory distress. NP #305 confirmed Resident #1's TAR only had as needed HME replacement listed and was completed on 01/12/26, 01/15/26, and 01/21/26 and no evidence of the HME being changed daily as ordered. NP #305 stated she was unsure where the orders come from since she does not give orders for tracheostomy or ventilator care. Interview with Director of Nursing (DON) on 01/22/26 at 12:58 P.M. revealed the order for Resident #1's HME to be changed stated daily but was only entered as needed. The DON stated he spoke with an RT who stated changing the HME does not need to be a separate order because it is a standard part of ventilator care and since the ventilator care was being documented daily, there was no concern. Interview on 01/28/26 at 7:08 A.M. with RT #160 revealed the HME is for humidification and it is called the heated moisture exchange and they keep the lungs moist. RT #160 stated HMEs are good for 24 hours and get changed every time care is completed. RT #160 stated the HME has to be its own separate order because if you provide ventilator care and everything is a mess, it doesn't mean the HME is a mess. RT #160 stated the HME is changed daily and as needed when soiled. RT #160 stated Resident #1's HME order was a clerical error and was entered incorrectly, but he was confident the care was still being completed daily despite the lack of documentation because he had gone in and checked dates on the HMEs with no concerns. RT #160 again stated the HME is it's own order and not grouped in with ventilator care orders. 2. Medical record review revealed Resident #2 was admitted on [DATE] with diagnoses including multiple sclerosis, chronic respiratory failure with hypoxia, tracheostomy and dependence on respirator/ventilator, history of ventilator associated pneumonia and sepsis. Review of the care plan: Alteration in respiratory function and requires tracheostomy, ventilator dated 04/02/25 revealed interventions included to change size 6 disposable tracheostomy inner cannula as ordered and cleanse tracheostomy site as ordered. Review of the electronic Physician Orders dated January 2026 revealed to cleanse the tracheostomy site with sterile water, pat dry and apply drain sponge. Change every shift and as needed (PRN), and change size 6 Shiley tracheostomy inner cannula every shift and PRN. On 01/28/26 between 8:20 A.M. to 8:39 A.M., observation of Resident #2's tracheostomy inner cannula and site care revealed the following: Respiratory Therapist (RT) #160 applied a protective gown, performed hand hygiene and donned non-sterile gloves. RT #160 was not observed to be wearing a mask. Observation of the bedside table revealed personal items were located on one-side of the table and treatment supplies were placed on the other side. There was no barrier or sterile field used for the tracheostomy supplies. RT #160 opened the tracheostomy care kit, split drain gauze, hydrogen peroxide and sterile saline. RT #160 removed the blue sterile gloves from the tracheostomy care kit and stated the sterile gloves were a medium size and did not fit his hands. RT #160 was observed throwing the sterile gloves in the trash. RT #160 removed the sterile items from the tracheostomy kit with non-sterile gloves, poured sterile water and hydrogen peroxide into the kit cleaning tray and inserted a split 4x4 gauze into the solution. RT #160 folded the gauze in half and cleaned around the lower aspect of Resident #2's tracheostomy stoma and disposed of the gauze. RT #160 grasped a second split 4x4 gauze with the same non-sterile gloves, inserted the gauze into the solution, cleaned around the upper aspect of Resident #2's tracheostomy stoma and disposed of the gauze. RT #160 removed his non-sterile gloves and disposed of them into the trash. RT #160 washed his hands at the sink, donned non-sterile gloves, returned to the bedside and placed a split gauze around the resident's tracheostomy stoma. RT #160 removed his gloves, washed his hands at the sink and donned non-sterile gloves. RT #160 grasped a sterile disposable tracheostomy inner cannula with his non-sterile gloved hand, disconnected the ventilator tubing, removed the used inner cannula from the resident's tracheostomy and inserted a new disposable inner cannula. RT #160 disposed of the used inner cannula, reattached the ventilator tubing to the tracheostomy, removed his gloves and isolation gown, and washed his hands at the sink. RT #160 stated the procedure was completed using a non-sterile procedure. On 01/28/26 at 3:34 P.M., interview with the Director of Nursing verified tracheostomy care was to be completed using sterile technique including sterile gloves, use of a barrier for supplies and appropriate personal protective equipment including a mask should be used. On 01/28/26 at 3:45 P.M., interview with RT #160 verified he did not use a barrier or wear a mask during tracheostomy care but stated he was arms length away from the resident during the procedure. RT #160 verified he wore non-sterile gloves because the sterile gloves in the tracheostomy kit were a medium size and he required a large sized glove. RT #160 verified the facility did have sterile gloves available to use but the procedure did not require a sterile procedure. RT #160 verified the facility policy was to use sterile techniques at all times; however, RT #160 stated the policy was wrong. Review of the undated policy: Tracheostomy and Tracheostomy Tube Care revealed a tracheostomy was a surgical opening in the trachea. Meticulous tracheostomy and trach tube care was mandatory to prevent complications. Since the tracheostomy was essentially an open wound and the normal protective mechanism in the upper airway are bypassed, the most hazardous complication was infection and prevention of infection was the primary goal of proper tracheostomy care techniques. To minimize the potential hazard of tracheostomy wound (stoma) infection the area was to be cleansed regularly using sterile technique at all times. To minimize the potential hazard of acute bronchopulmonary infection due to contamination of the artificial airway the inner cannula was to be cleaned regularly using sterile technique at all times. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2702282.

Based on medical record review, review of staff schedules, review of the National Library of Medicine literature, and interviews, the facility failed to ensure sufficient registered nurses or respiratory therapists were available at the facility to care for residents with ventilators. This affected two (#1 and #2) of two residents with ventilators. The facility census was 49. Findings include:1.Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including sepsis, pneumonia, and acute and chronic respiratory failure with hypoxia. Review of an order dated 01/08/26 revealed Resident #1 required a ventilator check every four hours and as needed. Review of a care plan dated 01/08/26 revealed resident #1 had an alteration in respiratory function related to respiratory failure with hypoxia and hypercapnia, pneumonia, dependence on a respiratory and tracheostomy. Goals included to be free of respiratory distress through the review date, show adequate oxygen perfusion through review date, and lungs will be clear to auscultation and spO2 will be above 90% through the review date. Interventions included but were not limited to assess lung sounds per orders and nursing judgment, report abnormal breath sounds to physician; evaluate shortness of breath for pain and discomfort when breathing and administer medications as ordered to relive; maintain head of bed elevated to prevent shortness of breath; medications for secretions; monitor vital signs as per orders and report any abnormalities to the provider; nursing to monitor resident and assess for effectiveness of respiratory treatment, vital signs, lung sounds, mental status, skin color, and will report abnormalities to provider, nursing to assure set up of all required equipment and clean up after; provide oxygen as ordered; and provide respiratory treatment as ordered. Review of orders dated 01/09/26 revealed Resident #1 required tracheostomy care: cleanse site with sterile water, pat dry, apply drain sponge, and change every shift and as needed; and change size 8 Shiley tracheostomy inner cannula every shift and as needed. Additionally, an order dated 01/09/26 revealed Resident #1 required suctioning via trach as needed and saline may be used if needed. Review of a care plan dated 01/09/26 revealed Resident #1 had an alteration in respiratory function and required oxygen use, tracheostomy, and ventilator. Goals included oxygen levels will be kept at desired levels set per physician through review dated. Interventions included but were not limited to administer oxygen as ordered; ensure ventilator is set on proper settings (PSV via tracheostomy: QHS 10/5, FIO230%); monitor lung sounds as ordered; monitor oxygen levels as ordered; observe for signs and symptoms of dyspnea: low oxygen, use of accessory muscles, cyanosis, changes in mental status, tachypnea; PMV as tolerated; size eight Shiley tracheostomy inner cannula; suction trach per orders; and trach care as needed. Review of orders revealed an order dated 01/12/26 to change Resident #1's heat moisture exchange (HME) daily and as needed. 2.Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including anemia, dependence on ventilator, and functional quadriplegia. Review of a care plan dated 04/02/25 revealed Resident #2 had an alteration in respiratory functions related to respiratory failure, tracheostomy and ventilator, history of aspiration pneumonia and mucus plugging or bronchus. Goals included to be free from respiratory distress through the review date. Interventions included but were not limited to assess lung sounds per orders and nursing judgement, report abnormal breath sounds to provider; AVAP per physician ordered; change tracheostomy tube every 30 to 45 days and as needed, trach size six Shiley; CPT as ordered; evaluate shortness of breath for pain and discomfort when breathing and administer medications as ordered to relieve; instruct resident in pursed lip breathing technique and coughing and deep breathing techniques; maintain head of bed elevated to prevent shortness of breath; monitor vital signs as ordered and report any abnormalities to provider; nursing to monitor resident and assess for effectiveness of respiratory treatment: vitals, lung sounds, mental status, skin color, and report abnormalities to provider, nursing to assure set up of all required equipment and clean up after; provide oxygen as ordered; and provide respiratory treatment as ordered. Review of a care plan dated 04/02/25 revealed Resident #2 had an alteration in respiratory function and required a tracheostomy and ventilator. Goals included oxygen level to be kept at desired levels set per provider through the review date. Interventions included but were not limited to administer oxygen as ordered; aerosol treatments as ordered; change aerosol nebulizer set-up as ordered; change closed suction catheter system as ordered; change heated moisture exchange as ordered; change size six Shiley tracheostomy inner cannula as ordered; change trach ties as ordered; change ventilator circuit as ordered; cleanse tracheostomy site as ordered; ensure ventilator is on proper settings per orders: AC/VC via tracheostomy continuous, PC 22, RR 20, I time 1.2, PEEP 6, FIO2 32%, ventilator checks every four hours; medications as ordered; monitor lung sounds as ordered; monitor oxygen levels as ordered; and observe for signs and symptoms of dyspnea: labored respiration, low oxygen, use of accessory muscles, cyanosis, changes in mental status, and tachypnea; provide inhalers as ordered; respiratory therapist to change tracheostomy tube every 35 to 40 days and as needed; and suction trach per orders. Review of orders dated 12/24/25 revealed Resident #2's ventilator circuit needed changed monthly and as needed, HME needed changed daily and as needed, a respiratory therapist was to change tracheostomy tube every 30 to 45 days and as needed with a size six Shiley, change size six Shiley tracheostomy inner cannula every shift and as needed, and cleanse tracheostomy site with sterile water, pat dry, and apply a drain sponge every shift and as needed. Review of staffing schedules from 12/25/25 through 12/31/25 revealed on 12/26/25 for nightshift (6:00 P.M. to 6:00 A.M.) there were three licensed practical nurses (LPNs) working and no Respiratory Therapists (RTs) or Registered Nurses (RNs). Interview on 01/28/26 at 3:34 P.M. with the Director of Nursing (DON) confirmed there was not an RN or RT working the nightshift of 12/26/25, but there were three LPNs. The DON stated he felt since there was an RN in the building eight hours earlier in the day as required, there did not need to be one at night. When asked if an LPN was permitted to provide ventilator care without the supervision of an RN or RT, he stated since the LPNs received an education and watched ventilator care being performed, he felt the LPNs could work with ventilator residents without supervision despite lack of certification or return demonstration completed. The DON was not sure if ventilator care was in the scope of an LPN's practice. Review of the National Library of Medicine literature dated 08/08/23 revealed mechanical ventilators are sophisticated and require training to ensure positive outcomes and limit harm. Inappropriate setting changes, failure to change alarms, changing settings without appropriate orders, and failure to communicate changes to the medical team result in poor patient outcomes. The individual who is best equipped suited to manage, adjust and document the ventilator is the respiratory therapist and the number of healthcare professionals who are allowed to make adjustments to the ventilator should be limited. All ventilators have alarms when there is a change in ventilation and it is vital to know what to do. This deficiency represents non-compliance investigated under Complaint Number 2702282.

Based on record review, review of facility investigations, observations, interviews, and policy review, the facility failed to ensure all allegations/ suspicions of misappropriation of resident property was reported to the State Survey Agency as required. This affected two (#8 and #50) of three residents reviewed for misappropriation of medications. Findings include: 1. Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, dysphagia (difficulty swallowing), amputation of the left leg below the knee, and osteoarthritis. Review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and her cognition was moderately impaired. She was coded on the MDS assessment as having had pain in the past five days she rated as a 4 on a 1-10 scale. She received both scheduled and prn pain medication for her pain. The medication section of the MDS assessment (Section N.) did not indicate that she had received opioid medications during the seven day assessment period (11/09/25- 11/15/25). Review of Resident #8's physician's orders revealed the resident had an order to receive Morphine Sulfate 20 milligrams (mg)/ milliliter (ml) with directions to give 0.25 ml by mouth (po) every four hours as needed (prn) for pain or shortness of breath. The order originated on 05/19/25, after she was placed under the care and services of hospice on 05/16/25. Review of Resident #8's medication administration records (MAR's) from May 2025 through November 2025 revealed the resident's prn order to receive Morphine Sulfate was included on the MAR's each month during that seven month period. There was no documented evidence of any prn doses of Morphine Sulfate having been administered to the resident for any complaints of pain or shortness of breath, since the order originated on 05/19/25. Review of Resident #8's Controlled Drug Receipt/ Record/ Disposition Form for her Morphine Sulfate revealed 30 ml of the liquid Morphine was filled by the facility's contracted pharmacy on 05/28/25. The form was blank and did not show any doses of the Morphine Sulfate had been used for the resident, since it was filled by the pharmacy. Review of a facility investigation file pertaining to Resident #8's liquid Morphine Sulfate revealed the facility obtained personal witness statements and/ or conducted phone interviews with facility nurses regarding the resident's Morphine Sulfate. A hand written statement from Licensed Practical Nurse (LPN) #115 dated 11/14/25 revealed she was doing the controlled narcotic drawer count when she noted a discrepancy with a Morphine Sulfate bottle for Resident #8. The contents of the bottle was below the 30 ml (approximately 27-28 ml's) that it should have been. She asked two other nurses (LPN #166 and LPN #350) when they started giving Resident #8 Morphine Sulfate and both denied knowledge of the resident ever receiving it. The resident just had the bottle on hand in case she needed it. She then informed the two nurses the bottle was low and some of the medication had been removed. The bottle appeared to be sealed, but when turned upside down, a drop of the liquid Morphine formed at the top of the bottle on the seal. She then noticed a very small hole in the seal. The plunger top and syringe for the liquid Morphine Sulfate bottle were still in the plastic packaging and had not been used. She checked another resident's liquid Morphine Sulfate bottle (Resident #50) and noted it too had a puncture hole in the seal at the top of the bottle, just like Resident #8's did. It appeared that the other resident's bottle contained the full amount of the 30 ml that it should have had in it. She called the unit manager (LPN #260) about her findings, who in turn instructed her to call the Director of Nursing (DON) immediately. The unit manager also informed her that they would probably need statements from everyone. The previous shift's nurses had already left the facility. She called the DON, as instructed, at 6:26 A.M. and left him a voicemail. When the unit manager came in, she showed the two bottles to the unit manager and informed her that she had already called the DON. On 11/19/25 at 1:25 P.M., an interview with the DON revealed he had been made aware of the discrepancy with Resident #8's Morphine Sulfate on 11/14/25 (Friday). He reported an oncoming day shift nurse (LPN #115) had placed Resident #8's bottle of Morphine Sulfate on top of the medication cart, when doing a controlled medication reconciliation with the off-going night shift nurse (LPN #166), and noted that the Morphine Sulfate bottle had about 3.5 ml less than it should have had. It was not documented on her Controlled Drug Receipt/ Record/ Disposition form, as having been used, since it had been filled by the pharmacy on 05/28/25. There was not a discrepancy noted during the previous controlled medication reconciliation count that was completed at shift change between the off-going day shift nurse (LPN #300) and the oncoming night shift nurse (LPN #166) on 11/13/25 (the shift change before the discrepancy was noted). He confirmed LPN #115 notified him of the discrepancy on the morning of 11/14/25. Once he had been made aware, he reached out to his clinical legal team and conducted a whole house audit of all controlled medications to identify any other discrepancies that may have existed, but none was noted. Resident #8's Morphine bottle had not been fully opened, but there was an obvious puncture hole in it. When he turned the bottle upside down the liquid medication in the bottle dripped out. He was not sure at the time, if it had been truly accessed, or if there was a faulty seal that allowed some of the liquid to leak out. They also noted another resident (Resident #50) had what appeared to be a puncture hole in the seal of his liquid Morphine Sulfate bottle too, when conducting a whole house audit of all controlled medications, to see if any other discrepancies were present. He contacted the facility's contracted pharmacist on Friday (11/14/25), who in turn notified the Ohio Board of Pharmacy. The Ohio Board of Pharmacy reached out to him on Monday (11/17/25) and informed him they would visit the facility on 11/19/25 around 1:30 P.M. to help assist in the investigation and to determine if any medication diversion had occurred. Resident #8's Morphine bottle was given to the Ohio Board of Pharmacy for review, as part of their investigation, when they arrived on-site on 11/19/25. The other resident's Morphine Sulfate bottle was provided for review as well. On 11/19/25 at 2:15 P.M., an observation of Resident #8's Morphine Sulfate 30 ml bottle that was in the Director of Nursing's (DON's) office and being examined by the State of Ohio Board of Pharmacy representatives (Agent and Compliance Specialist) revealed it had a puncture hole in the seal that was covering the top of the medication bottle. The amount of liquid in the bottle of Morphine Sulfate was below the 30 ml. line that would indicate a full bottle. It was confirmed by the representatives from the Ohio Board of Pharmacy that some of the medication solution had been removed from the bottle. On 11/19/25 at 2:55 P.M., a follow up interview with the DON confirmed it was determined that Resident #8 had approximately 3.5 ml of her liquid Morphine Sulfate removed from her bottle, when inspected by the Ohio Board of Pharmacy representatives. He further confirmed there was no documentation on the MAR's or on the Controlled Drug Receipt/ Record/ Disposition Form to show Resident #8 had been given any doses of her Morphine Sulfate liquid, since it had been ordered back in May 2025 to account for the amount of the medication that was missing. He reported the Ohio Board of Pharmacy representatives went ahead and removed the resident's liquid Morphine Sulfate bottle from the facility, after completing their on-site visit/ investigation earlier that day. He denied that he had submitted a self-reporting incident (SRI) for an allegation of misappropriation of medication to the state survey agency as he believed that was not required unless his investigation proved that misappropriation of medication had actually occurred. He acknowledged any allegation or suspicion of misappropriation of resident property, to include medications, should be reported to the state survey agency as required and in the time frame required. He indicated he had since submitted an SRI following the Ohio Board of Pharmacy's determination that controlled medications were unaccounted for, but acknowledged was not in the time frame in which they should have been reported. 2 a.) Review of Resident #50's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) affecting his right dominant side following a stroke, malignant neoplasm of the prostate, and unspecified dementia. He was admitted under the care and services of hospice on 07/30/25. Review of standing orders to implement with a hospice admission revealed it included the use of Morphine Sulfate 20 mg/ ml with directions to administer 0.25 ml po every four hours for pain or shortness of breath. A written prescription must be obtained from the physician for that order. A verbal order had been obtained by a hospice nurse for the above on 07/29/25. Review of Resident #50's physician's orders revealed the standing order for the use of Morphine Sulfate solution was not carried over into his active physician's orders after the verbal order was given on 07/29/25. Due to it not being carried over into his active physician's orders, the use of the Morphine Sulfate was not included on the medication administration record as one of the resident's prn medications. There was no evidence on the MAR's as any doses of the Morphine Sulfate as having been used for the resident, since the standing order originated on 07/29/25. Review of Resident #50's Controlled Drug Receipt/ Record/ Disposition Form for his Morphine Sulfate that had been sent by the facility's contracted pharmacy revealed 30 ml of the liquid Morphine was filled by the pharmacy on 07/29/25. A nurse signed receipt of the 30 ml of Morphine Sulfate on 07/30/25. The form was left blank where the nurses were to chart each dose administered reflecting no evidence of the liquid Morphine Sulfate having been used for the resident, since it had been filled and received by the facility on 07/30/25. On 11/19/25 at 2:15 P.M., an observation was made of Resident #50's Morphine Sulfate liquid bottle. The controlled medication bottle was in the DON's office being evaluated by representatives from the Ohio Board of Pharmacy, who was present and conducting their own investigation into the possible tampering of the resident's liquid Morphine. The seal on the top of the bottle was intact but there was an obvious puncture hole in the seal covering the top end of the bottle. The hole was approximately the size of a hole an ink pen would make, if it was pushed through paper. It appeared to have the full amount of 30 ml of liquid Morphine Sulfate in the bottle. The representatives from the Ohio Board of Pharmacy was performing a concentration test of the contents in the liquid Morphine Sulfate from Resident #50's bottle. They reported the control concentration was 10.8 and the actual concentration of the liquid medication inside that bottle was only reading 4.4 showing evidence that some of the liquid Morphine had been removed and replaced with some other solution. On 11/19/25 at 2:55 P.M., an interview with the DON confirmed the Ohio Board of Pharmacy was able to determine that Resident #50's liquid Morphine Sulfate had been accessed, as evidenced by the puncture hole in the seal. They were also able to confirm some of the liquid Morphine Sulfate had been removed with another solution added to make it appear the bottle was full. He stated that liquid Morphine Sulfate bottle had been confiscated by the Ohio Board of Pharmacy and taken with them upon their departure from the facility. He denied there was any documented evidence to show that Resident #50 had received any doses of his Morphine Sulfate that was supposed to be ordered prn for pain or shortness of breath, based on his standing orders from hospice. He acknowledged the standing order was never included in his active physician's orders to be reflected on a MAR, and the controlled medication sheet for that controlled medication was blank showing no evidence of any doses administered. He denied that he had submitted a self-reporting incident (SRI) for an allegation of misappropriation of medication to the state survey agency, as he believed that was not required unless his investigation proved that misappropriation of medication had actually occurred. He acknowledged any allegation or suspicion of misappropriation of resident property, to include medications, should be reported to the state survey agency as required and in the time frame required. He indicated he had since submitted an SRI, following the Ohio Board of Pharmacy's determination that there were controlled medications unaccounted for, but acknowledged it was still not submitted in the time frame in which it should have been reported. 2 b.) Review of Resident #50's physician's orders revealed he had an order in place to receive Oxycodone HCL 5 mg po every six hours as needed for pain. The order originated on 03/25/25. Review of a facility investigation file for allegations/ suspicions of misappropriation of medications/ medication diversion revealed the facility completed an investigation pertaining to the potential tampering of Resident #50's Oxycodone dated 07/10/25. The investigation file included a personal witness statement from LPN #210 for an incident date of 07/10/25 that indicated the DON had called her over to his office and informed her that LPN #166 had left the her medication administration cart keys on top of the medication administration cart. The DON removed the locked controlled medication box from the medication administration cart to see how long it took the nurse to realize it was missing. LPN #210 went to his office to see it, when she noted there was something off with the controlled narcotic card in the front right slot. LPN #210 pulled the medication card out of the slot and noticed light peeking through the back of each bubble when there should not have been light coming through. She then flipped the medication blister card over and saw slits along the bottom of each bubble's backing. She then noticed that some of the pills were not like the others and brought it to the attention of the DON. The DON took the blister card and looked at them as well, confirming what LPN #210 was seeing. Review of an email that was included in the facility's investigation file from a pharmacist contracted by the facility to provide their pharmaceutical services to the DON dated 07/16/25 at 11:26 A.M. revealed the contracted pharmacist communicated to the DON that she identified 15 out of 30 Oxycodone tablets with Rx #1446246 (card #2) had been replaced with Loratadine 10 mg tablets by cuts on the bottom of the foil coverings. Only 15 tablets of the remaining 30 tablets, were actually Oxycodone tablets. She further identified 12 tablets of Oxycodone 5 mg tablets had been removed from Rx 1446247 (card #1) and replaced with Loratadine 10 mg tablets. At the time of her inspection, only six of the 18 remaining tablets in the blister card were actually Oxycodone 5 mg tablets. On 11/20/25 at 9:40 A.M., an interview with the DON confirmed he conducted an investigation back in July 2025 pertaining to the possible tampering of Resident #50's Oxycodone 5 mg tablets ordered on a prn basis. He further confirmed the situation was first identified on 07/10/25, when he removed the controlled medication locked box from the 400 hall medication administration cart, after a nurse had left her keys to the medication cart sitting on top of the cart and unattended. He indicated it was LPN #210 that noted the backing on Resident #50's Oxycodone had small slits in the back of it and not all the pills in the blister card looked the same. He reported he then looked at the pills closer and verified the pills in that card were not all the same. They involved their contracted pharmacist, who visited the facility on 07/16/25, and verified some of the Oxycodone HCL 5 mg tablets had been removed and replaced with Loratadine 10 mg tablets. Observation of the blister cards during the interview with the DON revealed blister card #1 was filled on 03/26/25 and blister card #2 was filled on 05/20/25. Each were to contain Resident #50's Oxycodone HCL 5 mg tablets. Blister card #1 had 12 pills that had been removed with 18 remaining. Of the 18 pills remaining, 12 of the bubbles had small slits in the backing at the bottom of the bubble in the packaging. The remaining pills in those bubbles were noted not to have the same imprints on all of the remaining tablets. Some of them had 10's imprinted on the round white tablets, while others had K/18. Blister card #2 had 30 tablets present with one tablet in each of the 30 bubbles. It too was noted to have small slits in the backing on the reverse side of the card near the bottom of those bubbles. There was a total of 15 different slits in the backing of those 30 bubbles. Per the facility's DON, who remained present while the blister cards were inspected, it was determined by their contracted pharmacist that those 15 tablets of Oxycodone HCL 5 mg tablets in the bubbles with the slits had been replaced with Loratadine 10 mg tablets. That was confirmed by the facility's pharmacist, when they came on-site to inspect the blister cards on 07/16/25. He confirmed he had a copy of that email from their pharmacist following that visit on 07/16/25 showing what was found and included it in the facility's investigation file. He denied that he was able to confirm misappropriation of the resident's medication had occurred, as their investigation was not able to prove who took it. He acknowledged they did not have to prove who took the medication to show evidence of misappropriation of a resident's medication had occurred, only that there were doses unaccounted for that had not been used by the resident. He denied he had submitted a self- reporting incident (SRI) to the state survey agency for the suspicion/ allegation of misappropriation/ medication diversion, as he did not feel his investigation was able to determine that misappropriation of medication had occurred. He further acknowledged some of Resident #50's Oxycodone had been replaced with Loratadine 10 mg tablets and those Oxycodone tablets that were missing and replaced with Loratadine 10 mg tablets were not used for the resident as they were intended to be. Review of the facility's Abuse Prohibition policy (not dated) revealed residents of the facility would not be subjected to the misappropriation of their property by anyone. Misappropriation of resident property was defined as depriving, defrauding, or otherwise obtaining the real or personal property of a resident by any means prohibited by the Revised Code. It was also the patterned or deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. All alleged violations concern abuse, neglect, and misappropriation of property were to be immediately reported to the Administrator or designee. Allegations that involve abuse or result in serious bodily injury would be reported to the Ohio Department of Health as soon as possible, but no more than two hours after the alleged incident was discovered. Reporting of all allegations not involving abuse or serious bodily injuries must not exceed 24 hours. The results of a thorough investigation of the allegation would be reported to the Ohio Department of Health within five working days of the incident. This deficiency represents non-compliance investigated under Complaint Number 2672468.

Based on record review, review of facility investigations, observations, interviews, and policy review, the facility failed to ensure residents' controlled narcotic medications were not misappropriated. This affected two (#8 and #50) of three residents reviewed for misappropriation of medications. Findings include: 1. Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, dysphagia (difficulty swallowing), amputation of the left leg below the knee, and osteoarthritis. Review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and her cognition was moderately impaired. She was coded on the MDS assessment as having had pain in the past five days she rated as a 4 on a 1-10 scale. She received both scheduled and prn pain medication for her pain. The medication section of the MDS assessment (Section N) did not indicate that she had received opioid medications during the seven day assessment period (11/09/25- 11/15/25). Review of Resident #8's physician's orders revealed the resident had an order to receive Morphine Sulfate 20 milligrams (mg)/ milliliter (ml) with directions to give 0.25 ml by mouth (po) every four hours as needed (prn) for pain or shortness of breath. The order originated on 05/19/25, after she was placed under the care and services of hospice on 05/16/25. Review of Resident #8's medication administration records (MAR's) from May 2025 through November 2025 revealed the resident's prn order to receive Morphine Sulfate was included on the MAR's each month during that seven month period. There was no documented evidence of any prn doses of Morphine Sulfate having been administered to the resident for any complaints of pain or shortness of breath, since the order originated on 05/19/25. Review of Resident #8's Controlled Drug Receipt/ Record/ Disposition Form for her Morphine Sulfate revealed 30 ml of the liquid Morphine was filled by the facility's contracted pharmacy on 05/28/25. The form was blank and did not show any doses of the Morphine Sulfate had been used for the resident, since it was filled by the pharmacy. Review of a facility investigation file pertaining to Resident #8's liquid Morphine Sulfate revealed the facility obtained personal witness statements and/ or conducted phone interviews with facility nurses regarding the resident's Morphine Sulfate. A hand written statement from Licensed Practical Nurse (LPN) #115 dated 11/14/25 revealed she was doing the controlled narcotic drawer count when she noted a discrepancy with a Morphine Sulfate bottle for Resident #8. The contents of the bottle was below the 30 ml (approximately 27-28 ml's) that it should have been. She asked two other nurses (LPN #166 and LPN #350) when they started giving Resident #8 Morphine Sulfate and both denied knowledge of the resident ever receiving it. The resident just had the bottle on hand in case she needed it. She then informed the two nurses the bottle was low and some of the medication had been removed. The bottle appeared to be sealed, but when turned upside down, a drop of the liquid Morphine formed at the top of the bottle on the seal. She then noticed a very small hole in the seal. The plunger top and syringe for the liquid Morphine Sulfate bottle were still in the plastic packaging and had not been used. She checked another resident's liquid Morphine Sulfate bottle (Resident #50) and noted it too had a puncture hole in the seal at the top of the bottle, just like Resident #8's did. It appeared that the other resident's bottle contained the full amount of the 30 ml that it should have had in it. She called the unit manager (LPN #260) about her findings, who in turn instructed her to call the DON immediately. The unit manager also informed her that they would probably need statements from everyone. The previous shift's nurses had already left the facility. She called the DON, as instructed, at 6:26 A.M. and left him a voicemail. When the unit manager came in, she showed the two bottles to the unit manager and informed her that she had already called the DON. On 11/19/25 at 1:25 P.M., an interview with the DON revealed he had been made aware of the discrepancy with Resident #8's Morphine Sulfate on 11/14/25 (Friday). He reported an oncoming day shift nurse (LPN #115) had placed Resident #8's bottle of Morphine Sulfate on top of the medication cart, when doing a controlled medication reconciliation with the off-going night shift nurse (LPN #166), and noted that the Morphine Sulfate bottle had about 3.5 ml less than it should have had. It was not documented on her Controlled Drug Receipt/ Record/ Disposition form, as having been used, since it had been filled by the pharmacy on 05/28/25. There was not a discrepancy noted during the previous controlled medication reconciliation count that was completed at shift change between the off-going day shift nurse (LPN #300) and the oncoming night shift nurse (LPN #166) on 11/13/25 (the shift change before the discrepancy was noted). He confirmed LPN #115 notified him of the discrepancy on the morning of 11/14/25. Once he had been made aware, he reached out to his clinical legal team and conducted a whole house audit of all controlled medications to identify any other discrepancies that may have existed, but none was noted. Resident #8's Morphine bottle had not been fully opened, but there was an obvious puncture hole in it. When he turned the bottle upside down the liquid medication in the bottle dripped out. He was not sure at the time, if it had been truly accessed, or if there was a faulty seal that allowed some of the liquid to leak out. They also noted another resident (Resident #50) had what appeared to be a puncture hole in the seal of his liquid Morphine Sulfate bottle too, when conducting a whole house audit of all controlled medications, to see if any other discrepancies were present. He contacted the facility's contracted pharmacist on Friday (11/14/25), who in turn notified the Ohio Board of Pharmacy. The Ohio Board of Pharmacy reached out to him on Monday (11/17/25) and informed him they would visit the facility on 11/19/25 around 1:30 P.M. to help assist in the investigation and to determine if any medication diversion had occurred. Resident #8's Morphine bottle was given to the Ohio Board of Pharmacy for review, as part of their investigation, when they arrived on-site on 11/19/25. The other resident's Morphine Sulfate bottle was provided for review as well. On 11/19/25 at 2:15 P.M., an observation of Resident #8's Morphine Sulfate 30 ml bottle that was in the Director of Nursing's (DON's) office and being examined by the State of Ohio Board of Pharmacy representatives (Agent and Compliance Specialist) revealed it had a puncture hole in the seal that was covering the top of the medication bottle. The amount of liquid in the bottle of Morphine Sulfate was below the 30 ml. line that would indicate a full bottle. It was confirmed by the representatives from the Ohio Board of Pharmacy that some of the medication solution had been removed from the bottle. On 11/19/25 at 2:55 P.M., a follow up interview with the DON confirmed it was determined that Resident #8 had approximately 3.5 ml of her liquid Morphine Sulfate removed from her bottle, when inspected by the Ohio Board of Pharmacy representatives. He further confirmed there was no documentation on the MAR's or on the Controlled Drug Receipt/ Record/ Disposition Form to show Resident #8 had been given any doses of her Morphine Sulfate liquid, since it had been ordered back in May 2025 to account for the amount of the medication that was missing. He reported the Ohio Board of Pharmacy representatives went ahead and removed the resident's liquid Morphine Sulfate bottle from the facility, after completing their on-site visit/ investigation earlier that day. He denied that he had submitted a self-reporting incident (SRI) for an allegation of misappropriation of medication to the state survey agency as he believed that was not required unless his investigation proved that misappropriation of medication had actually occurred. He acknowledged any allegation or suspicion of misappropriation of resident property, to include medications, should be reported to the state survey agency as required and in the time frame required. He indicated he had since submitted an SRI following the Ohio Board of Pharmacy's determination that controlled medications were unaccounted for, but acknowledged was not in the time frame in which they should have been reported. 2 a.) Review of Resident #50's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) affecting his right dominant side following a stroke, malignant neoplasm of the prostate, and unspecified dementia. He was admitted under the care and services of hospice on 07/30/25. Review of standing orders to implement with a hospice admission revealed it included the use of Morphine Sulfate 20 mg/ ml with directions to administer 0.25 ml po every four hours for pain or shortness of breath. A written prescription must be obtained from the physician for that order. A verbal order had been obtained by a hospice nurse for the above on 07/29/25. Review of Resident #50's physician's orders revealed the standing order for the use of Morphine Sulfate solution was not carried over into his active physician's orders after the verbal order was given on 07/29/25. Due to it not being carried over into his active physician's orders, the use of the Morphine Sulfate was not included on the medication administration record as one of the resident's prn medications. There was no evidence on the MAR's as any doses of the Morphine Sulfate as having been used for the resident, since the standing order originated on 07/29/25. Review of Resident #50's Controlled Drug Receipt/ Record/ Disposition Form for his Morphine Sulfate that had been sent by the facility's contracted pharmacy revealed 30 ml of the liquid Morphine was filled by the pharmacy on 07/29/25. A nurse signed receipt of the 30 ml of Morphine Sulfate on 07/30/25. The form was left blank where the nurses were to chart each dose administered reflecting no evidence of the liquid Morphine Sulfate having been used for the resident, since it had been filled and received by the facility on 07/30/25. On 11/19/25 at 2:15 P.M., an observation was made of Resident #50's Morphine Sulfate liquid bottle. The controlled medication bottle was in the DON's office being evaluated by representatives from the Ohio Board of Pharmacy, who was present and conducting their own investigation into the possible tampering of the resident's liquid Morphine. The seal on the top of the bottle was intact but there was an obvious puncture hole in the seal covering the top end of the bottle. The hole was approximately the size of a hole an ink pen would make, if it was pushed through paper. It appeared to have the full amount of 30 ml of liquid Morphine Sulfate in the bottle. The representatives from the Ohio Board of Pharmacy was performing a concentration test of the contents in the liquid Morphine Sulfate from Resident #50's bottle. They reported the control concentration was 10.8 and the actual concentration of the liquid medication inside that bottle was only reading 4.4 showing evidence that some of the liquid Morphine had been removed and replaced with some other solution. On 11/19/25 at 2:55 P.M., an interview with the DON confirmed the Ohio Board of Pharmacy was able to determine that Resident #50's liquid Morphine Sulfate had been accessed, as evidenced by the puncture hole in the seal. They were also able to confirm some of the liquid Morphine Sulfate had been removed with another solution added to make it appear the bottle was full. He stated that liquid Morphine Sulfate bottle had been confiscated by the Ohio Board of Pharmacy and taken with them upon their departure from the facility. He denied there was any documented evidence to show that Resident #50 had received any doses of his Morphine Sulfate that was supposed to be ordered prn for pain or shortness of breath, based on his standing orders from hospice. He acknowledged the standing order was never included in his active physician's orders to be reflected on a MAR, and the controlled medication sheet for that controlled medication was blank showing no evidence of any doses administered. He denied that he had submitted a self-reporting incident (SRI) for an allegation of misappropriation of medication to the state survey agency, as he believed that was not required unless his investigation proved that misappropriation of medication had actually occurred. He acknowledged any allegation or suspicion of misappropriation of resident property, to include medications, should be reported to the state survey agency as required and in the time frame required. He indicated he had since submitted an SRI, following the Ohio Board of Pharmacy's determination that there were controlled medications unaccounted for, but acknowledged it was still not submitted in the time frame in which it should have been reported. 2 b.) Review of Resident #50's physician's orders revealed he had an order in place to receive Oxycodone HCL 5 mg po every six hours as needed for pain. The order originated on 03/25/25. Review of a facility investigation file for allegations/ suspicions of misappropriation of medications/ medication diversion revealed the facility completed an investigation pertaining to the potential tampering of Resident #50's Oxycodone dated 07/10/25. The investigation file included a personal witness statement from LPN #210 for an incident date of 07/10/25 that indicated the DON had called her over to his office and informed her that LPN #166 had left the her medication administration cart keys on top of the medication administration cart. The DON removed the locked controlled medication box from the medication administration cart to see how long it took the nurse to realize it was missing. LPN #210 went to his office to see it, when she noted there was something off with the controlled narcotic card in the front right slot. LPN #210 pulled the medication card out of the slot and noticed light peeking through the back of each bubble when there should not have been light coming through. She then flipped the medication blister card over and saw slits along the bottom of each bubble's backing. She then noticed that some of the pills were not like the others and brought it to the attention of the DON. The DON took the blister card and looked at them as well, confirming what LPN #210 was seeing. Review of an email that was included in the facility's investigation file from a pharmacist contracted by the facility to provide their pharmaceutical services to the DON dated 07/16/25 at 11:26 A.M. revealed the contracted pharmacist communicated to the DON that she identified 15 out of 30 Oxycodone tablets with Rx #1446246 (card #2) had been replaced with Loratadine 10 mg tablets by cuts on the bottom of the foil coverings. Only 15 tablets of the remaining 30 tablets, were actually Oxycodone tablets. She further identified 12 tablets of Oxycodone 5 mg tablets had been removed from Rx 1446247 (card #1) and replaced with Loratadine 10 mg tablets. At the time of her inspection, only six of the 18 remaining tablets in the blister card were actually Oxycodone 5 mg tablets. On 11/20/25 at 9:40 A.M., an interview with the DON confirmed he conducted an investigation back in July 2025 pertaining to the possible tampering of Resident #50's Oxycodone 5 mg tablets ordered on a prn basis. He further confirmed the situation was first identified on 07/10/25, when he removed the controlled medication locked box from the 400 hall medication administration cart, after a nurse had left her keys to the medication cart sitting on top of the cart and unattended. He indicated it was LPN #210 that noted the backing on Resident #50's Oxycodone had small slits in the back of it and not all the pills in the blister card looked the same. He reported he then looked at the pills closer and verified the pills in that card were not all the same. They involved their contracted pharmacist, who visited the facility on 07/16/25, and verified some of the Oxycodone HCL 5 mg tablets had been removed and replaced with Loratadine 10 mg tablets. Observation of the blister cards during the interview with the DON revealed blister card #1 was filled on 03/26/25 and blister card #2 was filled on 05/20/25. Each were to contain Resident #50's Oxycodone HCL 5 mg tablets. Blister card #1 had 12 pills that had been removed with 18 remaining. Of the 18 pills remaining, 12 of the bubbles had small slits in the backing at the bottom of the bubble in the packaging. The remaining pills in those bubbles were noted not to have the same imprints on all of the remaining tablets. Some of them had 10's imprinted on the round white tablets, while others had K/18. Blister card #2 had 30 tablets present with one tablet in each of the 30 bubbles. It too was noted to have small slits in the backing on the reverse side of the card near the bottom of those bubbles. There was a total of 15 different slits in the backing of those 30 bubbles. Per the facility's DON, who remained present while the blister cards were inspected, it was determined by their contracted pharmacist that those 15 tablets of Oxycodone HCL 5 mg tablets in the bubbles with the slits had been replaced with Loratadine 10 mg tablets. That was confirmed by the facility's pharmacist, when they came on-site to inspect the blister cards on 07/16/25. He confirmed he had a copy of that email from their pharmacist following that visit on 07/16/25 showing what was found and included it in the facility's investigation file. He denied that he was able to confirm misappropriation of the resident's medication had occurred, as their investigation was not able to prove who took it. He acknowledged they did not have to prove who took the medication to show evidence of misappropriation of a resident's medication had occurred, only that there were doses unaccounted for that had not been used by the resident. He denied he had submitted a self- reporting incident (SRI) to the state survey agency for the suspicion/ allegation of misappropriation/ medication diversion, as he did not feel his investigation was able to determine that misappropriation of medication had occurred. He further acknowledged some of Resident #50's Oxycodone had been replaced with Loratadine 10 mg tablets and those Oxycodone tablets that were missing and replaced with Loratadine 10 mg tablets were not used for the resident as they were intended to be. Review of the facility's Abuse Prohibition policy (not dated) revealed residents of the facility would not be subjected to the misappropriation of their property by anyone. Misappropriation of resident property was defined as depriving, defrauding, or otherwise obtaining the real or personal property of a resident by any means prohibited by the Revised Code. It was also the patterned or deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. All alleged violations concern abuse, neglect, and misappropriation of property were to be immediately reported to the Administrator or designee. Allegations that involve abuse or result in serious bodily injury would be reported to the Ohio Department of Health as soon as possible, but no more than two hours after the alleged incident was discovered. Reporting of all allegations not involving abuse or serious bodily injuries must not exceed 24 hours. The results of a thorough investigation of the allegation would be reported to the Ohio Department of Health within five working days of the incident. This deficiency represents non-compliance investigated under Complaint Number 2672468.

Based on review of a facility investigation pertaining to an alleged/ suspected tampering of controlled narcotic medications, review of shift to shift controlled medication reconciliation sheets, staff interviews, and policy review, the facility failed to ensure proper pharmacy procedures were followed in regards to performing an appropriate reconciliation of all controlled medications each time keys to medication administration carts providing access to those controlled medications were exchanged between nurses. This affected two (#8 and #50) of three residents reviewed for the handling of controlled narcotic medications. Findings include: Review of a facility investigation file pertaining to the suspected tampering of Resident #8 and Resident #50's liquid Morphine Sulfate revealed an allegation of potential tampering of the controlled medication was reported to the facility's Director of Nursing (DON) on 11/14/25. As part of the facility's investigation, personal witness statements and/ or phone interviews were conducted with the facility's nurses regarding Resident #8's Morphine Sulfate. Review of a hand written statement provided by Licensed Practical Nurse (LPN) #115 on 11/14/25 revealed she was doing the controlled narcotic drawer count when she noted Resident #8's Morphine Sulfate bottle to be below 30 milliliters (ml), with approximately 27-28 ml present. She asked two other nurses (LPN #166 and LPN #350) when they started giving Resident #8 Morphine Sulfate and both denied knowledge of the resident ever receiving it. The resident just had the bottle on hand in case she needed it. She then informed the two nurses the bottle was low and some of the medication had been removed. The bottle appeared to be sealed, but when turned upside down, a drop of the liquid Morphine formed at the top of the bottle on the seal. She then noticed a very small hole in the seal. The plunger top and syringe for the liquid Morphine Sulfate bottle were still in the plastic packaging and had not been used. She checked another resident's liquid Morphine Sulfate bottle (Resident #50) and noted it too had a puncture hole in the seal at the top of the bottle just like Resident #8's did. It appeared that the other resident's bottle contained the full amount of the 30 ml that it should have had in it. She called the unit manager (LPN #260) to report her findings, who in turn instructed her to call the DON immediately. The unit manager also informed her that they would probably need statements from everyone. The previous shift's nurses had already left the facility. She called the DON, as instructed, at 6:26 A.M. and left him a voicemail. When the unit manager came in, she showed the two bottles to the unit manager and informed her that she had already called the DON. Review of a personal witness statement from LPN #100 (not dated) revealed he verified count with LPN #185 on Thursday 11/13/25 at 6:00 P.M. (the conclusion of his shift) with no discrepancies noted. He denied that he visualized Resident #8's Morphine Sulfate bottle personally when he completed the reconciliation count of the controlled medication for the 400 hall, where Resident #8 resided. Review of a typed statement provided by LPN #185 dated 11/14/25 at 5:00 P.M. revealed she did count the 400 hall medication administration cart with LPN #100. She denied that she took the bottle of Morphine Sulfate out of Resident #8's box, as she indicated it had never been used by the resident according to the controlled medication disposition sheet. She then stated she took the keys from LPN #100 and sat them down at the computer to get caught up on her residents. LPN #210 came in before 7:00 P.M. and she handed LPN #210 the keys and LPN #210 then started the medication pass on the 400 hall. She denied that she recounted the controlled medications in the medication administration cart with LPN #210, as she had just counted them with LPN #100 and was never in the cart following that. Review of a personal witness statement from LPN #210 (not dated) for an incident date of 11/13/25 revealed she arrived to the facility per request to assist with the 400 hall medication pass. LPN #100 grabbed the keys off the nurses' station desk and handed them to her. She then took the keys from LPN #100, who informed her that he and LPN #185 had already counted the narcotic drawer prior to her arrival. LPN #210 then proceeded to chart and begin the 400 hall medication pass. After she completed the 400 hall medication pass, she then handed the keys to LPN #166 (night shift nurse), who was standing at the 100 hall medication administration cart. Review of a typed phone interview with LPN #166 on 11/14/25 at 4:40 P.M. (not indicating who completed the interview) revealed LPN #185 counted the 400 hall medication administration cart with LPN #100, prior to LPN #185 taking the medication administration cart keys from LPN #100. She denied she knew what had happened between LPN #210 and LPN #185, when LPN #210 arrived. She claimed she was standing at the 100 hall medication administration cart talking with another staff member, when LPN #210 walked up and dropped the keys on the medication administration cart and saying I'm done, and everything was fine. LPN #210 then walked away, got her stuff, and left. LPN #166 reported, after she was done talking with the other employee, she got LPN #300 and the counted the 400 hall medication cart in front of the camera. Review of a typed phone interview with LPN #300 dated 11/14/25 at 7:07 P.M. revealed LPN #166 came to her and told her LPN #210 had laid down the keys and report paper and just left. LPN #166 stated she was not going to take the 400 hall medication administration cart until it was counted. She responded to LPN #166 and said let's go count the cart. She denied that either nurse had inspected Resident #8's Morphine Sulfate bottle that was in the cart. Review of additional personal witness statements obtained from LPN #260 on 11/18/25 and LPN #400 on 11/18/25 revealed they provided statements to the facility for their investigation as they had recently had access to the 400 hall medication administration cart. LPN #260 reported she had the 400 hall medication administration cart on Wednesday 11/12/25. She reported she did not re-verify the count and had not taken Resident #8's Morphine out of the box. The statement provided by LPN #400 revealed she counted the 400 hall cart on 11/12/25 and pulled the Morphine bottle of Resident #8 out of the box, but did not remove the lid. She stated she now knew that it was a requirement to remove the lid and inspect the seals to liquid Morphine bottles to ensure they remained intact. Review of in-service education provided to facility nurses revealed the DON educated the nurses on the topic of narcotic counts. The date of the in-service was not identified, but was signed by 17 nurses. Four were in person and 13 were provided via phone. Included with the in-service education was a copy of the Ohio Administrative Code Rule 4729:5-9-03.2 Security, storage, and control of dangerous drugs in an institutional facility effective 01/23/23, a copy of the facility's Controlled Medication Storage policy from the Nursing Care Center Pharmacy Policy and Procedure Manual from the facility's contracted pharmacy with a copyright date of 2007, and additional information from the facility's contracted pharmacy under the topic of Controlled Substances: Preventing Diversion and Narcotic Documentation. Review of a Shift Change Controlled Substance Accountability form for the 400 hall medication administration cart dated 11/13/25 revealed the last documented controlled medication reconciliation completed between two nurses occurred on 11/13/25 at 6:00 A.M. Only one nurse (LPN #100) signed that a reconciliation of the controlled medications was performed for the 400 hall medication administration cart at 6:00 P.M. as the off nurse. The on nurse did not sign to provide evidence of a proper reconciliation of all controlled medications stored in that cart had been performed. LPN #166 was the next nurse to sign that a reconciliation of those controlled medications were completed and that was at 9:00 P.M. She did not have another nurse sign to indicate that the reconciliation count was completed in conjunction with another nurse. LPN #210's first name was hand written at the 9:00 P.M. time, but was not signed to provide evidence she participated in any reconciliation count of the controlled medications in that medication cart. On 11/19/25 at 1:25 P.M., an interview with the DON revealed he had been made aware of the discrepancy with Resident #8 and #50's Morphine Sulfate on 11/14/25 (Friday). He reported an oncoming day shift nurse (LPN #115) had placed Resident #8's bottle of Morphine Sulfate on top of the medication cart, when doing a controlled medication reconciliation with the off-going night shift nurse (LPN #166), and noted that the Morphine Sulfate bottle had about 3.5 ml less than it should have had. It was not documented on her Controlled Drug Receipt/ Record/ Disposition form, as having been used, since it had been filled by the pharmacy on 05/28/25. There was not a discrepancy noted during the previous controlled medication reconciliation count that was completed at shift change between the off-going day shift nurse (LPN #300) and the oncoming night shift nurse (LPN #166) on 11/13/25 (the shift change before the discrepancy was noted). He confirmed LPN #115 notified him of the discrepancy on the morning of 11/14/25. Once he had been made aware, he reached out to his clinical legal team and conducted a whole house audit of all controlled medications to identify any other discrepancies that may have existed, but none was noted. Resident #8's Morphine bottle had not been fully opened, but there was an obvious puncture hole in it. When he turned the bottle upside down the liquid medication in the bottle dripped out. He was not sure at the time, if it had been truly accessed, or if there was a faulty seal that allowed some of the liquid to leak out. They also noted another resident (Resident #50) had what appeared to be a puncture hole in the seal of his liquid Morphine Sulfate bottle too, when conducting a whole house audit of all controlled medications, to see if any other discrepancies were present. He contacted the facility's contracted pharmacist on Friday (11/14/25), who in turn notified the Ohio Board of Pharmacy. The Ohio Board of Pharmacy reached out to him on Monday (11/17/25) and informed him they would visit the facility on 11/19/25 around 1:30 P.M. to help assist in the investigation and to determine if any medication diversion had occurred. They (Ohio Board of Pharmacy) concluded both Resident #8 and Resident #50's Morphine bottles had been tampered with. They could not account for 3.5 ml of Resident #8's 30 ml Morphine Sulfate bottle and Resident #50 had some of his Morphine Sulfate removed and replaced with another kind of solution to hide the amount that had been removed. He confirmed his investigation showed concerns with the facility's nurses to not perform appropriate reconciliation of controlled medications stored in the medication administration cart for the 400 hall on 11/13/25- 11/14/25 when keys exchanged hands. He confirmed a reconciliation count of all controlled medications should be conducted for that medication administration cart anytime keys were passed to another nurse and the prior nurse had access to those controlled medications. Review of the facility's policy on Controlled Medication Storage dated December 2012 revealed medications included in the Drug Enforcement Administration (DEA) classification as controlled substances were subject to special handling, storage, and record keeping in the nursing care center in accordance with federal, state, and other applicable laws and regulations. The DON and the consultant pharmacist monitored for compliance with federal and state laws and regulations in the handling of controlled medications. At each shift change, or when keys were transferred, a physical inventory of all scheduled II medications was to be conducted between two licensed nurses or per state regulations and was documented on the controlled substances accountability record or verification of controlled substances count report. This deficiency represents non-compliance investigated under Complaint Number 2672468.

Based on record review, policy review and interviews, the facility failed to meet at least quarterly to coordinate and evaluate activities under the Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect all 52 residents residing in the facility. Findings include: Review of the facility QAPI program revealed no documented evidence, such as meeting minutes or sign-in sheets, that quarterly Quality Assessment and Assurance (QAA) committee meetings were held. In an interview on 01/08/25 at 10:16 A.M. Administrator #582 verified the facility had no documented evidence, such as meeting minutes or sign-in sheets, that quarterly QAA committee meetings were held. She stated that they worked on quality improvement at least weekly but did not have a formal meeting with minutes to prove that they had done so. Review of the undated policy titled Quality Assurance/Performance improvement (QAPI) revealed the Medical Director has the responsibility to attend the QAPI committee meetings at least quarterly. Further review revealed the committee should analyze system changes made over the quarter that might have affected the outcome of the findings.

Based on record review, resident interview, staff interview, and policy review, the facility failed to ensure a multi-disciplinary approach was taken and resident's and/or their representatives were included in the development of their care plans. This affected four (Resident #6, #19, #148, and #149) of four residents reviewed for care planning. The facility census was 52. Findings include: 1. Review of Resident #149's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including an encounter for other orthopedic aftercare, acute post-procedural pain, abnormalities of gait and mobility, need for assistance with personal care, adult-onset diabetes mellitus, hypertension, obstructive sleep apnea, anxiety disorder, fibromyalgia, and low back pain. Review of Resident #149's Admission Record (face sheet) revealed she was her own responsible party. She had a friend listed as her first emergency contact. Review of Resident #149's multi-disciplinary care conference form revealed a care conference meeting had allegedly taken place on 12/21/24 at 1:52 P.M. (day after admission). The notification of the plan of care (POC) meeting was indicated to have been made verbally. Attendance at meeting included the social worker, physical therapy (PT), and family. There was no place on the form for the facility to identify the resident as being one of the people who attended the meeting. There was a box to checkmark if a resident representative was present, and the form included a space for them to indicate the name of the representative who attended. That box was left unmarked, and the name of the resident representative that attended was left blank. Under a section titled Review, it indicated they were to review with team/ resident/ power of attorney (POA) ancillary services, physician's orders, preferences, advanced directives and discharge plans. Under the section titled Summary, problems/ needs and evaluation/ goals were to be identified from input from all those in attendance. Problems/ needs indicated the resident admitted for PT/ occupational therapy (OT) following a recent hospital stay. The resident was indicated to live alone and would return home with Passport services after rehabilitation goals had been met. There was nothing documented under the evaluation/ goals, which was under the Summary section. There was also nothing documented under the sections for Discharge Plan/ Summary, PT/ OT summary, and the Resident/ Family which was to include any expectations/ concerns/ preferences. They did not have anyone who may have been in attendance of that care conference meeting sign the form to show proof of attendance. Review of Resident #149's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not known to have displayed any behaviors or reject care during the seven days of the assessment period. On 12/30/24 at 10:09 A.M., an interview with Resident #149 revealed she had not been invited to participate in any care conference meetings since her admission on 12/10/24. An explanation of what the meeting would entail was provided, and Resident #149 again denied being part of any meeting like that. On 12/31/24 at 2:30 P.M., an interview with Social Service Director (SSD) #568 revealed Resident #149's care conference meeting on 12/21/24 was held in the resident's room. She acknowledged the care conference form that they filled out did not allow them to mark it to show the resident was in attendance of the meeting. She was asked who all participated in the care conference that was said to have been held in the resident's room. She replied it was her and PT. She denied any other disciplines were part of the care conference meeting. She was asked who the family member was that was marked as having attended the meeting. She started to pull the resident's information up from her profile on the computer before being informed the electronic medical record (EMR) indicated the resident did not have any family members listed. She only had a friend that was identified as her first emergency contact. She then stated that it was marked in error, and the resident did not have a family member present for the meeting. She was asked if the resident's friend would have been invited to attend the care conference since she was listed as her first emergency contact. She reported it would be up to the resident. SSD #568 was accompanied into the therapy room, where she went to talk with the PT who was indicated on the care conference form as having been part of that care conference meeting. She started to tell the PT the reason for coming to her office, explaining to her that the resident was questioning if the PT was part of her care conference. It was clarified with SSD #568 that Resident #149's concern was she did recollect having had a care conference meeting or that she had even been invited to attend one, after it had to be explained to her what a care planning conference was. The PT was not able to confirm or deny that she was part of the care conference meeting. She was attempting to pull up notes from her computer but was not able to provide any information about the care conference. SSD #568 then indicated she was the only one in the resident's room when the care conference took place. She reported the PT would have come into the resident's room either before or after she was in there. She acknowledged the purpose of the care conference was to ensure a multidisciplinary approach was taken to develop the resident's comprehensive care plan, and the resident should have had the opportunity to participate in the development of her care plans. She further acknowledged they should have checked with the resident to see if she wanted her friend to be invited to the care conference, since her friend was listed as her first emergency contact. On 12/31/24 at 3:35 P.M., a follow up interview with Resident #149 revealed she recalled the facility's SSD did come in her room the day after she was admitted to the facility. She recalled they briefly talked about her discharge intentions and what services she had in place prior to her admission. She recalled the SSD was happy she already had services set up in her home that were in place prior to her admission into the facility. She did not recall the PT or any other discipline being part of that meeting, but the therapist may have been in her room the day after her admission as well. She reported she would have liked to have had her friend invited to attend the meeting, as she was her emergency contact, and she would have liked to have her included with what was going on with her. She denied she had been asked if she wanted the friend invited to attend. She did not feel the interaction she had with the SSD the day after her admission was any type of meeting to review her orders, identify any issues/ concerns, establish any goals or allow her participation in the development of her plan of care. She described it more as just a brief, informal encounter. Review of the undated facility's policy on Care Conferences revealed the facility would conduct routine and scheduled care conferences to evaluate and re-evaluate each resident's plan of care to determine whether the established goals were appropriate and being met by the resident or if changes to the goals were necessary. The MDS nurse was responsible for coordinating the routine schedule of the resident's care conference. Social services would send letters two weeks in advance of the meeting to the resident's responsible party and/ or the residents notify them of the upcoming meeting. A resident care conference schedule would be distributed to the nurse's station and to each discipline. Any scheduling changes should be directed to the MDS nurse. Each member of the interdisciplinary team, including but not limited to, MDS, social services, nursing, dietary, therapy, activities, as well as the primary caregivers to include the residents most routine certified nursing assistant (CNA), would review the medical record, visit the resident, seek out any concerns, and assess the outcome of the last meetings recommendations prior to attending the care conference. The social service coordinator or the activities coordinator would ask each resident prior to the meeting if they would like to be present at the meeting. The MDS nurse would briefly review the resident's diagnoses, current medications, orders, labs, weights, restraint use, advanced directives, psychotropics, and change in status and resident concerns. The interdisciplinary team (IDT) would discuss the MDS assessment, care area assessments (CAA), triggers, as well as intervention for each area of concern. The social service coordinator would discuss the plans for discharge and make any necessary arrangements that need to be made. The resident or the responsible party would be asked if they had any concerns or questions. The physician, DON, Administrator, an CNA responsible for the individual resident, a member of the food or nutrition department, and rehabilitation services would be invited to attend to discuss the medical condition, give input, and answer any questions that may arise. The contents of the care conference would be documented by the MDS coordinator on the care conference form. The attendees of the care conference, including the resident and/ or responsible party, would sign the care conference form. The MDS coordinator should document the resident's and/ or the responsible party's decline to attend the care conference. The policy did not specifically address initial care conferences or the scheduling of them. 34299 2. Review of the medical record for Resident #6 revealed an admitted [DATE] with diagnoses including traumatic brain injury, schizoaffective disorder and dissociative conversion disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #6 had intact cognition with no behaviors. Resident #6 required assistance with activities of daily living (ADL). Review of the plan of care revealed no concerns. Review of the facility provided and identified as care conference notes dated 01/26/24, 04/27/24, 10/14/24 and 11/22/24 revealed Social Services documented review of mood/behaviors, cognition, decision making ability, vision/hearing/speech, diagnosis, family/support, psychoactive medications, code status, referrals and discharge plans. The documentation did not include the team members present, date and/or method of invitation to attend, including the resident or any family members. Interview on 01/02/25 at 9:32 A.M. with Resident #6 confirmed the resident did not have any kind of meeting with the care team about her medications, plans for discharge, changes, problems, activities or meals. Resident #6 also confirmed she was not invited or informed of any meeting to discuss her care. Resident #6 revealed the Activities Director would visit but no one else. Interview on 12/31/24 at 11:08 A.M. with Social Services #608 revealed she documented the care conferences in the EMR, and the meetings were held every quarter. Social Services #608 stated she notified residents and family members verbally. Social Services #608 confirmed she did not send any formal invitation and did not document the date and time of notification or include in the note those that attended. Interview on 01/02/25 at 2:16 P.M. with Activity Director #601 confirmed she had not been invited to any care conferences and did not attend any care conferences. Interview on 01/02/25 at 2:18 P.M. with CNA #507 confirmed she had not been invited to any care conference or attended any care conferences for the residents. Review of the undated facility policy titled Care Conference revealed the facility will conduct routine and scheduled care conferences to evaluate and re-evaluate each resident's plan of care to determine whether the established goals were appropriate and being met by the resident or if changes to the goals were necessary. Social Services will send letters two weeks in advance of the meeting to the resident's responsible party and/or the resident notifying them of the upcoming meeting. Each member of the IDT, including but not limited to, MDS nurse, Social Services, Nursing, Dietary, Therapy, Activities, as well as the primary caregiver to include the residents most routine CNA, will review the medical record, visit the resident, seek out any concerns and assess the outcome of the last meetings recommendations prior to attending the care conference. The physician, DON, Administrator, an CNA responsible for individual resident, a member of the food or nutrition department, and rehabilitation services will be invited to attend to discuss the medical conditions, give input, and answer any questions that may arise. The contents of the care conference will be documented by the MDS Coordinator on the care conference form. The attendees of the care conference, including the resident or responsible party, will sign the care conference form. The MDS Coordinator should also document the resident and or responsible parties decline to attend the care conference. 50538 3. Review of Resident #148's medical record revealed an admitted [DATE] with diagnoses including end stage renal disease, mechanical complication of surgically created arteriovenous fistula, thrombosis due to vascular prosthetic devices, diabetes, chronic respiratory failure, chronic obstructive pulmonary disease, congestive heart failure, depression and anxiety. Review of the admission MDS assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating Resident #148 had intact cognition. Further review revealed a document titled CHS Multidisciplinary Care Conference - Copy dated 12/20/24 at 10:40 A.M. that indicated the meeting was attended by the social worker and PT. No other attendees are marked as being present for the care conference. Interview on 12/30/24 at 3:19 P.M. Resident #148 on stated he had not attended a care conference. Interview on 12/31/24 at 2:00 P.M. with SSD #568 and Social Services Designee #513 they revealed there was no other documented evidence of the care conference or of the care conference attendees and verified that the only attendees marked were social services and PT. 47985 4. Record review revealed Resident #19 admitted to the facility on [DATE] with diagnoses including malignant neoplasm of stomach and esophagus, muscle wasting and atrophy, and hypertension. Review of a Multidisciplinary Care Conference assessment dated [DATE] revealed a care conference was held with Resident #19's family, a social worker, and a physical therapist. There was no documented evidence that Resident #19 was invited to the care conference or received a copy of the baseline care plan. Review of a MDS assessment completed 11/27/24 revealed Resident #19's cognition remained intact, and he had no behaviors. Interview on 12/30/24 at 9:46 A.M. with Resident #19 revealed he had not been invited to a care conference since his admission to the facility. Interview on 01/02/25 at 7:46 A.M. with SSD #568 confirmed Resident #19 was not at the care conference and the only attendees included Resident #19's family, a social worker, and a physical therapist. SSD #568 confirmed a full IDT should be in attendance for care conferences. Review of an undated policy titled Care Conference revealed each member of the IDT, including but not limited to MDS Nurse, Social Services, nursing, dietary, therapy, activities, a nursing aide, and the primary provider would be invited to the care conference.

Based on observation, staff interview and policy review, the facility failed to ensure stock medications were stored in its original packaging and in a manner that allowed the staff to identify the expiration date of that medication. This affected three (Resident #2, #6, and #12), who resided on the 200 hall and had orders to receive Tylenol Extra Strength medication and received medication from the 200-hall medication administration cart where the improperly stored stock medication was found. The facility census was 52. Findings include: On [DATE] at 8:07 A.M., a medication administration observation was made of Resident #12 receiving her morning medication. The medications were administered by Licensed Practical Nurse (LPN) #527. The resident was given Acetaminophen 500 milligram (mg) (analgesic/fever reducer) two tablets by mouth as ordered three times daily, among multiple other medications due at that time. The Acetaminophen was pulled from a small stock bottle stored in the top drawer of the 200-hall medication administration cart. The stock bottle it was pulled from was intended for Acetaminophen 325 mg tablets. The outside of the bottle showed a round shaped tablet, and the 500 mg tablets that were being stored in the bottle were elongated tablets. There was medical tape wrapped around the outside of the stock bottle that had Acetaminophen 500 mg written on the tape with a black Sharpie. There was no date written on the tape to indicate when the Acetaminophen 500 mg tablets would expire since they were not being stored in its original bottle. Findings were verified by LPN #527. On [DATE] at 8:12 A.M., an interview with LPN #527 was completed after Resident #12 received their medications. The nurse reported she had noted the Acetaminophen 500 mg tablets had been put into a bottle that was not intended for that medication. She reported the stock bottle the Acetaminophen 500 mg tablets came in was a larger bottle and was being stored in the bottom drawer of the medication administration cart. She suspected someone had put some of the 500 mg tablets in the bottle that was for the 325 mg tablets, as it was smaller and would allow for easier storage and access. She acknowledged medications should be stored in the same container they were originally packaged in by the manufacturer. On [DATE] at 9:05 A.M., an interview with the Director of Nursing (DON) revealed she was informed of the Acetaminophen 500 mg tablets that were placed in a bottle intended for Acetaminophen 325 mg tablets. She reported the nursing staff should not have placed the 500 mg tablets into the bottle that was intended for 325 mg tablets. She acknowledged that by moving the Acetaminophen 500 mg tablets into the bottle intended for 325 mg tablets, they would not know when the 500 mg tablets expired. Review of the facility's policy on Medication Storage that was from Nursing Care Center Pharmacy Policy and Procedure Manual with a copywrite date of 2007 by Pharmerica Corp. revealed it was the policy for medications and biologicals to be stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The provider pharmacy dispensed medications in containers that meet state and federal labeling requirements, including requirements of good manufacturing practices established by the United States Pharmacopeia (USP). Medications were to remain in those containers and stored in a controlled environment. Outdated, contaminated, discontinued, or deteriorated medications were to be immediately removed from stock.

Based record review, observations, and interviews, the facility failed to ensure Residents #4 and #19 were invited to participate in activities. This affected two residents (#4 and #19) of two residents reviewed for activities. The facility census was 52. Findings include: 1. Record review revealed Resident #4 admitted to the facility on [DATE] with diagnoses including venous insufficiency, hypertension, and gastro-esophageal reflux disease. Review of a care plan dated 03/16/24 revealed Resident #4 had an alteration in activity participation related to preferring independent activities and she preferred music, playing piano, reading, animals, and word puzzles. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4's cognition remained intact, and she had no behaviors. Interview on 12/30/24 at 3:32 P.M. with Resident #4 revealed she did not participate in activities or do anything other than lay in her bed. Interview on 12/31/24 at 1:10 P.M. with Certified Nurse Assistant (CNA) #503 revealed some residents do get invited to activities, but some do not. CNA #503 stated she does not see activities being offered on the hall she works. CNA #503 stated Resident #4 does nothing all day but lay in her bed except talk to nursing staff when they go to check on her. CNA #503 stated Resident #4 had not been out of her been in six to seven months due to the Hoyer lift and chair hurting her leg. CNA #503 stated in room activities were not offered on the hall she worked. Review of the Activity Participation Log for December 2024 revealed Resident #4 had no activities listed for 12/01/24, 12/02/24,12/12/24, 12/13/24, 12/14/24, 12/16/24, 12/17/24, 12/18/24, 12/19/24, 12/20/24, 12/23/24, 12/25/24, and 12/28/24. Interview on 12/31/24 at 3:13 P.M. with Activity Director (AD) #566 revealed residents are invited to activities by staff going room to room to inform them of activities each day, and they try to offer activities two to three times per day. AD #566 stated for residents who do not want group activities, materials were provided based on resident interest, such as word searches, crosswords, cards, and conversations. AD #566 confirmed there was missing documentation on the activity log, but stated they were struggling with staffing, so she was often busy providing the activities and completing documentation. AD #566 stated she had written down the activity participation on another document but did not have time to log it yet. AD #566 stated she would provide an updated log. Review of the updated activity log for December 2024 revealed no documentation for Resident #4 for 12/01/24 or 12/28/24. 2. Record review revealed Resident #19 admitted to the facility on [DATE] with diagnoses including malignant neoplasm of stomach and esophagus, muscle wasting and atrophy, and hypertension. Review of a MDS assessment completed 11/27/24 revealed Resident #19's cognition remained intact, and he had no behaviors. Review of a care plan dated 11/27/24 revealed Resident #19 had an alteration in activity participation related to preferring independent activities. Interview on 12/30/24 at 9:43 A.M. with Resident #19 revealed he does not ever get invited to activities, and all he does is sit in his room. Interview on 12/31/24 at 1:10 P.M. with CNA #503 revealed some residents do get invited to activities and some do not. CNA #503 stated she does not see activities being offered on the hall she works. CNA #503 stated Resident #19 did not go to activities and in-room activities were not offered. Review of the Activity Participation Log for December 2024 revealed there was no documentation of Resident #19 having activities from 12/01/24 through 12/03/24, 12/12/24 through 12/20/24, or on 12/28/24. Interview on 12/31/24 at 3:13 P.M. with AD #566 revealed residents are invited to activities by staff going room to room to inform them of activities each day, and they try to offer activities two to three times per day. AD #566 stated for residents who do not want group activities, materials were provided based on resident interest, such as word searches, crosswords, cards, and conversations. AD #566 confirmed there was missing documentation on the activity log, but stated they were struggling with staffing, so she was often busy providing the activities and completing documentation. AD #566 stated she had written down the activity participation on another document but did not have time to log it yet. AD #566 stated she would provide an updated log. An updated log was provided on 01/08/25 and it revealed no activities were completed for Resident #19 on 12/20/24 or 12/28/24. Interview on 01/08/25 at 9:59 A.M. with Licensed Practical Nurse (LPN) #557 confirmed there were holes in the activity documentation.

Based on record review, resident interview, staff interview, and policy review, the facility failed to ensure residents, who were dependent on staff for personal care, received the assistance needed to shower/ bathe when they were scheduled to receive them. This affected three (Resident #19, #147, and #149) of four residents reviewed for activities of daily living (ADL). The facility census was 52. Findings include: 1. Review of Resident #147's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including encounter for orthopedic aftercare following surgical amputation, idiopathic aseptic necrosis of right toes, acquired absence of other right toes, atherosclerosis of native arteries of extremities with rest pain right leg, pancreas transplant status, kidney transplant status, muscle weakness, Type I (juvenile onset) diabetes mellitus, neuromuscular dysfunction of the bladder, chronic kidney disease (CKD)- stage three, atrial flutter, hypertension (HTN), epilepsy, and presence of a cardiac pacemaker. Review of Resident #147's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She did not display any behaviors or reject care during the seven days of the assessment period. The resident indicated it was somewhat important for her to choose between a tub bath, shower, bed bath, or sponge bath. It did not ask her preference on how many times a week she wanted to receive the bathing activity of her choice. She did not have any functional limitations in her range of motion (ROM). The ability to shower/ bathe self was coded as being not applicable. Review of Resident #147's care plans revealed she required assistance with ADL related to debility, pain, weakness, and status post amputation of her right toes. The goal was for her to remain well-groomed and free of odors at all times. The interventions included applying a post-op shoe when out of bed, staff to adjust care as needed to meet the resident's needs, staff to encourage the resident to participate in ADL during care, staff would assist as needed with daily hygiene, and staff would assist with showering residents as per facility policy weekly. Review of Resident #147's physician's orders revealed she was to wear her post-op shoe when out of bed and non-weight bearing to the right lower extremity. There were no physician's orders that restricted her ability to take a shower or bath. Review of Resident #147's shower/ bath documentation under the task tab of the electronic medical record (EMR) revealed the resident was to receive showers/ baths every Tuesday, Thursday, and Saturday. The documentation from the time of 12/10/24 (date of admission) through 12/31/24 revealed out of the nine opportunities, in which a shower/ bath should have been given on her scheduled shower/ bath days, the resident was indicated to have only received three bathing activities occurring on 12/19/24, 12/24/24, and 12/26/24. It did not specify the type of bathing activity that was provided, as it only specified the level of assistance provided to complete that task. She was marked as being a substantial/ maximum assist on 12/19/24 and was marked as being dependent on staff for her bathing activity on 12/24/24 and 12/26/24. No bathing activities were documented as having been provided on 12/12/24, 12/14/24, 12/17/24, 12/21/24, 12/28/24, or on 12/31/24, which all were her scheduled shower days. On 12/30/24 at 1:32 P.M., an interview with Resident #147 revealed she only got a shower or bed bath once a week, usually on Sundays. She reported it would have been her preference to receive at least two a week. On 01/06/24 at 11:09 A.M., an email was sent to the facility's Director of Nursing (DON) to ask her to provide any additional documentation they may have that provided documented evidence of the resident having received a bathing activity for the missing dates above. She provided paper shower sheets that documented a bed bath had been provided to Resident #147 on 12/12/24 and 12/14/24. There was no additional documentation to show a bed bath or a shower had been provided to the resident on 12/17/24, 12/21/24, 12/28/24, or 12/31/24, which were all on her scheduled shower/ bath days. 2. Review of Resident #149's medical record revealed she was admitted to the facility on [DATE] with diagnoses including an encounter for orthopedic aftercare, acute post procedural pain, abnormalities of gait and mobility, need for assistance with personal care, type II (adult-onset diabetes mellitus) with diabetic neuropathy, morbid obesity, anxiety disorder, fibromyalgia, and low back pain. Review of Resident #149's admission MDS dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not known to display any behaviors or reject care during the seven days of the assessment period. She did not have any functional limitations in her ROM. She required a partial to moderate assist for showers/ bathing. Review of Resident #149's care plans revealed she had a care plan in place for requiring assistance with ADL related to debility, pain, and weakness. Her goal was to remain well groomed and free of odors at all times and to participate as able in ADL self-care. The interventions included the resident requiring setup and/or clean-up assistance with personal hygiene and showering, resident was totally dependent and did not participate in any aspect of the task for lower body dressing, putting on/taking off footwear, staff would assist as needed with daily hygiene and would assist with showering residents as per facility policy weekly. Review of Resident #149's physician's orders revealed the resident was to be non-weight bearing to her left lower extremity. Her physician's orders did not include any restrictions for the resident to be showered. Review of Resident #149's shower documentation under the task tab of the EMR revealed the resident was to shower/ bathe every Monday, Wednesday, and Friday. It did not specify the time of day at which the shower or bath was to be provided. Review of the resident's documented showers/ baths from 12/20/24 (date of admission) through 01/05/25 revealed the resident was only documented as having received a shower or bath on 12/25/24 and again on 01/01/25. It only documented the level of assistance the resident was provided when a shower or bath was documented and did not indicate if a shower or a complete bed bath had been given on those days. The resident was indicated to have refused a shower/ bath when it was offered on 12/20/24 and again on 12/30/24. There was no evidence of any shower or bath having been provided or refused on 12/23/24 or on 12/27/24, which were her scheduled days. On 12/30/24 at 10:11 A.M., an interview with Resident #149 revealed she had not been provided a shower in the past week since she had been admitted to the facility. She reported it was her preference to be given a shower as the bathing activity of her choice. On 01/02/24 at 9:00 A.M., Licensed Practical Nurse (LPN) #557 was asked to provide any paper shower sheets the facility might have had of any bathing activities provided to Resident #149 since her admission into the facility on [DATE]. The facility's DON had made it known that showers/ baths were documented under the task tab of the EMR or on paper shower sheets. He provided a copy of a paper shower sheet for 12/24/24 that indicated a shower/ bath had been offered on that date and refused by the resident. A second shower/ bath sheet had been provided for the date of 12/25/24 or 12/27/24. It was not clear what the date was as someone had written a 7 over top of the 5 making the date unclear. It did show that a bed bath had been given on one of those two days. The task tab of the EMR indicated set up or clean up assistance was provided to the resident on 12/25/24, which coincided with the original date on the paper shower/ bath sheet that was provided that had a 7 transcribed over top of the 5 on the date of 12/25/24. No assistance level was documented as having been provided on 12/27/24, under the task tab of the EMR. On 01/02/25 at 12:02 P.M., a follow-up interview with Resident #149 revealed again it was her preference to be given a shower on her scheduled shower days, instead of a bed bath. She denied that she had ever refused any showers that had been offered to her. She confirmed there was one day last week in which she was given a bed bath. She denied that a shower had been offered, when the bed bath had been given. She recalled a conversation she had with an aide about her having stitches on her left foot. The aide then went and got a wash basin to give her a bed bath. When the aide returned, the resident stated she made the comment no shower and the aide replied, nope bed bath. She denied the aide had checked with the nurse to see if a shower could be given. She preferred showers over bed baths so she could get her hair washed. She did not understand why they just could not wrap her foot in a plastic bag during a shower to keep it dry. She had been out for a follow-up appointment with the surgeon. She denied that they said anything about her not being able to receive a shower. On 01/02/25 at 1:50 P.M., an interview with Certified Nursing Assistant (CNA) #507 revealed she was somewhat familiar with Resident #149 and had taken care of her two or three times since the resident had been there. She reported that the resident did require assistance with ADL due to her legs. She was asked what type of bathing activity the resident was receiving on her scheduled days. She indicated with the resident's foot; she would think they were probably doing a bed bath with her. One of her feet had a brace on it and could not bear weight and the other had a callous on it. She went out today and had some of her callous removed. She denied that she had given the resident a shower during the two or three days she worked with her. She denied the resident had ever refused any care that she offered to her and was happy when the staff went into her room to help her. On 01/02/25 at 1:55 P.M., an interview with LPN #527 revealed Resident #149 required a one-person assist with transfers and personal care. She had surgical wounds on her foot that had dressing changes done daily. She was asked if the resident was being given showers or bed baths as her bathing activity. She started, with her foot, she imagined the resident was receiving a bed bath. She reported that was not what the resident preferred, as she assumed the resident would have wanted showers like most people do. She confirmed the resident did not have any orders from the physician or the surgeon that restricted her from receiving showers. She also confirmed they had used plastic bags for other residents with wounds to wrap an extremity allowing them to receive showers, without getting their wounds wet. She stated she would clarify with the physician or surgeon to see if it was okay for the resident to be showered as per her preference. She confirmed the shower documentation that had been provided or that was available in the computer indicated the resident had refused a bath or shower when offered on 12/30/24. She acknowledged the resident denied that she had been offered a bed bath or a shower that day when she was marked as having refused. They did not have any documentation of the resident being given a bed bath or a shower on 12/23/24 or 12/27/24, which were both her scheduled shower/ bath day. Review of the facility's undated policy on Personal Care/ Bathing revealed the residents of the facility would receive personal care in the facility according to the resident's plan of care to promote dignity, cleanliness, and general well-being. A shower, bath, or tub would be offered to the resident twice a week, as needed, and as often as the resident would like per their request. Residents with deeper breaks in the skin integrity such as incisions, would be offered a shower and not a tub bath to prevent the risk of infection. Bed baths were to be offered to residents on the other days that a shower or tub bath was not scheduled and/ or as often as the resident would like. 47985 3. Record review revealed Resident #19 admitted to the facility on [DATE] with diagnoses including malignant neoplasm of stomach and esophagus, muscle wasting and atrophy, and hypertension. Review of a MDS assessment completed 11/27/24 revealed Resident #19's cognition remained intact, and he had no behaviors. Interview on 12/30/24 at 9:42 A.M. with Resident #19 revealed he asks for showers but never gets them unless a certain aide is working. Review of EMR for showers and shower sheets from 12/02/24 through 12/30/24 revealed three scheduled showers were missed on 12/04/24, 12/20/24, and 12/25/24. Interview on 01/08/25 at 9:59 A.M. with LPN #557 confirmed three showers were missing for Resident #19.

Based on record review and interviews, the facility failed ensure Residents #4, #19, and #36 or their representatives were provided with a copy of their baseline care plan. This affected three residents (#4, #19, #36) of three residents reviewed for baseline care plans. The facility census was 52. Findings include: 1. Record review revealed Resident #4 admitted to the facility on [DATE] with diagnoses including venous insufficiency, hypertension, and gastro-esophageal reflux disease. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4's cognition remained intact, and she had no behaviors. Review of the medical record revealed no documented evidence of a new admission care conference being completed within 48 hours of admission. Review of typed notes dated 06/11/24, 09/15/24, and 12/15/24, and signed by Social Services Director (SSD) #568 revealed a quarterly care conference was held but did not include a list of who was present for the meeting and if a copy of the care plan was offered to Resident #4. Interview on 01/02/25 at 7:46 A.M. with SSD #568 confirmed Resident #4 did not have a new admission care conference completed within 48 hours of her admission to the facility because the facility previously had an assisted unit, and Resident #4 admitted to the skilled nursing facility when the assisted living closed. SSD #568 confirmed there was no sign-in sheet or list of those in attendance at the care conferences or documented evidence if a copy of the care plan was given to the resident or the resident's representative. 2. Record review revealed Resident #19 admitted to the facility on [DATE] with diagnoses including malignant neoplasm of stomach and esophagus, muscle wasting and atrophy, and hypertension. Review of a Multidisciplinary Care Conference assessment dated [DATE] revealed a care conference was held with Resident #19's family, a social worker, and a physical therapist. There was no documented evidence Resident #19 was invited to the care conference or received a copy of the baseline care plan. Review of a MDS assessment completed 11/27/24 revealed Resident #19's cognition remained intact, and he had no behaviors. Interview on 12/30/24 at 9:46 A.M. with Resident #19 revealed he had not been invited to a care conference since his admission to the facility. Interview on 01/02/25 at 7:46 A.M. with SSD #568 confirmed Resident #19 was not at the care conference and the only attendees included Resident #19's family, a social worker, and a physical therapist. SSD #568 confirmed a full interdisciplinary team should have been in attendance for care conferences. SSD #568 confirmed there was no documented evidence Resident #19 received a copy of his baseline care plan. 3. Record review revealed Resident #36 admitted on [DATE] with diagnoses including displaced intertrochanteric fracture of left femur, muscle wasting and atrophy, chronic kidney disease stage three, and hypertension. Review of an assessment titled CHS Multidisciplinary Care Conference dated 11/21/24 revealed the assessment was completely blank with no documented evidence of an initial care conference being completed and/or a copy of the baseline care plan being given to the resident or the resident's representative. Review of progress notes from 11/20/24 through 11/23/24 revealed no documented evidence Resident #36 or her representative received a copy of her baseline care plan. Review of an MDS completed 12/02/24 revealed Resident #36's cognition remained intact, and she had no behaviors. A printed copy of the incomplete care conference dated 11/21/24 was requested on 12/31/24 at approximately 4:30 P.M. Review of a printed copy of the CHS Multidisciplinary Care Conference assessment dated [DATE] revealed the assessment had been completed and locked on 12/31/24. Interview on 01/02/24 at 7:46 A.M. with SSD #568 confirmed an admission care conference was not completed within 48 hours of Resident #36's admission and there was no documented evidence Resident #36 or her representative received a copy of her baseline care plan. SSD #568 confirmed the care conference assessment was started on 11/21/24 but it was not completed until 12/31/24. SSD #568 confirmed only social services and physical therapy were present for the care conference.

Based on medical record review, staff interview and facility policy review, the facility failed to notify the mental health authority by completing a resident Pre-Admission Screening and Resident Review (PASARR)Level II assessment for Resident #6 with a new diagnosis. This affected one resident (#6) of three residents reviewed for PASARR. The facility census was 52. Findings include: Review of the medical record for Resident #6 revealed an admitted [DATE] with diagnoses including traumatic brain injury, schizoaffective disorder and dissociative conversion disorder. Review of the plan of care initiated on 12/12/23 revealed Resident #6 had a behavior problem related to belief in delusions that staff was abusive towards the resident, visual and auditory hallucinations and calling 911 (emergency). The goal stated Resident #6 would be free from behaviors by the review date of 02/11/25. The interventions included to administer medications as ordered, monitor for effectiveness of medication and potential side effects, intervene and redirect the resident as needed, monitor and assess for behaviors, document and notify physician of increased behaviors, provide a calm and relaxing environment, refer to psych as needed and see staff psychologist as needed. Review of Resident #6's most recent PASARR and Level II dated 01/16/24 revealed the resident diagnoses included schizophrenia, panic disorder, depression and insomnia. Resident #6 was prescribed antipsychotic, antidepressant, and antianxiety medications. Resident #6 did not require level II services. Review of the plan of care initiated on 01/23/24 revealed Resident #6 had an alteration in mood with anxiety related to repetitive anxious complaints and or concerns, sad anxious appearance and unrealistic fears and anxiety. The goal stated Resident #6 would be able to verbalize positive aspects of daily life through review date of 02/11/25 and would exhibit the ability to express anxiety in a calm manner through review date of 02/11/25. The interventions included one on one meetings as needed, medications as ordered by physician and refer to counseling/psychiatry as needed. Review of the diagnoses list of Resident #6 revealed a new diagnosis of dissociative conversion disorder was added on 09/30/24. Interview on 12/31/24 at 3:49 P.M. with Director of Nursing (DON) #591 confirmed the most recent PASARR was dated 01/16/24, the facility did not complete a new PASARR with new diagnosis of disassociate conversion disorder added on 09/30/24 or submit a Level II to the mental health authority.

Based on medical record review, staff interview and facility policy review, the facility failed to complete a new Pre-Admission Screening and Resident Review (PASARR) assessment for Resident #6 with a new diagnosis. The facility also failed to ensure the admission PASARR for Resident #37 was accurate. This affected two residents (#6 and #37) of three residents reviewed for PASARR completion. The facility census was 52. Findings include: 1. Review of the medical record for Resident #6 revealed an admitted [DATE] with diagnoses including traumatic brain injury, schizoaffective disorder and dissociative conversion disorder. Review of the plan of care initiated on 12/12/23 revealed Resident #6 had a behavior problem related to belief in delusions that staff was abusive towards the resident, visual and auditory hallucinations and calling 911 (emergency). The goal stated Resident #6 would be free from behaviors by the review date of 02/11/25. The interventions included to administer medications as ordered, monitor for effectiveness of medication and potential side effects, intervene and redirect the resident as needed, monitor and assess for behaviors, document and notify physician of increased behaviors, provide a calm and relaxing environment, refer to psych as needed and see staff psychologist as needed. Review of Resident #6 most recent PASARR dated 01/16/24 revealed the resident diagnoses included schizophrenia, panic disorder, depression and insomnia. Resident #6 was prescribed antipsychotic, antidepressant and antianxiety medications. Review of the plan of care initiated on 01/23/24 revealed Resident #6 had an alteration in mood with anxiety related to repetitive anxious complaints and or concerns, sad anxious appearance and unrealistic fears and anxiety. The goal stated Resident #6 would be able to verbalize positive aspects of daily life through review date of 02/11/25 and would exhibit the ability to express anxiety in a calm manner through review date of 02/11/25. The interventions included one on one meetings as needed, medications as ordered by physician and refer to counseling/psychiatry as needed. Review of the diagnoses list of Resident #6 revealed a new diagnosis of dissociative conversion disorder was added on 09/30/24. Interview on 12/31/24 at 3:49 P.M. with Director of Nursing (DON) #591 confirmed the most recent PASARR was dated 01/16/24, and the facility did not complete a new PASARR with the new diagnosis of disassociate conversion disorder added on 09/30/24. 28923 2. Review of Resident #37's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses upon admission included unspecified dementia. Review of Resident #37's PASARR Identification Screen completed on 11/19/24 revealed the pre-admission screening (PAS) was completed as an out of State PAS. The PAS was completed by a social worker from a local hospital, prior to the resident's admission to the facility on [DATE]. Section (D.) of the PAS was to indicate what medical diagnoses the resident was known to have. Section (D.) (1.) asked if the individual had a diagnosis of dementia. The social worker from the local hospital indicated that the resident did not by checking the box no. As a result of that PAS, it was determined that the resident did not have any indications of serious mental illness and/or developmental disability, with an effective date of 11/19/24. Further review of Resident #37's medical record revealed it was absent for any additional PASARR's completed for the resident since her admission to the facility on [DATE]. Findings were verified by Admissions Director #541. On 01/20/25 at 11:35 A.M., an interview with Admissions Director #541 revealed it was her responsibility to review PASARR's for all residents that had been completed prior to their admission into the facility. Part of her review was to ensure the PASARR had been completed accurately. After reviewing the PASARR, she uploaded a copy of them into the computer under each resident's electronic medical record. She tried the best she could to check them for accuracy, but did not always catch them when they were filled out incorrectly. They have been having issues with the hospital social workers not completing them accurately. She questioned if it would just be easier if she completed a new one every time a resident was admitted , due to the issues they have been having. After the initial PASARR was completed, checked, and uploaded, it would be the responsibility of the facility's social worker to complete new PASARR's with any significant change or added mental illness diagnoses. She confirmed Resident #37's PASARR completed on 11/19/24 was not completed accurately, as it did not identify the resident as having dementia. She verified dementia was part of the resident's diagnoses that were present upon her admission. She further confirmed she should have completed a new PASARR for the resident, if it was noted that the resident's PASARR was not completed accurately. She acknowledged she did not catch that the PASARR was not accurate, as it did not indicate the resident had a diagnosis of dementia. Review of the facility's policy on PASARR's updated 01/01/19 revealed the purpose of the policy was to assure that all admissions to the nursing facility were screened for indications of serious mental illness or developmental disabilities in effort to prevent inappropriate admissions to the nursing facility. The protocol included a Level I screen to be completed by the hospital discharge planners through the Healthcare Electronic Notification System ([NAME]) system. The Admission Director of the facility or designee should verify the Level I screen was completed through [NAME], prior to admission. The policy was not specific to having the Admission Director ensure accuracy of the PASARR that had been completed prior to the resident's admission.

Based on medical record review and staff interview, the facility failed accurately reflect Resident #14's significant change, including hospice, in the comprehensive significant change in condition assessment. This affected one resident, (Resident #14) of one resident reviewed for Hospice care. The facility census was 52. Findings include: Review of the medical record for Resident #14 revealed an admitted [DATE] with diagnoses including chronic kidney disease stage three, cerebral infarction, chronic obstructive pulmonary disorder, atherosclerotic heart disease, cardiomegaly, atrial fibrillation, dementia and peripheral venous insufficiency. Review of physician orders revealed an order dated 12/12/24 to admit Resident #14 to Buckeye Hospice care on 12/11/24. Review of the significant change Minimum Data Set (MDS) assessment opened 12/11/24 and signed on 12/16/24 revealed Resident #14 was cognitively intact. Resident #14 had a decline in bed mobility and eating assistance. The assessment did not indicate Resident #14 had a life expectancy of less than six months and did not indicate Resident #14 was receiving hospice services. Review of the nursing progress notes from 09/01/24 through 12/31/24 revealed no documentation of Resident #14 admission to hospice services. Review of hospice provider folder for Resident #14 revealed an admitted [DATE] related to diagnosis of chronic kidney disease and hypertensive heart disease. The folder contained nursing and Certified Nurse Aide (CNA) visits and documentation. Review of the plan of care dated 12/13/24 revealed Resident #14 received hospice care and services related to chronic kidney disease, and hypertensive heart disease. The goal to receive palliative measures to provide comfort care and emotional support for pain, nausea, vomiting, shortness of breath and diarrhea through the review date. The interventions included receiving hospice services as ordered, monitoring the resident for breakthrough pain, inspecting skin during care, assisting with the grieving process, contacting hospice for changes in condition, medications as ordered, and hospice to collaborate care with facility staff. Interview on 12/31/24 at 3:04 P.M. with MDS Nurse #604 revealed Resident #14 had a significant change MDS dated [DATE] related to a decline in two areas of activities of daily living. MDS Nurse #604 confirmed the assessment did not address hospice care and that hospice care would require a significant change. MDS Nurse #604 confirmed there was not an MDS completed for Resident #14 related to hospice care and services.

Based on record review, staff interview and policy review, the facility failed to ensure Resident #37, who received an antipsychotic medication, had an abnormal involuntary movement scale (AIMS) assessment completed to monitor the resident for any extrapyramidal side effects of the medication. This affected one resident (#37) of five residents reviewed for unnecessary medications. The facility assessment was 52. Findings include: Review of Resident #37's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified psychosis, unspecified dementia, and anxiety disorder. Review of Resident #37's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was severely impaired. She was not known to have displayed any behaviors or reject care during the seven days of the assessment period. She was documented as having received antipsychotic medications during the seven-day assessment period. Review of Resident #37's physician's orders revealed the resident had an order to receive Olanzapine (Zyprexa) 7.5 milligrams (mg) by mouth at bedtime related to unspecified psychosis. The order originated on 11/20/24 (when the resident was admitted ) and continued through 12/04/24. It was re-ordered on 12/13/24, upon the resident's return from a hospital stay. Resident #37's medical record was absent for any documented evidence of an AIMS assessment having been completed, since the resident's admission to the facility on [DATE]. There was also no evidence of an AIMS assessment being completed, after the Zyprexa was restarted on 12/13/24. On 01/02/25 at 3:15 P.M., an interview with the Director of Nursing (DON) confirmed there was no evidence of an AIMS assessment having been completed on Resident #37 despite her receiving Zyprexa on a scheduled basis. She confirmed an AIMS assessment should be completed for every resident receiving an antipsychotic medication. She stated she would go ahead and have an AIMS assessment completed since one had not been done. Review of the facility's undated policy on Assessments revealed AIMS testing was to be completed initially on admission, then every six months for residents on psychotropic medications.

Based on record review, interview and facility policy review, the facility failed to address signs and symptoms of pain Resident #36 in a timely manner. This affected one resident (#36) of one resident reviewed for pain. The facility census was 52. Findings include: Record review revealed Resident #36 admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of left femur, difficulty in walking, muscle wasting and atrophy, and hypertension. Review of a care plan dated 11/21/24 revealed Resident #36 was at risk for an alteration in comfort related to generalized pain, gout, rheumatoid arthritis, and left femur fracture post-surgical repair. Interventions included, but were not limited to, medications as ordered to manage pain, monitor for increased levels of pain, and monitor for effectiveness of interventions. Review of a Minimum Data Set (MDS) assessment completed on 12/02/24 revealed Resident #36's cognition remained intact, no behaviors, and had a pain rating of seven, on a scale of zero to ten, ten being the worst. Review of a medication administration record (MAR) for December 2024 revealed Resident #36 had an order for acetaminophen tablet 325 milligrams (mg) (analgesic) two tablets by mouth every four hours as needed for pain starting on 11/30/24. The were no parameters to direct when to give the as needed acetaminophen. Review of a medication administration record (MAR) for December 2024 revealed Resident #36 had an order for Norco (opioid pain medication) 5-325 mg one tablet by mouth every six hours as needed for pain relief starting 12/02/24. There were no parameters to direct when to give the as needed pain medication. Review of an orthopedic consult dated 12/04/24 revealed Resident #36 complained of intermittent left forearm pain. Review of a medication administration record (MAR) for December 2024 revealed Resident #36 had a pain level of five during the dayshift and nightshift for 12/11/24; a pain level of four for dayshift and one for nightshift of 12/12/24; a pain level of four during day shift and three during night shift of 12/13/24; a pain level of seven on dayshift and a pain level of four on nightshift of 12/16/24; and a pain level of seven for dayshift and nightshift of 12/27/24. Further review of the MAR revealed Resident #36 did not receive her as needed Norco on 12/11/24 through 12/13/24, 12/16/24, or 12/27/24. Resident #36 also did not receive as needed acetaminophen during nightshift of 12/11/24, on 12/12/24, during nightshift on 12/13/24, on nightshift for 12/16/24, or on 12/17/24. Review of a narcotic log for the ordered Norco for Resident #36 revealed one dose of Norco was pulled on 12/16/24 at 6:00 A.M. and two doses were pulled on 12/27/24 at 9:22 A.M. and 7:01 P.M. with no further information in the medical record regarding whether the resident received her medication. These doses were not signed as administered on the MAR. Interview on 12/30/24 at 1:54 P.M. with Resident #36 revealed she had waited almost six hours one day to get her pain medications, two and half hours another time, and two hours a third time. Resident #36 stated her daughter called the facility and after that, she received her medication timelier. Interview on 12/31/24 at 1:10 P.M. with Certified Nursing Assistant (CNA) #503 revealed Resident #36 will sometimes request her pain medication then wait an hour or two to receive it. CNA #503 would tell the nurse, then complete her rounds again in two hours and Resident #36 still had not received the medication, so she had to tell the nurse again. Interview on 12/31/24 at 2:18 P.M. with Director of Nursing (DON) confirmed the MAR showed Resident #36 had pain on 12/11/24 through 12/13/24, 12/16/24, and 12/17/24 and did not receive as needed Norco. The DON also confirmed the as needed Norco and acetaminophen did not have parameters to direct nursing staff which to administer. Interview on 12/31/24 at 3:10 P.M. with the DON confirmed Norco had been signed out three times but was not documented in the medical record as administered. The DON stated she would have her nurses sign off on the MAR for the days they missed. Interview on 01/02/24 at 9:27 A.M. with Resident #36 revealed she kept a log of each time she had pain but had to wait for her medications, including 12/16/24 due to the aide forgetting to tell the nurse. Review of an undated policy titled Pain Management revealed the facility recognizes the need to identify pain and its underlying cause, respond promptly, assess, monitor, intervene, and re-evaluate resident's pain while updating the necessary documentation routinely.

Based on record review, observations, interview and policy review, the facility failed to ensure Resident #4's oxygen tubing was changed once per week as ordered by the physician. This affected one resident (#4) of two residents reviewed for respiratory services. The facility census was 52. Findings include: Record review revealed Resident #4 admitted to the facility on [DATE] with diagnoses including venous insufficiency, hypertension, and gastro-esophageal reflux disease. Review of a medication administrator record from December 2024 revealed Resident #4 had orders in place for oxygen at two liter per minute continuously via nasal canula as resident will allow (09/29/24), change oxygen tubing every week and as needed on Wednesdays (09/29/24), and change aerosol nebulizer set-up every week on Wednesday and as needed (09/29/24). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4's cognition remained intact, and she had no behaviors. Observation on 12/30/24 at 3:28 P.M. revealed Resident #4's oxygen and nebulizer tubing were last changed on 12/18/24. Observation on 12/31/24 at 9:48 A.M. revealed Resident #4's oxygen and nebulizer tubing were still dated for 12/18/24. Interview on 12/31/24 at 9:50 A.M. with Certified Nursing Assistant (CNA) #503 confirmed Resident #4's oxygen and nebulizer tubing were dated for 12/18/24. Interview on 12/31/24 at 9:55 A.M. with Licensed Practical Nurse (LPN) #522 confirmed Resident #4's oxygen and nebulizer tubing should be changed weekly and should have been changed on 12/25/24. Review of an undated policy titled Nasal Cannula revealed the nasal cannula is recommended to be changed weekly and as needed.

Based on record review, interview and facility policy review, the facility failed to address signs and symptoms of a urinary tract infection (UTI) in a timely manner for Resident #36. This affected one resident (#36) of one resident reviewed for UTIs. The facility census was 52. Findings include: Record review revealed Resident #36 admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of left femur, difficulty in walking, muscle wasting and atrophy, and hypertension. Review of a care plan completed on 11/21/24 revealed Resident #36 had an alteration in elimination related to indwelling Foley catheter with an intervention to monitor for signs and symptoms of a UTI such as elevated temperature, dysuria, flank pain, hematuria, foul smelling urine and report to provider to seek diagnosis and treatment. Review of a Minimum Data Set (MDS) assessment completed on 12/02/24 revealed Resident #36's cognition remained intact, no behaviors, required setup or clean-up help for toileting, and was occasionally incontinent of bladder. Review of an orthopedic consult dated 12/04/24 revealed Resident #36 reported urinary incontinence and dysuria ongoing for over one week. A recommendation was given to the facility for staff to order a urinalysis related to urinary symptoms. Review of a nursing note dated 12/04/24 revealed Resident #36 returned from her orthopedic appointment and had reported dysuria and urinary incontinence with a recommendation for a urinalysis to rule out a UTI. Review of a nursing note dated 12/05/24 revealed a new order was received for Resident #36 to have a urinalysis with culture and sensitivity related to dysuria. Review of a urinalysis for Resident #36 revealed the urine was collected on 12/06/24 and the results were reported to the facility on [DATE] revealing the resident had a UTI with Escherichia coli (E. coli). Review of a Medication Administration Record (MAR) for December 2024 revealed a new order was given for Resident #36 on 12/09/24 for Cipro (an antibiotic) tablet 500 milligrams (mg) by mouth two times a day for UTI until 12/16/24. Further review of the MAR revealed Resident #36 did not receive the first dose of cipro until 12/10/24. Review of a document titled Inventory Summary revealed the facility keeps Cipro 500 mg tablets in their Pyxis (automated medication dispensing system). Interview on 12/30/24 at 1:54 P.M. with Resident #36 revealed she told the staff for approximately two weeks she had a UTI because she was having symptoms of frequent urination, burning, and odorous urine. Resident #36 stated when she went to her follow-up orthopedic appointment, she asked her physician to help get a urinalysis completed due to the facility staff not listening to her. Interview on 12/31/24 at 1:10 P.M. with Certified Nursing Assistant (CNA) #503 revealed Resident #36 carried on for about two weeks with complaints of having a UTI due to having pressure and burning with urination and the odor was bad. CNA #503 stated Resident #36 is a retired nurse and would know the signs. CNA #503 stated she reported this multiple times to the nurses on her hall with no success in getting antibiotics for two weeks. Interview on 12/31/24 at 2:14 P.M. with Director of Nursing (DON) confirmed the urinalysis was completed on 12/06/24 with results being reported on 12/08/24, an order for antibiotics on 12/09/24 that were not started until 12/10/24. Interview on 01/08/25 at 9:59 A.M. with Licensed Practical Nurse (LPN) #557 revealed if someone was complaining about signs or symptoms of a UTI, staff should contact the provider to get orders for a urinalysis and treatment. LPN #557 stated the facility did interview several nurses with all of them denying they were aware of Resident #36's symptoms. Review of an undated policy titled Status Change in Resident Condition- Notification revealed the facility will promptly notify the resident, their provider, and the responsible party of change in resident's condition.

Based on observation, closed medical record review, review of a facility investigation, review of the facility Elopement policy and procedure, employee file review, local weather reporting and interview with facility staff, Physician #325 and Visitor #600, the facility failed to provide adequate supervision to prevent Resident #51, who had diagnoses of dementia, [CONDITION(S)], chronic obstructive pulmonary disease ([CONDITION(S)]) and was at high risk for elopement from eloping from the facility. This resulted in Immediate Jeopardy on 08/12/21 at 9:28 P.M. when Resident #51 exited the front door of the facility without staff knowledge. Although the resident was wearing a secure care/wander guard bracelet and the door did alarm at the time the resident exited, staff failed to respond appropriately to the door alarm. The likelihood of actual harm occurred when Resident #51 was discovered by Visitor #600 in the facility parking lot, calling for help and was short of breath with the weather temperature 86 degrees Fahrenheit. Resident #51 was also at risk for falls and was found outside without her walker at the time of the incident. The area/drive outside the facility had a gradual downgrade and was observed to be uneven, with missing concrete posing an additional fall risk hazard for the resident. The resident was found by Visitor #600 approximately 89 feet from the facility. At the time of the incident, Visitor #600, who found the resident, had to obtain staff from inside the facility to assist Resident #51 back into the building. This affected one resident (#51) of five residents reviewed for elopement. The facility identified five residents (#19, #23, #25, #37 and #51) who were at risk for elopement. The census was 49. On 09/01/21 at 3:12 P.M. the Administrator, Regional Director of Operations #500 and Registered Nurse (RN) #100 were notified Immediate Jeopardy began on 08/12/21 at 9:28 P.M. when Resident #51, who displayed exit seeking behaviors, exited the facility via the front door without staff knowledge. The front door had a keypad and a 15 delayed egress second push release on it and a keypad to override the alarm as well as a secure care alarm system (a system that alerts staff if a resident wearing a secure care bracelet exits the facility). State tested Nursing Assistant (STNA) #125 heard the alarm but did not report the alarm to any other staff, did not check the area in or around the facility for residents at the time it sounded and subsequently reset the keypad to silence the alarm without identifying Resident #51 was outside the facility. Resident #51 was located outside the facility in the parking lot by Visitor #600. The facility investigation, record review and interview with Visitor #600 revealed discrepancies in the time Resident #51 was actually located outside the facility unattended by staff. The Immediate Jeopardy was removed on 08/13/21 when the facility implemented the following corrective actions: · On 08/12/21 at the time Resident #51 was found outside the facility by Visitor #600, STNA #225 was notified and assisted the resident back into the facility. A head-to-toe assessment was attempted by Licensed Practical Nurse (LPN) #175. The resident was not assessed to be in physical distress by staff. Resident #51's daughter and Physician #325 were notified of the incident. Resident #51 was placed on one on one (1:1) supervision provided by Admissions Coordinator (AC) #475 and remained with 1:1 supervision until discharged to another facility on 08/13/21 at 12:52 P.M. The resident did not return to the facility following discharge. · On 08/12/21 following the incident, LPN #550 verified the facility census and all current residents were accounted for in the facility. · On 08/12/21 following the incident, Maintenance #450 checked facility doors including the front door. The front door was functioning correctly as well as dining room door, 100 hall emergency exit, 200 hall emergency exit, 300 hall emergency exit, entrance to the assisted living (AL), courtyard, break room and service emergency exit. All other secure care devices including door pads and secure care bracelets were checked and were in proper placement and functioning correctly. · On 08/12/21 beginning at 11:05 P.M. the DON/designee provided immediate education for the two LPNs (LPN #175 and LPN #550) and four STNAs (STNA #125, #150, #200 and #225) on duty at the time of the incident and additional oncoming staff related to elopement and wandering. · On 08/13/21 the DON/Administrator completed an investigation of the incident. Staff interviews were obtained, secured doors and secure care bracelet functioning was assessed and video footage was reviewed. The facility determined the root cause of the incident was related to staff member (STNA #125) noncompliance with the facility Elopement policy and procedure. · On 8/13/21 at 10:00 A.M. a facility Quality Assessment Performance Improvement (QAPI) meeting was held to review facility policy. Present at the meeting were the Administrator, DON, Physician #325, Business Office Manager #575, Social Services Designee #625, Maintenance #450, Environmental Services #650, Therapy Director #675, Admissions Director #475 and LPN/Unit Manager #700. · On 08/13/21 at 11:00 A.M. the Administrator placed a STOP sign on the handicap door exit button (at the front door). · On 08/13/21 at 3:00 P.M. the DON provided 1:1 education to STNA #125 related to the facility elopement policy, secure care devices and door function, including what the light indicators meant on the doors and how to respond appropriately. · On 08/13/21 at 8:00 P.M. the DON/designee completed elopement assessments for all facility residents to identify other residents potentially at risk for elopement. No new residents were identified. · On 08/13/21 at 8:30 P.M. the DON/designee reviewed the care plans for all residents at risk for elopement to ensure appropriate interventions were in place. · On 08/13/21 at 8:32 P.M. the DON/designee reviewed all residents with secure care orders to ensure orders were correct. Resident #53 was the only resident in the facility with secure care orders at that time. · On 08/13/21 at 8:35 P.M. the Administrator/designee initiated education for all licensed nursing staff and non-licensed staff on all shifts related to wandering, elopement and resident safety. Education was provided in person or via telephone. A plan was implemented for any staff who did not receive education at this time to receive the education before their next shift. · On 08/13/21 the DON/Designee initiated an audit of all new admissions related to elopement risk and to ensure appropriate interventions were in place. A plan for the ongoing audits to be completed by the DON/Designee two times a week for four weeks was initiated. · On 08/13/21 a plan for all new hires to receive education related to wandering, elopement and resident safety in writing by the HR Director #750 was initiated. The education would also be verbally provided by HR Director #750 during general orientation tour, onsite ongoing. · On 08/13/21 the DON/Designee initiated interviews/audits from various departments and staff members five times a week to check staff competency of elopement prevention for four weeks. · On 8/13/21 the facility determined Maintenance #450 would continue to conduct a weekly audit of the secure care door alarms and secure care bracelets for functioning as was being completed prior to the elopement incident involving Resident #51. · On 08/13/21 the facility Quality Assurance Performance Improvement (QAPI) team reviewed and interpreted audit findings. A plan for all ongoing audits and findings to be discussed at the monthly QAPI meeting for a minimum of three months or until the pattern of compliance was maintained. · On 08/30/21 at 1:05 P.M. through 09/03/21 at 4:23 P.M. interviews with five staff (STNA #150, #200, #225; LPN #175 and Receptionist #750) revealed all staff interviewed were knowledgeable of the facility elopement policy and the keypad door alarming system. Although the Immediate Jeopardy was removed on 08/13/21, the deficiency remained at a Severity Level II (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility failed to complete a comprehensive and thorough investigation related to the elopement incident including information/statements from all persons with knowledge of/involvement in the incident to determine the circumstances of the incident and failed to ensure accurate information regarding the incident was contained in the resident's medical record. Findings Include: Review of Resident #51's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, [CONDITION(S)], difficulty walking and chronic obstructive pulmonary disease ([CONDITION(S)]). The resident was admitted to the facility from the residential care/assisted living facility. Review of the CHS Admission Packet V 11 form, completed on 07/02/21 by LPN #425 revealed Resident #51 was mobile in a wheelchair and was at low risk for elopement. Review of the progress note, dated 07/27/21 at 9:24 A.M. and authored by RN #300 revealed Resident #51 refused to take her morning medication and was trying to smack them out of my hand. The note indicated the resident had been restless with a lot of exit seeking behaviors and a secure care/wander guard was placed to the resident's left leg. Review of the Elopement Evaluation completed on 07/27/21 by the DON revealed Resident #51 had exit seeking tendencies. The evaluation revealed the resident attempted to open exit doors, attempted to follow visitors out of doors, hovered near exit doors and demonstrated exit seeking behaviors such as packing belongings, stating she wanted or needed to leave, searched for exit doors, put on coat, etc. The evaluation revealed Resident #51 was ambulatory and mobile in a wheelchair. The resident was now assessed as a high risk for elopement. Review of the at risk for elopement /wandering related to impaired cognition and unaware of safety limitations plan of care, initiated 07/27/21 revealed interventions including to assess risk factors per facility protocol, follow facility elopement procedures, monitor and report changes in behavior such as restlessness, pacing, etc., provide diversional activities of interest as needed, redirect as needed, secure care to ankle to prevent elopement and check every shift for placement, function and skin irritation; wander guard. Record review revealed a physician's order, dated 07/27/21 for a secure care (bracelet) to left ankle to prevent unsafe wandering. The order indicated to check every shift for placement, function and skin irritation. Review of the progress note dated 07/28/21 at 3:01 P.M. and authored by the DON revealed the resident visited her (previous) roommate on the assisted living (AL), had confusion and continued to exit seek, attempting to open exit doors along with making statements of going home. One on one and redirection were successful for short periods. Physician #325 was updated. There was no evidence of any new interventions implemented for the resident at this time. Review of the progress note dated 08/02/21 at 11:30 A.M. and authored by LPN #350 revealed Resident #51 was hitting at staff and visitors. Exit seeking for two days. Unable to redirect resident. Granddaughter unable to redirect. Yelling at people in German. Family aware. There was no evidence of any new interventions implemented for the resident at this time. Review of the progress note dated 08/03/21 at 1:40 P.M. and authored by LPN #350 revealed the resident's granddaughter was at the facility to take the resident to the local hospital emergency room for a well check (psychiatric assessment). The resident was admitted to the hospital on this date. Review of a psychiatry note, dated 08/10/21 and authored by Physician #525 revealed psychiatry was asked to re-evaluate Resident #51 regarding transfer to a psychiatric unit with a resident's main issue identified as wandering. The note revealed the nursing home would not accept the resident back until she had 24 hours without a sitter (the resident had a 1:1 sitter with her during the hospitalization ). The note revealed this was discussed over the weekend with another physician and it was suggested to take the resident to the nurses' station, give her tasks and provide alarms (tab and bed alarms) to minimize falls. The resident was seen by Physician #525 on the unit. The note revealed the resident was in bed with no sitter present as the sitter must have been discontinued. The resident's reality testing, judgement and insight were poor. The resident did not meet the guidelines for an in-patient psych stay as wandering was a common consequence of dementia. The note revealed we suggest as stated before; distraction, walking with the resident routinely in the halls, utilizing tasks such as folding laundry, having her sit at the nursing station and using bed, tab and floor alarms as interventions. The note indicated hopefully Resident #51 could be discharged soon since there was no sitter with her now. The resident had diagnosis of major neurocognitive disorder with behavioral disturbance. Review of the Hospital Discharge Summary, dated 08/11/21 at 8:34 A.M. and authored by Physician #500 revealed Resident #51 had advanced Alzheimer's dementia with behavioral disturbances. Psychiatry was consulted and the resident had been wandering and needed re-direction. The resident was not aggressive or violent and had been off the sitter since the morning of 08/10/21. A psych admission was declined. The resident's acute problems were Alzheimer's Disease, urinary tract infection and abnormal electrocardiogram (EKG). The resident was discharged back to the nursing home on 08/11/21. Review of the progress note, dated 08/11/21 at 4:15 P.M. and authored by RN #375 revealed Resident #51 arrived to the facility from the hospital. A secure care bracelet was applied to the resident's right lower extremity on admission to (the) room. Review of the late entry progress note (created on 08/14/21 at 1:18 A.M.) revealed on 08/12/21 at 7:43 P.M. LPN #175 documented Resident #51 was found outside the facility under the main entrance awning by staff. The resident was assisted into the facility, alert and oriented to person. A head-to-toe assessment was completed with no injuries noted. The resident denied pain. A secure care bracelet was in place to the resident's left ankle and checked for functioning. The note included Physician #325 was notified as well as the resident's family. The note indicated the resident was currently 1:1 with staff. Review of the progress note, dated 08/13/21 at 12:52 P.M. and authored by RN #400 revealed report was called to a sister facility. Medications and belongings were gathered and the resident's grandson signed for them. The resident was wheeled out to a private car and left the facility to be discharged to another long-term care facility. Record review revealed no evidence the incident of Resident #51's elopement was reported to the State Agency as a self-reported incident for a potential incident of neglect. Review of the facility abatement plan (also identified by the facility as their investigation) dated 08/13/21 revealed the following: On 08/12/21 Resident #51 exited out the front door at 9:28 P.M. by pushing the handicapped button repeatedly. Her secure care bracelet sounded the alarm as she went out the door with her walker. She was appropriately dressed and had a Brief Interview for Mental Status (BIMS) score of 6 (severe cognitive impairment). The investigation did not describe what the resident was wearing to support she was dressed appropriately. On 08/12/21 at 9:31 P.M. new employee, STNA #125, turned off the alarm and did not survey the outside area. At 9:35 PM on duty STNA #225 came to the front area to look for the resident and then returned to the main (interior) areas of the facility. At 9:41 PM Visitor #600 (Resident #52's family member) informed staff Resident #51 was under the portico. STNA #225 returned the resident. On 08/12/21 (no time indicated) maintenance staff came and checked the front door. The front door was functioning correctly and all other doors were checked and functioning properly. On 08/12/21 (no time indicated) the family was notified and agreed to sit with the resident. At 11:00 P.M. the Administrator and DON were notified. Education for all staff present and oncoming staff was provided on the elopement drill policy, wandering and resident safety by the DON/designee. The facility also provided staff statements which included the following: A handwritten statement, dated 08/12/21 (no time included) completed by the DON revealed Resident #51 was interviewed (by the DON) regarding being outside without family or staff. The resident stated I'm not sure what the big deal is, I was just getting some air and coming back. Review of a handwritten witness statement authored by STNA #150 on 08/12/21 (no time) revealed the STNA was passing snacks on the 300 hall and LPN #175 asked STNA #225 where his grandma was so then we went looking for her down every hall and all over the building for her. That's when Resident #52's family brought her back up to the door and said the resident was outside and the alarm didn't go off. Review of a handwritten witness statement authored by LPN #175 with an incident date of 08/12/21 (no time included) revealed the LPN had asked STNA #225 around 9:15 P.M.-9:30 P.M. (I think) where Resident #51 was and STNA #225 went to look for the resident. The LPN was down at the end of 300 hall passing medications. STNA #225 came walking the resident back to her room but the resident did not have her walker when she came back in (the building). The resident still had the secure care in place to her left ankle and the front door did not alarm. Review of a handwritten witness statement authored by STNA #200 with an incident date of 08/12/21 at 10:50 P.M. revealed STNA #200 was helping in Room 402 when STNA #225 came down and asked if STNA #200 had seen Resident #51. STNA #200 stated no and we started looking for the resident. STNA #225 found the resident outside. STNA #200 did not hear an alarm going off. Review of a handwritten witness statement authored by STNA #125 with an incident date of 08/12/21 and time of 10:50 P.M. revealed the STNA was on the 200 hall and did not know the incident occurred until someone asked if we had Resident #51 and someone found her down in the second parking lot. Resident #52's family member told STNA #225 there was a resident outside. STNA #225 went down there and it was Resident #51. The STNA stated no one, including me did not hear any alarm going off. Review of a handwritten witness statement authored by STNA #225 with an incident date of 08/12/21 at 9:30 P.M. revealed the nurse asked where Resident #51 was. When the STNA was searching, STNA #225 found the resident outside but no alarm had went off. When STNA #225 found Resident #51, it was reported to the nurse. On 08/30/21 at 1:00 P.M. interview with STNA #150 revealed she generally worked day shift but she had come in on 08/12/21 to help out and was passing snacks on the 300 hall when the incident with Resident #51 had occurred. STNA #150 revealed she did not hear an alarm while she was passing snacks. On 08/30/21 at 4:52 P.M. an additional interview with STNA #150 revealed she had not provided care to Resident #51 since the resident's re-admission to the facility on [DATE] and came in to help on 08/12/21 due to numerous new-admissions to the facility on [DATE]. On 08/30/21 at 1:05 P.M. interview with STNA #200 revealed she was working the night of the incident with Resident #51 and was helping in a resident room on the 400 hall when STNA #225 asked if she had seen Resident #51. STNA #200 thought it was sometime around nine-ish when he asked. The resident had been exit seeking earlier in the shift and had to be re-directed away from doors. STNA #200 denied hearing any door alarm sound and indicated there was a difference with the door alarm and the secure care/wander guard alarm sounds. On 08/30/21 at 4:12 P.M. interview with LPN #175 revealed she was working the night Resident #51 left the facility without staff knowledge. LPN #175 revealed the resident had been exit seeking since she started her shift at 6:00 P.M. and she had been re-directed from the door at least six times. The resident had been trying to go to the front door, was speaking German and was actively exit seeking. LPN #175 denied knowledge of how the resident's behavior was earlier in the day, but LPN #175 told the staff to keep an eye on the resident during medication pass, bed and snack time as it was hard to monitor residents during this busy time. LPN #175 revealed monitoring the resident's whereabouts was the responsibility of everyone and when LPN #175 hadn't noticed the resident pacing for a few minutes she stated she asked STNA #225 if he knew the location of the resident. LPN #175 denied hearing a door alarm sound and said she had not seen the resident in 10-15 minutes. LPN #175 stated she then learned the resident was outside. The LPN described it as being hot outside and denied notifying administration staff of the resident's exit seeking behavior earlier in the shift. LPN #175 revealed the resident had her walker while she was outside. The LPN verified she did complete a statement for the incident and made a late entry in the medical record regarding the elopement but was unsure why she documented the time she did (7:43 P.M.) but thought the incident occurred around 9:30 P.M. Further interview revealed the resident had been out to the hospital and the facility thought she was going to be admitted for a psychiatry stay but the resident wasn't kept for a psychiatric stay and was returned to the facility. The LPN revealed the night of 08/12/21 was very busy and no additional staff had been added to assist in monitoring the resident. On 08/30/21 at 5:18 P.M. interview with STNA #225 revealed he was assigned to the 300 hall on 08/12/21 and was responsible for Resident #51's care. The STNA revealed staff were very busy on 08/12/21 and when the nurse (LPN #175) asked where Resident #51 was, STNA #225 began looking for the resident. Further interview revealed the resident had been actively going to doors and expressing she wanted to go outside. The STNA revealed the resident was found under the awning by a family member of another resident and STNA #225 brought the resident inside the facility. The STNA revealed the resident had her walker with her when she eloped from the building thought the resident had pressed the handicapped exit button for 15 seconds and then was able to exit the building as it unlocked after alarming for 15 seconds. STNA #225 denied hearing a door alarm to notify staff a resident had left the facility. STNA #225 verified it was warm and humid outside when the resident was found. On 8/30/21 at 5:37 P.M. interview with Physician #325 revealed he was notified of the incident of Resident #51 eloping. Physician #325 revealed the resident was not safe to be outside the facility without staff. The physician indicated when the facility identified the resident's exit seeking behaviors had increased, different interventions/approaches should have been implemented. The physician also indicated when the door alarmed, the perimeter of the facility should have been assessed for potential resident elopement. On 08/30/21 at 7:10 P.M. telephone interview with STNA #125 revealed she worked the night Resident #51 eloped. The STNA revealed staff were super busy and she was unaware the resident exited the building without staff knowledge. STNA #125 revealed the facility informed her they watched video footage of the incident and the alarm was turned off at 9:31 P.M. on 08/12/21, after the resident had exited the building. STNA #125 thought she was disarming the door because someone had exited without the code and she did not investigate the incident, she only turned off the alarm and returned to work. The STNA denied knowledge she was to scan the perimeter to ensure residents did not exit without staff knowledge. Lastly, the STNA revealed the alarm for the door sounding was not unusual especially with the number of visitors the facility had in and out. STNA #125 revealed it was hot and humid on this date. On 08/30/21 at 7:35 PM interview and observation of the door alarms with Maintenance #450 revealed pressure on the door or handicapped paddle would cause the door to pop and you could exit after 15 seconds but the door made a loud alarm sound once pressure was applied to the door. Differentiation between the exit alarm and the secure care/wander guard alarm was present and verified with Maintenance. Staff had to manually reset the keypad when an alarm goes off or it would continue until it was reset. Maintenance #450 verified the keypad showed when a resident with a wander guard/secure care bracelet exited the building without the staff entering the code into the door keypad but once the resident was out of range for the secure care alarm, the keypad for the secure care would no longer illuminate red and would only continue to sound until the keypad code was entered by staff. On 08/30/21 at 8:10 P.M. interview with the Administrator and DON verified the surveyor had been provided the entire investigation (as noted above), no additional information was available to be provided and the timeline titled abatement plan was provided to be reviewed. Both the Administrator and DON revealed they had watched video footage to determine a timeline of events involving Resident #51 on 08/12/21, however the video had recorded over itself after five days and the timeline/investigation provided did not indicate the specifics from the video footage to provide this timeline. Information from the administrative staff revealed the door alarm sounded at 9:28 P.M., was turned off by STNA #125 at 9:31 P.M. and the resident was found outside by Resident #52's family at 9:41 P.M. The Administrator and DON verified they had no documentation from the investigation or staff to indicate when the last time the resident was seen or what she was doing at the time of the last observation prior to the elopement. They also verified they did not obtain a statement from Resident #52's family member (Visitor #600), who was the person who found the resident outside to assist in the investigation. The Administrator revealed she felt the investigation was cut and dry and the statement from Resident #52's family member was not necessary. Further interview verified the root cause of the incident was a result of STNA #125, who heard the exit alarm, disarm the alarm and not sweep (observe) the area to ensure no residents had exited the building or alerted any other staff she heard the exit alarm before resuming her work. Further interview verified the facility did not identify the resident's secure care had not been assessed for function since it was reapplied on 08/11/21 and had no documented evidence this had been completed. The Administrative staff verified they did not have a comprehensive investigation to identify the discrepancies in staff statements, whether the resident was using her walker at the time of the incident, what the resident was doing prior to exiting unsupervised and did not obtain statements from all parties involved in the incident. The Administrator and DON revealed STNA #125 had received training on elopement upon her hire on 07/14/21 which was included and reviewed on the STNA's orientation documentation, however the staff member did not follow proper procedure when responding to an exit alarm. The administration staff verified the outside temperature was 86 degrees at the time the resident exited placing the resident at risk due to excessive heat. They also verified the driveway from the facility was cracked and uneven and a gradual downgrade also presenting a risk to the resident since she ambulated with a walker and could potentially cause the resident to fall. On 09/01/21 at 2:35 P.M. telephone interview with Visitor #600 revealed she was the person who discovered Resident #51 outside on 08/12/21. The visitor revealed she found the resident between 10:00 P.M. to 10:30 P.M. as she was leaving the facility from visiting Resident #52. The visitor revealed as she was exiting the building, she could hear a resident yelling Hey! Hey! Come here! Resident #51 was to the right of the front door, in the handicap parking area, holding on to an awning pillar. The resident did not have her walker while she was at the pillar. She asked the resident if she needed help and the resident answered yes. The visitor began to assist the resident to walk back to the facility and after approximately 15 feet, the resident became short of breath. The visitor revealed she told the resident she would go inside and get the staff to assist. The visitor stated she went back to the main entrance and had to ring the door bell five times before she was greeted by staff. An STNA (STNA #225) came out to assist. The family member revealed STNA #225 checked to make sure Resident #51 had a bracelet on and told her the resident often watched the doors to ensure she could leave without setting off the alarm. The visitor revealed she assisted with getting the resident closer to the door and then got into her car to leave. When she was exiting the parking lot, she saw Resident #51's walker in the lower lot and called Admissions Coordinator (AC) #475 to alert her the resident's walker was in the parking lot. Unfortunately, AC #475 did not answer her phone so the visitor left a voicemail. She stated AC #475 returned her call and was grateful the visitor saw the resident's walker as she stated she told her the staff had been looking for the walker. On 09/01/21 at 8:25 P.M. interview with RN #100 revealed the facility identified the root cause of the incident as STNA #125 not appropriately responding to the alarm and turning off the alarm so additional staff would not have heard the alarm. Further interview with RN #100 revealed the facility did not feel three minutes (9:28 P.M. to 9:31 P.M.) to respond to an alarm was too long as the facility was also providing care to other residents and the staff could not always leave those residents to answer an alarm. The RN verified at least six staff were working at the time of the incident and it took at least three minutes for staff to respond to an alarm for the emergency exit and secure care system. Lastly, the RN verified the facility did not address this concern as they did not feel the length of time was the issue, but the issue was that STNA #125 did not appropriately respond to the alarm and turning off the alarm did not afford the other staff to hear the alarm even though it sounded for three minutes according to the facility timeline/investigation. On 09/03/21 at 10:50 A.M. interview with AC #475 revealed she did receive a call from Visitor #600 on 08/12/21 but was unsure of the time the call came in. The call did provide information about Resident #51's walker location (outside the facility) but she was unable to recall the location of the walker. Lastly, AC #475 revealed she was in the facility at the time of Resident #51's elopement but she did not hear a door alarm or respond as she was in Resident #50's room at that time. AC #475 denied completing a statement as a result of the investigation. On 09/03/21 at 11:13 A.M. a follow-up interview with STNA #125 revealed she was unable to recall how long after she reset the alarm STNA #225 alerted her Resident #51 was unable to be found. She revealed the alarm had been going off for three to four minutes before she responded and stated she did not know the appropriate procedure when disarming the keypad in terms of checking outside. On 09/03/21 at 3:51 P.M. observation an [TRUNCATED]

Based on record review, physician and staff interviews the facility failed to ensure therapeutic drug monitoring was implemented resulting in a significant medication error for one resident of three residents reviewed for antibiotic use (Resident #48). Harm occurred to Resident #48 when the facility failed to notify the physician and pharmacist of a critical [MEDICATION NAME] trough level (therapeutic monitoring of the blood level of a drug), administered a dose of [MEDICATION NAME] despite the critical trough level resulting in a hospitalization for acute [MEDICAL CONDITION] and treatment for [REDACTED]. Findings include: Review of Resident #48's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact and required limited assistance of one staff member with activities of daily living. Review of the physician orders [REDACTED]. Further review of the physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. The dose on 03/31/18 was administered at 4:00 P.M. and the dose on 04/01/18 was administered at 7:24 A.M (less than 24 hours apart). Review of the physician ordered [MEDICATION NAME] trough levels obtained every three days prior to the administration of the drug revealed the following: On 03/30/18 the level was obtained pre-[MEDICATION NAME] dose and was 14.5 micrograms per milliliter (reference range 5.0-20.0). On 04/02/18 the level could not be obtained. On 04/03/18 the trough level was critical with a result greater than 50 micrograms per milliliter. The level was obtained at 11:00 A.M., after the [MEDICATION NAME] had been administered. On 04/05/18 the trough level remained critical with a result greater than 50 micrograms per milliliter. Review of the nurses progress notes revealed on 04/02/18 at 12:59 P.M. the laboratory specimen was bad and the laboratory study could not be completed. The physician was notified and ordered level on 04/03/18. The progress note revealed no physician or pharmacist notification regarding the critical [MEDICATION NAME] trough on 04/03/18. The medical record lacked documentation the physician or pharmacist was notified prior to the administration of the 04/04/18 dose of the [MEDICATION NAME]. On 04/05/18 the morning dose of [MEDICATION NAME] was not given and documentation reflected physician and pharmacist notification regarding the critical [MEDICATION NAME] trough level. The pharmacist ordered to hold the [MEDICATION NAME] until further notice and to obtain a [MEDICATION NAME] trough on 04/09/18. Review of the laboratory study dated 04/06/18 revealed a creatinine level (kidney function) of 5.2 with normal range of 0.6-1.3 milligrams per deciliter. The resident did not have a history of kidney failure and was transferred to the hospital for acute kidney failure. Review of Physician #80's progress note dated 04/06/18 revealed Resident #48 had been on [MEDICATION NAME] and unfortunately repeat labs this date showed a creatinine level of 5.2. The physician diagnosed the resident with acute [MEDICAL CONDITION] possibly secondary to dehydration and [MEDICATION NAME]. The resident was referred to the emergency room . Review of the pharmacy documentation revealed on 03/30/18 the resident's trough level was normal and to continue the [MEDICATION NAME] dose with a repeat trough on 04/02/18. On 04/04/18 the trough was drawn on 04/03/18 but was not at the correct time. The pharmacy indicated the trough was drawn too early at 11:00 A.M. due to evening dose of [MEDICATION NAME]. The pharmacist asked for the trough to be drawn correctly on 04/05/18. On 04/05/18 the trough came back greater than 50. A random [MEDICATION NAME] level was ordered for 04/09/18. Review of the emergency room and hospital documentation revealed Resident #48 was evaluated by nephrology on 04/07/18 after an admission to the hospital with acute [MEDICAL CONDITION] possibly secondary to [MEDICATION NAME] use. Per Nephrologist #800's documentation dated 04/07/18 the resident's [MEDICATION NAME] levels had been very high with a level greater than 60 on 04/06/18. The resident had risk factors for [MEDICATION NAME] toxicity including obesity and diabetes. The [MEDICATION NAME] was discontinued and the resident's level was 49 on 04/07/18. On 06/13/18 at 2:00 P.M. interview with the Director of Nursing revealed the [MEDICATION NAME] time had been changed to better facilitate communication with the facility and pharmacy regarding laboratory results. On 06/13/18 at 3:10 P.M. interview with Pharmacist #90 revealed the pharmacy expected to be notified of all critical laboratory values related to medications and dosing. Further interview revealed the pharmacy was unaware of a time change related to the [MEDICATION NAME] resulting in two doses administered in approximately 15 hours time. Pharmacist #90 stated had she been aware of the critical lab value and the close dosing, this may have caused her to consider the incorrect trough level on 04/03/18 and recommend a repeat on 04/04/18 prior to the dose administration. Pharmacist #90 stated she was not aware of the critical [MEDICATION NAME] trough until the late afternoon of 04/04/18 and after the [MEDICATION NAME] had been administered. Lastly, Pharmacist #90 stated the dose on 04/04/18 should not have been administered without discussing the laboratory results with the pharmacist first. On 06/13/18 at 4:07 P.M. interview with Physician #80 revealed he was unaware of the critical [MEDICATION NAME] level or he would have ordered to consult the pharmacy for further instruction. Physician #80 stated he expected to be notified of all critical lab values and he did not approve the [MEDICATION NAME] time change that occurred on 04/01/18. Lastly, Physician #80 stated [MEDICATION NAME] can cause elevated kidney functions. On 06/13/18 at 5:28 P.M. interview with Licensed Practical Nurse (LPN) #62 verified she administered the dose of [MEDICATION NAME] on 04/04/18 despite the critical trough level because no one from pharmacy ordered the [MEDICATION NAME] be held. LPN #62 stated she faxed the results to the pharmacy on 04/03/18 but did not verify the pharmacy was aware of the results. This deficiency is an incidental finding to Master Complaint Number OH 339 and Complaint Number OH 210.