Every finding on record at Brookside Healthcare Center

Based on observation, record review and interview, the facility failed to ensure portion sizes were served as planned. This had the potential to affect all 94 residents in the facility. Findings include: Review of the dietary spreadsheet for the breakfast meal on 04/17/25 revealed the serving sizes for the scrambled eggs was 1/4 cup, ground ham was a #16 scoop (1/4 cup), pureed ham was a #16 scoop, pureed eggs was a #16 scoop, and pureed muffin was a #16 scoop. During an observation on 04/17/25 at 8:00 A.M., the breakfast tray line revealed [NAME] #24 utilized #8 scoops (1/2 cup) for the ground ham, pureed ham, and pureed eggs and #12 scoops (1/3 cup) were utilized for the scrambled eggs and pureed muffins. During an interview on 04/17/25 at 8:06 A.M., Registered Dietitian (RD) #330 verified [NAME] #24 was not utilizing the correct size scoops for the ground ham, pureed ham, pureed eggs, scrambled eggs, and pureed muffins. During an interview on 04/17/25 at 8:08 A.M., [NAME] #24 stated he utilizes the dietary spread sheets to determine scoop sizes, however got mixed up and was referring to the lunch portions of the spread sheet instead of breakfast.

Based on observation, record review, interview and policy review, the facility failed to maintain infection control principles during tracheostomy care. This affected one (Resident #19) of one resident observed for tracheostomy care. The facility identified one resident who currently has a tracheostomy. The facility census was 94. Findings include: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of tracheostomy, stenosis of larynx, post-procedural subglottic stenosis, paranoid schizophrenia, drug induced dyskinesia and morbid obesity. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #19 had intact cognition and was always continent of bowel and bladder. The resident required supervision with eating, oral and personal hygiene, toileting, bathing, dressing, bed mobility and transfers. Review of physician orders revealed an order dated 02/22/24 for Resident #19 to have her tracheostomy inner cannula cleansed during tracheostomy care every day and as needed, and to apply a dressing around the tracheostomy to protect the skin. Review of physician orders revealed an order dated 04/17/24 for Resident #19 to have Enhanced Barrier Precautions (EBP) implemented for tracheostomy care, dressing, bathing, showering, transfers in room or therapy gym, personal hygiene, changing linen, providing hygiene, changing briefs or assistance with toileting. Review of physician orders revealed an order dated 02/27/25 for Resident #19 to have tracheostomy care completed every shift and as needed. The nurse is to cleanse the stoma with soap and water, assist the resident with removal of tracheostomy and clean with tracheostomy care cleaning kit solution, reinsert the tracheostomy and apply tracheostomy after care. Ensure tracheostomy ties are secure. During an observation on 04/16/25 at 11:00 A.M., Licensed Practical Nurse (LPN) #46 attempted to provide tracheostomy care to Resident #19 who had Enhanced Barrier Precautions (EBP) in place. Observation revealed that LPN #46 did not perform hand hygiene with alcohol-based hand sanitizer or soap and water prior to entering the resident's room and putting on Personal Protective Equipment (PPE) that included gown, mask and gloves. LPN #46 was observed using her gloved hand to push down overflowing trash in the trash can, then used the same gloved hand to pick up a cup, to be used for saline solution for suctioning, with her thumb inside the cup, and used the same gloved hand to open the tracheostomy care kit, pick up the tracheostomy inner-cannula cleaning brush and place it on the overbed table, and picked up the tracheostomy cleaning kit by placing her gloved thumb inside of the area used to hold the tracheostomy cleaning solution. At this point, LPN #46 was asked to stop the tracheostomy care process due to infection control concerns. This was reported to the Director of Nursing (DON). During an interview on 04/16/25 at 11:25 A.M., LPN #46 verified she did not perform hand hygiene upon entering the room of Resident #19 and before putting on PPE. LPN #46 also verified her gloved hand came in contact with trash in the trash can and she then touched the inside of the plastic cup to hold saline for suctioning, and then used the same gloved hand to open the tracheostomy kit, touched the brush used to clean the inner cannula, and then touched the inside of the tracheostomy kit reservoir that was to be used for the tracheostomy inner cannula cleaning solution. During an interview on 04/17/25 at 11:00 A.M. the DON verified LPN #46 did not adhere to EBP guidelines for proper hand hygiene fore entering the room of Resident #19, and did not maintain aseptic technique while attempting to perform tracheostomy care. Review of the policy titled, Enhanced Barrier Precautions (EBP), undated, revealed EBP refer to an infection control intervention designed to reduce transmission of Multi-Drug Resistant Organisms (MDRO) that employs hand hygiene, targeted gown and glove use during high contact resident care activities that include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care with any skin opening requiring a dressing. Review of the policy titled, Standard Precautions, undated, revealed the facility will adhere to Centers for Disease Control and Prevention (CDC) guidelines and recommendations for hand hygiene unless otherwise explicitly stated. When using soap and water, rub hands vigorously for at least 20 seconds, covering all surfaces of the hands, top of hands and fingers, and wrists. Review of the policy titled, Tracheostomy Care, undated, revealed the purpose of the policy is to provide guidance for tracheostomy care for the licensed and competent nurse or respiratory therapist. Process steps may be performed using a different sequence and does not imply incorrect procedure. Maintaining key areas of aseptic technique and working efficiency to resume oxygenation are the critical components of this process. Maintain an aseptic environment, to the extent possible, to reduce pathogen transmission. Remove gloves and perform hand hygiene prior to opening the sterile tracheostomy kit, set up sterile field, and apply sterile gloves.

Based on record review, resident interview, staff interview, review of online medication resource, and review of the facility's policy, the facility failed to ensure resident medications were administered as ordered by the physician. This affected one (Resident #80) of three residents reviewed for medication administration. The facility census was 93. Findings include: Review of the medical record for Resident #80 revealed an admitted [DATE] with a diagnosis of alcohol dependence and withdrawal. Review of the hospital continuity of care form dated 08/08/22 revealed Resident #80's discharge medication list included [MEDICATION(S)] (treats [CONDITION(S)]) 15 milligram (mg) capsule, commonly known as [MEDICATION(S)], take one capsule by mouth at bedtime for 30 days. Review of the admitting physician orders for Resident #80 dated 08/08/22 revealed an order for [MEDICATION(S)] 15 mg one capsule by mouth at bedtime for 30 days. Review of the August 2022 Medication Administration Record (MAR) revealed Resident #80 did not receive [MEDICATION(S)] four times on 08/08/22, 08/09/22, 08/10/22, and 08/11/22. Review of the nursing progress notes for Resident #80 dated 08/09/22, 08/10/22, and 08/11/22 revealed [MEDICATION(S)] was not administered due to medication had not been delivered from pharmacy. The progress notes did not include physician notification of the missed doses on 08/08/22, 08/09/22, 08/10/22, and 08/11/22. Interview on 08/12/22 at 12:46 P.M. with Resident #80 confirmed he had not received his routine dose of [MEDICATION(S)] on 08/08/22, 08/09/22, 08/10/22, and 08/11/22, and he wasn't sure why nursing hadn't given it. Resident #80 stated he felt anxious and hadn't been sleeping well because he was used to having the [MEDICATION(S)] at nighttime. Interview on 08/12/22 at 12:55 P.M. with Licensed Practical Nurse (LPN) #100 confirmed Resident #80 had not received his routine dose of [MEDICATION(S)] since admission and had missed doses on 08/08/22, 08/09/22, 08/10/22, and 08/11/22. LPN #100 further confirmed the progress notes did not include physician notification of the missed doses. Review of online medication resource found at Medscape at https://reference.medscape.com/drug/[MEDICATION(S)]-[MEDICATION(S)]- 1#5 revealed the following information regarding [MEDICATION(S)]: stopping abruptly or reducing dosage too quickly can result in withdrawal reactions, including seizures, which can be life-threatening. Review of the facility's policy titled Medication Administration, dated 01/05/22, revealed medications should be administered as prescribed. This was an incidental finding during the course of the complaint investigation.

Based on record review, staff interview, review of information from the National Pressure Injury Advisory Panel (NPIAP), and policy review, the facility failed to assess and monitor a newly applied lower left extremity immobilizer for a pressure area. This resulted in Actual Harm when Resident #57 was readmitted to the facility with a left lower extremity immobilizer on 03/25/22. The immobilizer was not checked for skin breakdown causing a subsequent avoidable unstageable pressure ulcer that was found on 04/06/22. This affected one (Residents #57) of two residents reviewed for pressure ulcer care. The facility census was 93. Findings included: Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #57's quarterly Minimum Data Set (MDS) assessment, dated 05/22/22, revealed the resident was severely cognitively impaired and was totally dependent for bed mobility, dressing, and toileting. Resident #57 required extensive assistance with eating, and personal hygiene and transfers did not occur during the MDS timeframe. Resident #57 had one or more unhealed pressure ulcers or injuries with one Stage III pressure area, two unstageable pressure areas due to coverage of the wound bed by slough or eschar and one unstageable pressure injury presenting as a deep tissue injury. The resident was receiving hospice services. Review of Resident #57's skin care plan, dated 10/06/20, revealed Resident #57 was at risk for altered skin integrity due to moisture secondary to obesity, incontinence, limited mobility, diabetes mellitus and right [CONDITION(S)]. Resident #57 had reoccurrence of excoriation under the bilateral breasts, bilateral groin, and abdominal folds due to moisture. Resident #57 refused showers and to get out of bed. Interventions included upper half rails for turning and repositioning while in bed due to flaccid [CONDITION(S)] affecting the right dominant side related to [CONDITION(S)] ([CONDITION(S)]), administer medications as ordered, monitor for side effects and effectiveness of medications, administer treatments as ordered and monitor for effectiveness, assess, record and monitor wound healing, assist resident to reposition the left side every four hours, a low air loss mattress as ordered, monitor nutritional status, serve diet as ordered, monitor intake and record, obtain and monitor lab work as ordered, report results to the physician and follow up as indicated, pressure reduction mattress to bed, trapeze to assist with bed mobility, and treatment as ordered to coccyx. Resident #57's care plan did not contain any documentation related to a lower left extremity immobilizer. Review of the facility's Braden scale dated 01/06/22 revealed Resident #57 was at moderate risk for pressure ulcers. Review of the hospital continuation of care dated 03/25/22 revealed Resident #57 was to wear a lower left extremity immobilizer at least 80 percent of the day and night for three weeks. Review of Resident #57's medical record from 03/25/22 to 04/06/22 contained no documentation that Resident #57's lower left extremity immobilizer was being removed or checked for skin impairment. Review of the nursing notes dated from 03/25/22 to 04/05/22 revealed no documentation related to Resident #57's lower left extremity immobilizer or checking the lower left extremity immobilizer. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #57 received weekly skin checks on 03/31/22 and on 04/06/22. Review of Resident #57's admission initial evaluation dated 03/25/22 revealed direct nursing care was being provided for wound care for a left [CONDITION(S)] repair. Resident #57 did not have any new skin areas noted. The assessment did not contain any documentation regarding a lower left extremity immobilizer. Review of Resident #57's wound care notes dated 04/01/22 revealed Resident #57 was seen by the wound nurse practitioner on 04/01/22 for a surgical wound to her left hip, an unstageable pressure area to her left buttock acquired prior to admission on 03/25/22 and a surgical wound to her left knee. Review of Resident #57's weekly skin check dated 04/01/22 revealed resident had skin conditions, changes, ulcers, or injuries. There were no new areas since the last documented skin check. Resident #57 had an area to her coccyx. Resident returned from the hospital with the area and was followed by the wound nurse practitioner weekly. Review of weekly wound evaluations from 04/06/22 to 07/12/22 revealed weekly wound evaluations were completed. Review of the Resident #57's wound evaluation dated 04/06/22 revealed Resident #57 had a device related pressure injury from a lower left extremity immobilizer that was an unstageable pressure ulcer on the posterior ankle. The pressure ulcer was acquired in house. The area was 2.68 centimeters (cm) in length, 7.99 cm in width and was zero centimeters in depth. No odor was present. The wound was 100 percent slough or eschar, and an order was put in place to paint the wound with [MEDICATION(S)] two times a day and secure with a four by four foam and dry dressing. Resident was to offload the lower left extremity with pillows and heel protector boots and the site was to be monitored closely. Review of Resident #57's wound evaluation dated 07/12/22 revealed Resident #57 had a device related pressure injury from a lower left extremity immobilizer that was an unstageable pressure ulcer on the posterior ankle that was acquired in house on 04/06/22. The area was 10.73 cm in length, 2.59 cm in width and was .10 cm in depth. No odor was present with scant drainage. The wound was 100 percent slough or eschar, and an order was put in place to apply [MEDICATION(S)] soaked gauze and secure with an abdominal pad and kerlix. Resident #57 was recommended to offload heels, frequent turning and repositioning, optimized nutrition, specialty mattress and to provide frequent incontinence care. Telephone interview on 07/21/22 at 9:31 A.M. with Nurse Practitioner (NP) #900 verified Resident #57's pressure ulcer to left posterior ankle on 04/06/22 was found while doing wound rounds on Resident #57's surgical wounds. NP #900 stated that she found the wound because she saw drainage coming from Resident #57's lower left extremity immobilizer and upon further investigation she found a pressure area to the posterior ankle that was unstageable. NP #900 verified the pressure area to Resident #57's posterior ankle was avoidable because it was caused by her lower left extremity immobilizer and frequent checks and repositioning of the immobilizer and lower left extremity could have prevented the pressure ulcer. NP #900 reported the deterioration of the left posterior ankle wound after it was discovered was unavoidable due to Resident #57's vascular insufficiency. NP #900 reported Resident #57 was admitted to hospice services after the posterior ankle wound was acquired. Interview with Regional Director of Clinical Operations (RDCO) #901 on 07/21/22 at 10:49 A.M. verified Resident #57 returned from the hospital on 03/25/22 with a lower left extremity immobilizer. RDCO #901 confirmed Resident #57 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RDCO #901 verified there was no documentation in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the NPIAP Pressure Injury Stages undated defined an Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss, Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Review of the facility's skin care and wound management overview policy dated 05/30/19 revealed staff strives to prevent resident skin impairment and to promote healing of existing wounds. The facility will identify diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility will develop a care plan with individual interventions to address risk factors. The facility will communicate risk factors and interventions to the care giving team and will evaluate for consistent implementation of interventions and effectiveness at clinical meeting. This deficiency substantiates Complaint Number OH 718.

Based on observation, record review and staff interview, the facility failed to ensure infection control precautions were followed and failed to ensure staff wore personal protective equipment (PPE) to prevent the spread of coronavirus (COVID-19). This affected four (Residents #80, #37, #31 and #33) residents and had the potential to affect all residents it the facility. The census was 93. Findings include: 1. Review of the facility's COVID19 line list revealed Resident #80 tested positive for covid on 07/17/22 and had a cough. Resident #37 did not have covid. During observation of the third floor of the facility on 07/18/22 at 4:09 P.M., Resident #80 was walking in the hall wearing a cloth mas. Resident #80 went to the outdoor smoking area and sat next to Resident #37. Resident #80 and Resident #37 were smoking without a staff member present while sitting approximately three feet apart. During interview on 07/18/22 at 4:09 P.M., Licensed Practical Nurse (LPN) #110 verified Resident #80 was sitting next to Resident #37 outside while smoking and were not socially distanced. LPN #110 verified Resident #80 was positive for covid and was on droplet precautions and Resident #37 did not have covid. LPN #110 stated the facility was supposed to have separate smoking times for covid positive residents. 2. Review of the facility's covid list revealed Resident #33 tested positive for COVID19 on 07/17/22 and had a cough. Resident #31 did not have covid. During observation on 07/18/22 at 4:07 P.M., Resident #33 was walking in the hallway. Resident #33 stopped at the nursing station next to Resident #31, who was sitting in her wheelchair. Resident #33 was approximately two feet from Resident #31. Resident #33 was wearing an N95 mask with the bottom strap loose and the top part of the N95 mask below his nose. Resident #31 told Resident #33 to go back to his room because he had COVID and she did not want to get it. During interview on 07/18/22 at 4:07 P.M., LPN #110 verified Resident #31 was not wearing his mask properly. 3. During observation on 07/18/22 at 8:45 A.M., State tested Nursing Assistant (STNA) #98 was passing food trays from room on the third floor. STNA #98 was not wearing a gown or gloves. She was wearing an N95 mask and face shield. STNA #98 was observed to enter Resident #85's room and place Resident #85's tray on her walker while not wearing a gown or gloves. STNA #98 was observed to sanitize her hands using hand sanitizer and then entered Resident #22's room with his tray without a gown or gloves and place Resident #22's tray on his bedside table. STNA #98 was observed to sanitize her hands with hand sanitizer and then proceeded to enter Resident #341's rom and place her tray on her bedside table without a gown or gloves. STNA #98 was then observed to sanitize her hands with hand sanitizer and then entered Resident #68's room without gown or gloves to deliver his breakfast tray on his bedside table. STNA #98 then sanitized her hands with hand sanitizer and then entered Resident #13's room and place her tray on her bedside table without wearing a gown or gloves. STNA #98 then sanitized hand hands and delivered Resident #23 and #25's tray to their room and left their trays on their bedside tables without wearing gown or gloves. Interview with STNA #98 on 07/18/22 at 8:45 A.M. verified she was passing room trays from room to room and she did not put on a gown or gloves to enter Resident #85, #22, #341, #23 and #25's room despite there being a yellow zone droplet precautions sign stating a gown, gloves, N95 and face shield should be worn to enter Resident #85, #22, #341, #23 and #25's room and a red zone droplet precautions sign stating a gown, gloves, N95 and face shield should be worn to enter Resident #13 and #68's room. STNA #98 stated she was not sure if any of the residents had coronavirus (COVID19). Interview with Licensed Practical Nurse (LPN) #105 on 07/18/22 at 8:45 A.M. verified Resident #13 and Resident #68 were positive for COVID19 and that a gown, gloves, N95 and face shield should be worn to enter their rooms. LPN #105 also verified Resident #85, #22, #341, #23 and #25 were on yellow zone droplet precautions due to exposure and a gown, gloves, N95 and face shield should be worn to enter their rooms. LPN #105 verified STNA #98 did not wear a gown or gloves to enter Resident #85, #22, #341, #68, #13, #23 and #25's rooms. Review of the facility policy titled 'Standard Precautions and Transmission Based Precautions, dated 06/25/21, revealed staff will utilize the proper personal protective equipment upon entering the room of a resident on droplet precautions including using gloves, a mask, and eye protection before contracting the resident or environment. Staff will discard the personal protective equipment before leaving the room. 4. Review of the facility COVID-19-line listing dated 07/18/22 revealed Resident #29, #44, #51, residing on the 300 Hall west unit had tested positive for COVID -19 and were currently in droplet isolation. Observation on 07/18/22 at 12:31 P.M. revealed Resident #29 had a sign on his door indicating his room was a red zone and was in droplet isolation. The sign indicated staff should don a fresh N-95 facemask, a face shield, a gown, and gloves before entering. STNA #14 was wearing an N-95 face mask and goggles and she donned a gown and took a lunch tray into Resident #29's room and came back into the hallway. STNA #14 then took a lunch tray into Resident #44 (Resident #29's roommate.) STNA #14 removed the gown in the hallway and discarded it in a trash receptacle in the hallway. STNA #14 then donned a new gown. Observation on 07/18/22 at 12:35 P.M. revealed STNA #14 then took a lunch tray into Resident #66's room who was COVID-19 negative. STNA #14 removed the gown in the hallway and discarded it in a trash receptacle in the hallway. STNA #14 then donned a new gown. Observation on 07/18/22 at 12:40 P.M. revealed Resident #51 had a sign on his door indicating his room was a red zone and he was in droplet isolation. STNA #14 took a lunch tray into Resident #51's room and came out into the hallway and discarded her gown. Interview on 07/18/22 at 12:41 P.M. with STNA #14 confirmed she did not perform hand hygiene between resident rooms, she did not don a new N-95 mask or cover her N-95 mask with a surgical facemask when going from COVID positive rooms in droplet isolation to COVID negative rooms with no isolation precautions. STNA #14 further confirmed she did not don a face shield and she did not sanitize her eye protection goggles after exiting a COVID-19 positive room. STNA #14 confirmed she entered Resident #51's room with her gown hanging loosely over her uniform and she did not properly secure the gown prior to entering a COVID 19 positive room. Review of the facility policy titled Use of Personal Protective Equipment (PPE), dated 03/02/22, revealed in red zone rooms where a resident has a COVID positive diagnosis, full PPE should be worn to include N95 masks, gloves, gown, and eye protection. Staff should discard PPE at the door and eye protection may be cleaned when in exiting between the room patient rooms or new eyewear applied. 5. Review of the census on 07/18/22 and 07/19/22 revealed there were 50 residents on the East and West 400 unit. During observation on 07/18/22 at 9:32 A.M. and 07/19/22 at 12:10 P.M. on Unit 400, Licensed Practical Nurse, (LPN) #90 did not wear a surgical or N95 mask. All the resident room doors on the East and West 400 unit had a sign indicating they were on transmission-based droplet precautions. During interview on 07/18/22 at 1:30 P.M., LPN #90 verified she worked on the 400 unit. She stated she was not wearing a surgical or N95 mask and all the residents were on transmission-based droplet precautions. She stated she did not have to wear a mask because she had a doctor approved medical excuse. This deficiency substantiates Complaint Numbers OH 968 and OH 101.

Based on record review, observation, interview and policy review, the facility failed to appropriately secure and store resident medications which had the potential to affect all residents on the 400 West Hall (#2, #3, #5, #12, #17, #18, #19, #20, #32, #35, #36, #40, #41, #43, #46, #47, #52, #53, #54, #61, #63, #75, #81, #87, #88.) The facility also failed to discard expired medication which had the potential to affect all residents receiving medications from the 3 East medication cart (#9, #10, #13, #21, #22, #24, #25, #28, #30, #57, #64, #65, #68, #69, #72, #85, #341, #342) The census was 93. Findings include: 1. Observation on [DATE] at 9:07 A.M. revealed the 400 Hall West medication cart was unlocked and unattended and there was a plastic cup sitting on top the cart containing two tablets. Interview on [DATE] at 9:13 A.M. with Licensed Practical Nurse (LPN) #130 confirmed she had left the cart unlocked and unattended and the medications sitting on top of the cart included an iron tablet and a vitamin D tablet she had prepared for administration for Resident #40. Further observation on [DATE] at 9:14 A.M. with LPN #130 confirmed the top drawer of the cart included two cups of unidentified loose pills. Interview on [DATE] at 9:14 A.M. with LPN #130 confirmed the first cup included medications she had prepared for administration to Resident #19 ([MEDICATION(S)], [MEDICATION(S)], ibuprofen, omeprazole, [MEDICATION(S)], [MEDICATION(S)]. LPN #130 confirmed the second cup included medications she had prepared for administration to Resident #41 ([MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)].) LPN #130 confirmed the medication cart should be locked when unattended and medications should be not be left unattended. Medications should not be prepoured but should be administered at the time of preparation. Review of the facility policy titled Storage of Medications, dated [DATE], revealed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. All medications dispensed by the pharmacy are stored in the pharmacy container with the pharmacy label. 2. Review of the medical record for Resident #24 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [DATE] monthly physician orders for Resident #24 revealed an order dated [DATE] for [MEDICATION(S)] nasal spray to be given routinely at bedtime for allergies. Review of the [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on [DATE] at 9:40 A.M. of the 3 East medication cart with Licensed Practical Nurse (LPN) #105 revealed the cart contained an open bottle of [MEDICATION(S)] for Resident #24 with a manufacturer's expiration date of ,d+[DATE]. Interview on [DATE] at 9:40 A.M. with LPN #105 confirmed the 3 East medication cart contained an open bottle of [MEDICATION(S)] for Resident #24 which had a manufacturer's expiration date of ,d+[DATE]. LPN #105 confirmed the [MEDICATION(S)] was expired and should have been discarded. 3. Observation on [DATE] at 9:41 A.M. with LPN #105 revealed the 3 East medication cart contained an open house stock bottle of vitamin B complex tablets with a manufacturer's expiration date of ,d+[DATE] and an open house stock bottle of liquid Tylenol with a manufacturer's expiration date of ,d+[DATE]. Interview on [DATE] at 9:41 A.M. with LPN #105 confirmed the vitamin B tablets and the liquid Tylenol were expired and should have been discarded. Review of the facility policy titled Storage of Medications, dated [DATE], revealed outdated medications are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. This deficiency substantiates Complaint Number OH 654.

Based on observation, interview, and review of facility meal times, the facility failed to ensure resident meals were delivered timely. This had the potential to affect 91 of 93 residents who received meals from the kitchen. The facility identified two residents (#27 and #44) who did not received food from the kitchen. The facility census was 93. Findings include: Observations made on 07/18/22 from 12:30 P.M. to 1:11 P.M. revealed dietary staff delivered meal carts to the 300-Unit at 12:30 P.M., the 400-East Unit at 12:58 P.M., and The 400-West Unit at 1:11 P.M. Observation on 07/20/22 at 1:42 P.M. revealed Dietary staff delivered the meal cart to 400-West Unit. Interviews on 07/18/22 from 10:32 A.M. to 12:16 P.M. Residents #5 and #18 complained that meals were late. Interview on 07/20/22 at 1:48 P.M. State tested Nurse Aide (STNA) #42 stated when he first started working they made trays in the kitchenette on the unit , but after COVID , it all changed. The kitchen never notified when they make substitutes to the menus and the trays were always late. It happened all the time. During an interview on 07/21/22 at 10:21 A.M. Dietary Manager #42 - stated carts stated meal times included breakfast at 8:00 A.M., lunch at 12:00 noon, and dinner at 5:00 P.M. Dietary Manager #42 stated meal services on 07/20/22 were affected by a call off which threw everything off. Review of document titled Brookside Meal Times no date, revealed breakfast was served at 8:00 A.M., lunch at 12:00 P.M., and dinner at 5:00 P.M.

Based on interview, observation, and record review, the facility failed to ensure residents received food items as printed on the dietary ticket and the facility failed to provide food portions and therapeutic diets as planned by the dietitian. This affected one (Resident #41) of six residents reviewed for dietary services, and this had the potential to affect 91 of 93 residents who received meals from the kitchen. The facility identified two residents (#27 and #44) who did not received food from the kitchen. The facility census was 93. Findings include: 1. Resident #41 admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] disorder [CONDITION(S)] type, paranoid [CONDITION(S)], dementia with behavioral disturbances, Barrett's esophagus without [CONDITION(S)], and impulsiveness. Review of the most recent Minimum Data Set (MDS) assessment, dated 06/30/22 revealed Resident #41 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #41 was frequently incontinent of B&B with no toileting program and independent with Activities of Daily Living (ADL's) with setup assistance as needed. Review of the medical record revealed Resident #41 had physician orders dated 07/01/2022 for regular diet with regular texture and consistency. Review of care plan revised 06/28/22 revealed Resident #41 was at risk for nutrition/hydration complications due to diagnoses of dementia, hypertension, Barrett's esophagus, GERD, and constipation. Resident #41 continuously refused weights and had no weight on file. Interventions included medications as ordered, encouraged to comply with weights, report signs/symptoms of malnutrition/dysphagia, serve diet as ordered, offer alternates as needed, document meal intakes, and dietary consult as needed. Review of dietary lunch ticket dated 07/20/22 revealed Resident #41 was ordered hamburger on bun, ketchup, lettuce, tomato, pickle spear, tater tots, cucumber and onion salad, chilled peaches, assorted yogurt cup, and coffee or hot tea. Observation on 07/20/22 at 1:48 P.M. State tested Nurse Aide (STNA) #42 delivered the lunch tray to Resident #41 . The tray contained a cheeseburger, tater tots, california blend vegetables, a bowl of lettuce, a cup of peaches, a carton of 2 percent milk, and a tumbler of Kool-Aid. During an interview on 07/19/2022 at 8:42 A.M. Resident #41 stated he wanted yogurt with every meal but only received it sometimes. Resident #41 stated he did not always receive all of the items listed on the meal tickets. During an interview on 07/20/22 at 1:48 P.M. STNA #42 verified the contents of Resident #41's lunch tray did not match the dietary ticket. STNA #42 verified there was no cucumber salad and no yogurt on the tray. STNA #42 stated the kitchen never notified when they made substitutes to the menu. During an interview on 07/20/22 at 1:50 P.M. Resident # 41 verified there was no yogurt, cucumber salad, coffee, pickle, or tomato on the lunch tray. 2. Review of physician ordered diets listed by the facility, there were 21 Consistent Carbohydrate Diets, (CCD), six Therapeutic Lifestyle Changes diets, (TLC), and two Renal Diets. There were six residents identified with puree consistency. Review of breakfast menu spreadsheet dated 07/19/22 revealed the protein portion of the regular diet meal consisted of one biscuit and three ounces of sausage gravy. The CCD, TLC and Renal diets consisted of one fourth cup of scrambled egg. During observation on 07/19/22 at 6:55 A.M., Cook #126 served 300 East unit residents on diets of CCD, TLC, and renal diets, one biscuit and three ounces of sausage gravy. During interview on 07/19/22 at 6:55 A.M., Cook #126 verified he served the residents ordered on CCD, TLC and renal diets one biscuit and three ounces of sausage gravy. He revealed he did not know what foods to serve the CCD, TLC and renal diets at breakfast, the lunch or the supper meals because he did not have the Registered Dietitian planned spreadsheet to review and follow. He stated he did not prepared foods according to the Registered Dietitian diet plans as he did not know there was a spreadsheet and had not been trained to use a spreadsheet for food preparation and serving foods. He stated he did not know who to contact to clarify the correct foods to prepare for specific diets. During observation on 07/19/22 at 6:55 A.M., Cook #126 served pureed biscuits and gravy with a #20 scoop and the spreadsheet listed a #16 scoop. The puree cereal was served with a #16 scoop and the spreadsheet listed a #6 scoop. The puree potato was served with a #16 scoop and the spreadsheet listed a #8 scoop. During interview on 07/19/22 at 7:00 A.M., Cook #126 verified he was unaware of how much food to serve and the scoop sizes for the puree diets as he did not have the spreadsheet planned by the Registered Dietitian. Review of policy titled Therapeutic Diets , dated September 2017, revealed all diets are prescribed by the attending physician and diets are prepared in accordance with guidelines of the Diet Manual. This deficiency substantiates Complaint Number OH 259.

Based on record review, observation and interview, the facility failed to label and date stored foods, discard expired foods and maintain kitchen sanitation. This had the potential to affect 91 residents who received food from the kitchen. The facility census was 93. Findings include: Observation on [DATE] at 8:45 A.M. revealed following in the main kitchen areas: 1. No hand soap or drying towels at the employee hand sink 2. Three-hole dish washing temperature log completed to [DATE] 3. Opened cheese slices undated 4. Opened Medpass supplement undated 5. Open taco sauce dated [DATE] 6. Nine covered plated salads undated 7. Three sealed meat packages in a pan of water in a sink During interview on [DATE] at 8:45 A.M., Assistant Cook #49 and Diet Manager, (DM) #42 verified the undated and expired foods. Assistant Cook #49 verified the meat should have been thawed running water. Cook #126 verified there should have been soap and towels at the employee hand sink. Observation on [DATE] at 6:55 A.M. revealed following in the main kitchen areas: 1. The floor drains near the cooking equipment had visible buildup of food debris. 2. The steam table well water had a greasy appearance and food debris in the water 3. The three compartment sink third well drain would not hold sanitizing water. 4. White granulated substance in a closed clear container unlabeled and undated near hand sink. 5. Dishwashing log missing temperatures and concentration of chemical for a low temperature dish machine for dates [DATE] through [DATE]. 6. In dishwashing room, a trash container with lid broken exposing trash. During interview on [DATE] at 6:55 A.M., Cook #126 verified the floor drain and the steam table had not been clean for over a week. Cook #126 was unable to identify the white granulated substance and verified it should be labeled and dated. DM #42 verified the three compartment sink third drain needed repaired During observation on [DATE] at 11:55 A.M. revealed a sign attached to the front exterior of the refrigerator dated [DATE], No staff food in this refrigerator. Any Resident food must be labeled and dated. Any items not labeled will be pitched daily. There was no temperature log to record refrigerator temperatures. The following was observed in the 300 Unit Resident refrigerator: 1. Three large bags of multiple containers of food unlabeled and undated. 2. Two milk cartons dated expired date of [DATE] 3. A loaf of open bread undated 4. A gallon closed pitched of red liquid undated and unlabeled 5. Six four ounce closed containers of thick substance unlabeled and undated During interview on [DATE] at 11:55 P.M , Licensed Practical Nurse # 110 verified the refrigerator was for resident use only, but employee often use it for food storage. She verified the unlabeled, expired and undated foods. During observation on [DATE] at 11:55 A.M. revealed a sign attached to the front exterior of the refrigerator dated [DATE], No staff food in this refrigerator. Any Resident food must be labeled and dated. Any items not labeled will be pitched daily. There was no temperature log to record refrigerator temperatures. The following sanitation violations were observed in the 400 Unit Resident refrigerator: 1. Five closed containers of unidentifiable foods which were also undated. 2. Six bags of multiple containers of food unlabeled and undated. 3. Open [NAME] creamer dated [DATE]. 4. The refrigerator interior had dried food debris on the bottom shelf. 5. Six containers of unopened supplement dated [DATE]. During interview on [DATE] at 11:55 A.M. Licensed Practical Nurse (LPN) # 90 verified the refrigerator was for resident use only but employee often use it for food storage. LPN #90 verified the supplement dated was an expiration date, and the refrigerator needed cleaned. Review of the facility policy, Food Preparation, dated [DATE], revealed foods are to be labeled and dated, equipment sanitized after every use and staff must practice proper hand washing techniques.

Based on record review, interview and policy review, the facility failed to ensure the physician was notified of abnormal resident blood sugars as ordered. This affected one (Resident #82) of 16 residents with orders for routine blood sugar monitoring. The census was 93. Findings include: Review of the medical record for Resident #82 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) for Resident #82 dated 06/12/22 revealed resident was cognitively intact and required limited assistance of one staff with activities of daily living. Review of physician exam note for Resident #82 dated 07/20/22 revealed resident was being treated in the facility for chronic medical problems which included diabetes and a history of diabetic foot ulcers. The physician's plan for diabetic management included to monitor blood sugars and administer insulin as ordered. Review of July 2022 monthly physician's orders for Resident #82 revealed an order dated 01/20/22 for [MEDICATION(S)] [MEDICATION(S)] per sliding scale: If blood sugar was under 80, call physician. If blood sugar was 100 - 199 = 0 Units, 200 - 249 = 3 Units; 250 - 299 = 6 Units; 300 - 349 = 9 Units; 350 - 400 = 12 Units, over 400 = 15 Units, and call physician. Review of the June 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M., blood sugar was 78 at 12:00 P.M. on 06/01/22, blood sugar was 64 on 6/10/22 at 6:00 A.M., blood sugar was 66 on 06/11/22 at 6:00 A.M., and blood sugar was 75 on 06/30/22 at 12:00 P.M. Review of the nurse progress notes for Resident #82 dated 06/01/22, 06/10/22, 06/11/22, and 06/30/22 revealed the notes did not include documentation of physician notification of blood sugars below 80 for resident. During interview on 07/21/22 at 10:32 A.M., Licensed Practical Nurse (LPN) #77 confirmed Resident #82 had a physician's order to notify the physician if resident's blood sugar was under 80. LPN #77 further confirmed Resident #82's record did not include documentation of physician notification of resident's blood sugar being under 80 on 06/01/22, 06/10/22, 06/11/22, and 06/30/22. Review of the facility policy titled Notification of Changes in Condition, dated 05/30/19, revealed the facility would notify the physician of changes in clinical condition which included poor glycemic control. Documentation of physician notification should be made in the resident's medical record. This deficiency substantiates Complaint Number OH 854.

Based on record review and staff interview, the facility failed to complete and transmit a significant change Minimum Data Set (MDS) assessment for a resident that was admitted to hospice services. This affected one (Resident #57) of 19 residents reviewed for assessments. The facility census was 93. Findings include: Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #57's quarterly Minimum Data Set (MDS) assessment, dated 05/22/22, revealed the resident was severely cognitively impaired and was totally dependent with bed mobility, dressing, and toileting. Resident #57 required extensive assistance with eating, and personal hygiene and transfers did not occur during the MDS timeframe. Resident #57 was on hospice services. Review of Resident #57's MDS assessments revealed Resident #57 did not have a significant change MDS upon admission to hospice services on 04/21/22. Review of Resident #57's hospice certification and plan of care dated 04/21/22 revealed Resident #57 was admitted to hospice services on 04/21/22 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During interview on 07/20/22 at 8:12 A.M., the Administrator verified Resident #57 was admitted to hospice services on 04/21/22 and Resident #57 did not have a significant change assessment upon her admission to hospice services. Review of the facility policy titled MDS Responsibilities, dated 06/03/21, revealed the interdisciplinary assessment will be completed for all residents utilizing the guidelines provided in the resident assessment instrument (RAI).

Based on record review, observation, and interview, the facility failed to ensure the resident assessment was accurate regarding the presence of gastrostomy tubes (g-tubes.) This affected one (Resident #33) of three residents in the facility with g-tubes. The census was 93. Findings include: Review of the medical record for Resident #33 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) for Resident #33 dated 04/21/22 revealed resident was cognitively intact and required assistance of staff with activities of daily living. Review of section K of the MDS for Resident #33 revealed resident was coded as negative for the presence of a feeding tube. Review of admission nursing assessment for Resident #33 dated 04/14/22 revealed resident had a g-tube in his abdomen present upon admission. Observation on 07/18/22 10:51 A.M. of Resident #33 revealed resident had a g-tube inserted in his abdomen. During interview on 07/18/22 at 10:51 A.M., Resident #33 confirmed resident was admitted to the facility with the g-tube and the facility did not provide food or fluids through the tube. During interview on 07/21/22 at 10:27 A.M., Licensed Practical Nurse (LPN) #77 confirmed Resident #33 had a g-tube which was present upon admission. LPN #77 confirmed the MDS for Resident #33 dated 04/21/22 was not accurate regarding the presence of a g-tube.

Based on record review, observation, interview and policy review, the facility failed to ensure dependent residents were provided with adequate toenail care. This affected one (Resident #33) of 19 residents sampled. The census was 93. Findings include: Review of the medical record for Resident #33 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) for Resident #33 dated 04/21/22 revealed resident was cognitively intact and required assistance of staff with personal hygiene. Review of admission physician orders for Resident #33 dated 04/14/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the care plan for Resident #33 dated 05/04/22 revealed resident had an activities of daily living (ADL) self-care performance deficit. Interventions included staff would provide assistance with grooming, dressing, bathing, locomotion, and ambulation. Observation on 07/20/22 at 8:35 A.M. of Resident #33 with Licensed Practical Nurse (LPN) #110 revealed resident's toenails were thick and mycotic and extended approximately one-half inch from the end of the toe. Interview on 07/20/22 at 8:35 A.M. with Resident #33 confirmed he had not had his toenails cut since his admission to the facility in April 2022 and they were getting too long. Interview on 07/20/22 at 8:36 A.M. with LPN #110 confirmed Resident #33's toenails were thick and mycotic and extended approximately one-half inch from the end of the toe. LPN #110 confirmed Resident #33 should have his toenails trimmed by a podiatrist because they were very thick. Interview on 07/21/22 at 8:02 A.M. with the Administrator confirmed Resident #33 had not been seen by a podiatrist during his stay at the facility. Review of the facility policy titled Nail and Hair Hygiene Services dated 02/15/22 revealed residents would have routine nail hygiene as part of the bath or shower and the nurse would inspect the nails and obtain a podiatrist consult if indicated. This deficiency substantiates Complaint Numbers OH 822 and OH 259.

Based on observation, record review and staff interview, the facility failed to ensure residents smoked safely and in designated smoking areas. This affected one (Resident #39) of 39 residents reviewed for smoking. The facility census was 93. Findings include: Record review revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including metabolic [CONDITION(S)], traumatic subdural hemorrhage with loss of consciousness of unspecified duration initial encounter, unspecified bacterial pneumonia, chronic [CONDITION(S)] C, [CONDITION(S)] disorder, difficulty in walking, other psychoactive substance abuse, acidosis, generalized anxiety disorder and nicotine dependence. Review of Resident #39's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #39 was independent with activities of daily living. Review of Resident #39's smoking care plan dated 05/12/22 revealed Resident #39 used nicotine products and was known to smoke off and in areas that were not designated. Resident #39 was independent with smoking. Interventions included provide safe smoking devices such as smoke aprons, smoke blankets and cigarette extenders and educate the resident to the smoking policy and obtain the resident's signature. Review of Resident #39's smoking assessment dated [DATE] revealed Resident #39 smoked cigarettes. Resident #39 was able to light his own cigarette and had no needs for adaptive equipment. During observation on 07/21/22 at 9:04 A.M., Resident #39 was smoking in the front of the facility next to the signs that stated no smoking. Resident #39 had his surgical mask below his chin while he was smoking a cigarette. During interview on 07/21/22 at 9:04 A.M., Receptionist #67 verified Resident #39 was smoking in a no smoking area with his mask below his chin. Receptionist #67 stated that Resident #39 smokes in the non smoking area without supervision daily despite staff telling him that the area was not a designated smoking area. Review of the facility policy titled Smoking, dated 05/30/19, revealed the facility will promote resident centered care by providing a safe smoking area for residents that request to smoke and are capable of safe smoking either independently or with supervision unless the facility is designated a non smoking facility. Smokers will be permitted to smoke only in designated smoking areas.

Based on record review, observation, interview and policy review, the facility failed to ensure residents were provided with adequate care and management of gastrostomy tubes (g-tubes.) This affected one (Resident #33) of three residents in the facility with g-tubes. The census was 93. Findings include: Review of the medical record for Resident #33 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) for Resident #33 dated 04/21/22 revealed resident was cognitively intact and required assistance of staff with activities of daily living (ADLs.) Review of section K of the MDS for Resident #33 revealed resident was coded as negative for the presence of a feeding tube. Review of admission nursing assessment for Resident #33 dated 04/14/22 revealed resident had a g-tube in his abdomen present upon admission. Review of monthly physician orders for Resident #33 for July 2022 revealed the orders did not include orders for care and management of resident's g-tube. Review of the dietary progress note for Resident #33 dated 07/14/22 revealed the note did not include documentation regarding the presence of g-tube for resident. Observation on 07/18/22 10:51 A.M. of Resident #33 revealed resident had a g-tube inserted in his abdomen. During interview on 07/18/22 at 10:51 A.M., Resident #33 confirmed resident was admitted to the facility with the g-tube and the facility did not provide food or fluids through the tube. During interview on 07/20/22 at 2:25 P.M., Registered Dietitian (RD) #125 confirmed she was not aware Resident #33 had a g-tube and resident's care plan did not include information regarding care and management of a g-tube, and resident did not have orders for care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 07/21/22 at 10:27 A.M., Licensed Practical Nurse (LPN) #77 confirmed Resident #33 had a g-tube which was present upon admission. LPN #77 further confirmed Resident #33 did not have a care plan for care and management of the g-tube and did not have orders for care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility policy titled Enteral Nutrition Guidelines, dated 01/05/22, revealed the facility would obtain physician orders for care and management of g-tubes which included the type of feeding solution (if any), the amount of feeding solution, frequency of feedings, amount and frequency of flushes, and orders to change dressings to tube insertion site.

Based on observation, staff interview, review of facility policy, and review of online resources per the Center for Medicare and Medicaid Services (CMS) and the Centers for Disease Control (CDC), the facility failed to ensure staff wore appropriate eye protection and/or facemasks in resident care areas to potentially prevent the spread of Coronavirus Disease (COVID-19). This had the potential to affect all residents residing in the facility except for the eight residents residing in the COVID-19 unit (#30, #31, #32, #33, #34, #35, #36 and #37). The census was 92. Findings include: 1. Interview on 01/07/22 at 10:57 A.M. with the Director of Nursing (DON) confirmed the facility was experiencing a COVID-19 outbreak and had eight (#30, #31, #32, #33, #34, #35, #36 and #37) residents residing in the facility COVID 19 unit. DON further confirmed the positivity rate for the county in which the facility was situated was high (red) and all staff in all departments should wear eye protection and face masks in the facility. Observation on 01/07/22 at 11:14 A.M. revealed Dietary Aide (DA) #125 was pushing a cart down the resident hallway and was not wearing eye protection. DA #125 had eye protection (goggles) propped up on top of her head. Interview on 01/07/22 at 11:14 A.M. with DA #125 confirmed she was in a resident area and was not wearing eye protection, but had it propped up on top of her head in case she needed it. Observation on 01/07/22 at 1:18 P.M. revealed DA #125 approached the surveyor in a resident area and asked a question. DA #125 had eye protection propped up on top of her head and had her facemask pulled below her chin with her mouth and nose exposed. Interview on 01/07/22 at 1:18 P.M. with DA #125 confirmed she was in a resident area with residents in the vicinity and she had eye protection propped up on top of her head and had her facemask pulled below her chin with her mouth and nose exposed. 2. Observation on 01/07/22 at 11:27 A.M. revealed Licensed Practical Nurse (LPN) #100 was standing behind the nurses' station desk with residents in the vicinity and was not wearing eye protection. Nurses' station was not a separate room with a door and was open to the common area where residents congregated. Interview on 01/07/22 at 11:27 A.M. with LPN #100 confirmed she was not wearing eye protection, and because she was standing behind the nurses' station desk, she did not need wear eye protection. 3. Observation 01/07/22 at 1:50 P.M. revealed DA #150 was sitting at the receptionist desk in the front lobby and there were residents in the vicinity. DA #150 was observed eating and drinking and was not wearing a facemask or eye protection. Further observation revealed after surveyor interviewed DA #150, he took his food and drink and exited the resident area and went to the employee break room to take his break. Interview on 01/07/22 at 1:50 P.M. with DA #150 confirmed he was not wearing a facemask or eye protection and he was eating and drinking in area accessible to residents and where residents were congregating. DA #150 confirmed he was newly hired and was in orientation. Interview on 01/07/22 at 1:51 P.M. with Receptionist #175 confirmed DA #150 was a new employee and was taking his break at the front desk and was not wearing a face mask or eye protection. Receptionist #175 further confirmed employees had a break area where they could go when needed to remove their personal protective equipment (PPE) to eat and drink. Review of facility policy titled Criteria for COVID-19 Isolation dated 06/22/21 revealed eye protection is not required in the resident units if the county positivity rate was less than 5 percent (%). Review of the facility policy titled Personal Protective Equipment (PPE) General Statement dated 2004 revealed employees will utilize PPE when conditions are such that an adverse exposure may occur. Training and education are provided for general PPE use upon hire, annually and with updates or significant changes. Review of an online resource from CMS titled COVID-19 Nursing Home data at https://data.cms.gov/covid-19/covid-19-nursing-home-data revealed the county in which the facility was situated was experiencing a high spread (red) of COVID 19 with a positivity rate of 15.9 % for the week ending in 12/27/21. Review of an online resource per the CDC titled Infection Control Guidance for Healthcare Professionals about Coronavirus (COVID-19) at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html revealed the use of eye protection in healthcare facilities is recommended in areas with moderate to substantial community transmission and staff should don eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area. This deficiency substantiates Complaint Number OH 856.

Based on record review and resident and staff interview, the facility failed to arrange and coordinate resident visits with outside medical provider as ordered by the attending physician. This affected one (#56) of three residents reviewed for coordination of care. The census was 92. Findings include: Review of the medical record for Resident #56 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) for Resident #56 dated 10/21/21 revealed resident was mildly cognitively impaired and required extensive assistance of two staff with activities of daily living (ADL's). Review of the care plan for Resident #56 dated 06/25/21 revealed the resident had altered cardiovascular status with a goal for resident to be free of cardiac complications. Interventions included the following: administer medications per medical provider's orders, observe for side effects and effectiveness, report abnormal findings to medical provider, resident / resident representative, educate resident / resident representative on importance of maintaining a normal weight for height, value of regular exercise, limiting salt, adverse effects of tobacco and alcohol, importance of medication and diet compliance, monitor vital signs and report findings to medical provider, obtain lab work and diagnostic studies as ordered. Review of the January 2022 monthly physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Review nurse progress note for Resident #56 dated 10/04/21 revealed notes contained no documentation regarding the appointment with Cardiologist #225 scheduled for 10/04/21. Review of nurse progress note for Resident #56 dated 10/17/21 resident needed appointment to be made for Cardiologist #225 because transport canceled for the appointment scheduled on 10/04/21. Further review of the note revealed the appointment needed to be rescheduled. Review of nurse progress notes for Resident #56 dated 10/17/21 through 01/07/22 revealed notes contained no documentation regarding rescheduling of appointment for resident with Cardiologist #224. Review of medical record for Resident #56 revealed it did not include office visit notes for an appointment with Cardiologist #225. Interview on 01/07/22 at 12:51 P.M. with Resident #56 confirmed he has not had an appointment with Cardiologist #225. Interview on 01/08/22 at 5:00 P.M. with the Director of Nursing (DON) confirmed the facility had no evidence the appointment for Resident #56 with Cardiologist #225 originally scheduled for 10/04/21 was ever rescheduled or that an appointment took place. This deficiency substantiates Complaint Number OH 528.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure the security of resident medications which had the potential to affect the 16 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) residents with medications stored in the 300 Hall East cart. The facility also failed to properly store [MEDICATION(S)] sulfate tablets which had the potential to affect four (#10, 12, #13 and #16) residents with orders for [MEDICATION(S)] sulfate. The facility failed to properly store [MEDICATION(S)] which had the potential to affect one (#7) resident with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to discard outdated allergy medication which had the potential to affect two (#12, #16) residents with orders for [MEDICATION(S)]. The census was 74. Findings include: 1. Observation on 07/02/21 at 8:50 A.M. revealed the 300 Hall East medication cart was unattended by a nurse and there was a set of keys sitting on top of the cart. Interview on 07/02/21 at 8:55 A.M. with Licensed Practical Nurse (LPN) #110 confirmed she had left the cart unattended while she was inside Resident #14's room with the door shut providing care. LPN #110 further confirmed the keys on top of the cart were the keys to the cart and included the keys to controlled substance storage in the cart. LPN #110 confirmed the medication cart and controlled substance keys should be kept on her person at all times. The facility confirmed there are 16 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) residents with medications stored in the 300 Hall East cart that could potentially be affected. Review of the facility policy titled Storage of Medications dated August 2020 revealed he medication supply should be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Review of the facility policy titled Medication Administration dated 12/14/17 revealed the narcotic key is to be carried by nurse administering medications. 2. Observation on 07/02/21 at 9:05 A.M. revealed the 300 Hall East medication cart contained a cup of six green tablets with no labeling or identifying information. Interview on 07/02/12 at 9:05 A.M. with LPN #110 confirmed the 300 Hall East medication cart contained a cup of six green tablets with no labeling or identifying information and she believed the green tablets were [MEDICATION(S)] sulfate. The facility confirmed there are four (#10, 12, #13 and #16) residents with orders for [MEDICATION(S)] sulfate that could potentially be affected. Review of the facility policy titled Medication Administration dated 12/14/17 nurses should not administer medication if the label is not legible or missing. 3. Observation on 07/02/21 at 9:06 A.M. revealed the 300 Hall East medication cart contained a large house stock bottle of [MEDICATION(S)] tablets with no lid. Interview on 07/02/21 at 9:06 A.M. with LPN #110 confirmed the house stock bottle of [MEDICATION(S)] being stored in the 300 Hall East medication cart did not have a lid on it and she was not sure where the lid was or for how long it had been missing. The facility confirmed there is one (#7) resident with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled Storage of Medications dated August 2020 revealed medications and biological's are stored safely, securely, and properly. 4. Review of the medical record for Resident #12 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2021 monthly physician orders for Resident #12 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of medication administration on 07/02/21 at 9:17 A.M. to Resident #12 per LPN #110 revealed the 300 Hall East medication cart contained one bottle of house stock [MEDICATION(S)] 180 mg tablets and had a manufacturer's expiration date of June 2021. Further observation revealed LPN #110 discarded the expired medication. Interview on 07/02/21 at 9:17 A.M. with LPN #110 confirmed 300 Hall East medication cart contained a bottle of house stock [MEDICATION(S)] 180 mg tablets with a manufacturer's expiration date of June 2021. The facility confirmed there are two (#12, #16) residents with orders for [MEDICATION(S)] that could potentially be affected. Review of the facility policy titled Storage of Medications dated August 2020 revealed all expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation, staff interview, and review of facility policy, the facility failed to appropriately dispose of used sharps (needles). This had the potential to affect five (#1, #3, #5, #11 and #15) residents identified as cognitively impaired and independently mobile residing on the 300 Hall. The census was 74. Findings include: Observation on 07/02/21 at 8:50 A.M. revealed the 300 Hall East medication cart was unattended by a nurse and there was a clear plastic cup on top of the cart containing two used lancets used for blood glucose testing. Further observation revealed there was a sharps container which was half full attached to the medication cart. Interview on 07/02/21 at 8:55 A.M. with Licensed Practical Nurse (LPN) #110 confirmed she had left the cart unattended while she was inside Resident #14's room with the door shut providing care. LPN #110 further confirmed the lancets on top of the cart had been used for blood glucose testing earlier in the shift and should have been disposed immediately after use in a sharps container. The facility identified five (#1, #3, #5, #11 and #15) residents who are cognitively impaired and independently mobile residing on the 300 Hall who could potentially access the unattended and used lancet devices. Review of the facility policy titled Blood Glucose Point of Care Testing dated 05/29/19 lancets used for testing should be disposed of into a sharps container immediately after testing. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review, staff and nurse practitioner (NP) interview, provider interview, review of facility policy, and review of online medication resource from Medscape, the facility failed to ensure a resident was free from unnecessary medications when the staff administered insulin without appropriate blood sugar monitoring as ordered by the provider. This affected one (#14) of five residents in the facility who receive insulin. The census was 74. Findings include: Review of the medical record for Resident #14 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment for Resident #14 dated 04/09/21 revealed the resident was cognitively intact and required extensive assistance of one to two staff with activities of daily living (ADL's). Review of the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the June 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. from 06/02/21 to 06/29/21. Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Interview on 07/02/21 at 4:54 P.M. with NP #160 confirmed she gave a verbal order on 06/01/21 for Resident #14 to receive 10 units of Novolog insulin in the morning and to check blood sugar prior to administration and hold the dose if blood sugar was less than 100. NP #160 confirmed she did not give an order to hold if systolic blood pressure is less than 100. Interview on 07/02/21 at 5:30 P.M. with the Administrator confirmed the nurses had not checked Resident #14's blood sugar prior to insulin administration at 6:00 A.M. from 06/02/21 to 06/29/21. The Administrator confirmed Resident #14's order dated 06/02/21 was written incorrectly and should of been to hold the insulin is blood sugar is less than 100 and not systolic blood pressure. Review of the facility policy titled Blood Glucose Point of Care Testing dated 05/29/19 revealed both hyper and [CONDITION(S)] are treatable and reversible with early recognition and treatment and blood glucose point of care or bedside testing should be performed by a licensed nurse as ordered by a physician. Review of medication information per Medscape at https://reference.medscape.com/drug/[MEDICATION(S)]-[MEDICATION(S)]-insulin-[MEDICATION(S)]- 3#5 revealed to increase frequency of glucose monitoring with changes to insulin dosage, coadministered glucose lowering medications, meal pattern, or physical activity and any changes to a patient's insulin regimen should be made under close medical supervision with increased frequency of blood glucose monitoring. This deficiency substantiates Complaint Number OH 396.

Based on medical record review, staff interviews, resident interview, and personnel file review, the facility failed to ensure required safety measures were in place to prevent a resident from sustaining injuries from a fall. This resulted in actual harm when State tested Nursing Assistant (STNA) #93 did not use the required two-person assistance when turning a resident in bed. The resident was rolled out of bed, onto the floor, hitting his face on a trash can, and subsequently sustained a L3 (lower back) compression [MEDICAL CONDITION] spine. This affected one resident (#30) of three reviewed for falls. The facility census was 61. Findings include: Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the fall risk assessment completed on admission revealed the resident was at high-risk for falls. Review of Resident #30's plan of care dated 11/23/18, revealed the resident was at risk for falls due to impaired balance and weakness. Interventions included anticipate and meets needs, assuring call light was within reach, ensure resident was wearing appropriate footwear, keep needed items in reach, and to use a sling Hoyer lift for transfers. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact. The resident was noted to be a two-person physical assist with bed mobility, and transfers. Resident #30 was dependent on a wheelchair for mobility. Review of Resident #30's progress notes dated 12/28/18 at 7:03 A.M., revealed Resident #30 sustained a fall when he was turned to his side during incontinence care. The resident rolled off the side of the bed, stuck the left side of his face near his ear on the trash can. Resident #30 was assisted back to bed with four staff members, he had no complaints of pain and full range of motion with all extremities. Redness and [MEDICAL CONDITION] were noted from hitting the trashcan and ice was applied. The physician, Director of Nursing (DON), and the resident's son was made aware. Review of progress note dated 12/28/18 at 10:45 A.M., revealed Resident #30's lab results received from a morning blood draw noted a critically low hemoglobin (red blood cell count) of 7.9 grams per deciliter. Normal levels for a male are 13.5 to 17.5 grams per deciliter. An order was received to send the resident to the local emergency room (ER). Review of progress note dated 12/28/18 at 3:53 P.M., revealed the hospital rechecked Resident #30's hemoglobin and it was normal for him, and no intervention were necessary. An X-ray of the resident's hip and spine, and computed tomography (CT) of his head, were completed due to his fall that occurred at the facility earlier. The resident had bruising to the face and complained of right hip pain. The X-ray results revealed a compression [MEDICAL CONDITION] lumbar spine vertebrae area. Review of local hospital After Visit Summary and X-ray results dated 12/28/18 revealed Resident #30's discharge [DIAGNOSES REDACTED]. The X-ray noted the resident fell out of bed this morning at the nursing home with findings including compression fracture at L3. Review of the facility's fall investigation dated 12/28/18 revealed Resident #30 rolled out of bed, striking the left side of his face on a trash can, while reaching for something on the bed side table during care. Ice was applied to the left side of the resident's face. STNA #93's written statement revealed he turned the resident to his side and while taking off his brief the resident reached for something on the table and rolled off the bed. Review of progress note dated 01/13/19 at 8:31 A.M., revealed STNA #93 went to the nurse and said Resident #30 slid from his wheelchair and he eased him to the floor. Upon entering the room, the resident was noted to be laying flat on his back with legs straight out and arms across his chest. STNA #93 stated when he got Resident #30 up with the stand-up lift (Hoyer) when he unhooked him he started sliding from the wheelchair, he grabbed him, and eased him to the floor. The resident denied pain. The physician, DON, and the resident's son was notified. Review of the facility's second fall investigation for Resident #30 dated 01/13/19 revealed STNA #93's written statement noted he got Resident #30 up, by himself, in the sit-to-stand lift, put straps under his arms, buckled him around the belly and raised him up, he changed his brief, then when lowering him back down to his chair, he unhooked the strap, and Resident #30 was too far on the edge of the seat and started sliding. STNA #93 noted he grabbed his upper torso and eased him to the ground. Observation and interview with Resident #30 on 01/16/19 at 3:45 P.M., revealed the resident was being transferred from his wheelchair to his bed by two staff members using a Hoyer lift. Resident #30 was observed with a bruise noted to his left cheek. Resident #30 stated the bruising on his left cheek was due to an incident with STNA #93 a couple weeks ago. The resident revealed STNA #93 was providing incontinence care and wanted him to roll over, the STNA pushed him a little bit to turn him to his left side, and he just kept going, right off the bed, hitting his face on a trash can as he was going down. Resident #30 revealed the STNA was providing care by himself and there were always supposed to be two staff members present to change him and get him up. Resident #30 stated there was no fall matt on the floor at that time and he tried to catch himself, however could not. He stated the same STNA (#93) who had rolled him out of bed on 12/28/18, also hooked him up to the stand-lift on 01/13/19 and forgot to buckle him up and he started sliding out on to the floor. STNA #93 grabbed him and lowered him to the floor. Resident #30 stated STNA #93 was the only staff member who would try to move him and get him up with no help. Interview on 01/17/19 at 2:42 P.M., with STNA #99 revealed she had worked with Resident #30 frequently. STNA #99 stated Resident #30 had always been required two-person assistance with all care activities. She revealed she was not providing care for the resident on 12/28/18, however was told a STNA was changing him and pushed him right out of bed. STNA #99 revealed Resident #30 was a big guy and did not know why the STNA would attempt to change him alone. Telephone interview on 01/17/19 at 3:21 P.M., with STNA #93 revealed he was new to the facility and was still in his orientation period. He stated he went into Resident #30's room to provide incontinence care on 12/28/18. He revealed he turned Resident #30 to his side, away from him, by himself, and was holding on to his hip for support when the resident reached for his side table and fell out of the bed. STNA #93 stated he tried to stop him from falling, however he couldn't stop 270 pounds. STNA #93 stated it wasn't until after the incident when staff informed him the resident was supposed to be two-person assist with care. Interview on 01/22/19 at 9:33 A.M., with Therapy Program Manager (TM) #110 revealed Resident #30 had always been either a stand-lift or Hoyer lift with two-person, maximum assistance required, since admission. TM #110 stated both stand-lift and Hoyer lifts require two persons. TM #110 revealed he was a big guy and weak. Review of STNA #93's personnel file revealed his orientation began on 12/19/18. The orientation checklist revealed no evidence he had been checked off regarding competency skills for Mechanical Lift Transfer, Range of Motion, Transfers, or Ambulation. Review of STNA #93's employee memorandum signed 01/07/19, revealed STNA #93 was provided a one on one in-service on turning a resident to ensure you turn the resident towards you, and if they were a two person assist to ensure there were two people providing the care. Review of STNA #93's employee coaching form, level one, signed 01/14/19 revealed STNA #93 was coached on using any mechanical lift required two people, either another STNA or a Nurse, and to never transfer a two person assist resident by yourself. This deficiency substantiates Complaint Number OH 987.

Based on closed medical record review, review of hospital records, staff and emergency medical technician (EMT) interviews, review of the paramedic incident report review, and review of the blood glucose monitoring system user's guide, the facility failed to ensure one resident, identified as having a Full Code status, was appropriately monitored for a change in condition and received cardiopulmonary resuscitation (CPR) immediately upon [MEDICAL CONDITION], without a pulse, respirations, or blood pressure. This resulted in Immediate Jeopardy when Resident #3 was not monitored once she became unresponsive with deteriorating vital signs and as a result did not receive CPR until emergency medical services (EMS) arrived at the facility and found the resident in [MEDICAL CONDITION]. This affected one (#3) of three residents reviewed for death. The facility identified 47 current residents who were designated as having a Full Code status. On [DATE] at 4:37 P.M., Regional Nurse Consultants (RNCs) #75 and #76 were notified Immediate Jeopardy began on [DATE] at 7:10 P.M. when Resident #3 was assessed at the request of the family. Resident #3 had an oxygen saturation at 72 percent (%) and respirations were eight to 10 per minute. Oxygen was applied and at 7:20 P.M., nine-one-one (911) was called at the family's request. The residents' medical status was not monitored and Resident #3 was in [MEDICAL CONDITION] when the paramedics arrived at 7:25 P.M. Resident #3 was pronounced dead at the facility at 7:53 P.M. Immediate Jeopardy was removed on [DATE] at 3:30 P.M. when the facility implemented the following corrective actions: · On [DATE] at 10:00 A.M., the Director of Nursing (DON) began educating all facility Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) on advanced directives and monitoring for changes in clinical condition. All education was completed on [DATE] at 3:30 P.M. by RNC #75 and #76, after the surveyor informed the facility that staff were working who had not been educated, including LPN #93 who was directly involved in the incident. · On [DATE] a 100% audit was completed on advanced directives of residents by RNC #76 and Social Service Coordinator (SSC) #78, after EMT Lieutenant #50 brought forth his concerns with the advanced directives not being correct. No issues were noted at the time of the audit. · Review of the medical records for Residents #4 and #5 who expired in the facility revealed no CPR concerns were identified. · Interviews were conducted on [DATE] between 6:42 P.M. and 6:52 P.M. and on [DATE] between 5:28 P.M. and 5:38 P.M. of RN #201, LPN's #94, #97, #230 and #234 and STNA's #62 and #69 revealed all were knowledgeable on advanced directives and monitoring for a change in condition. · The DON or designee will monitor advanced directives on new admissions and or residents with a change in code status five times a week for 90 days and discuss during clinical review Monday through Friday. Audit results will be reviewed with the quality assurance committee monthly for three months. Facility will also review all new admission records the following business day after admission during clinical review Monday through Friday, amd this will be ongoing. Although the Immediate Jeopardy was removed, the facility remains out of compliance at a Severity Level 2 (No actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of monitoring their corrective action plan to ensure on-going compliance. Findings include: Closed medical record review revealed Resident #3 was admitted to the facility on [DATE] at 7:30 P.M. with [DIAGNOSES REDACTED]. Review of the 48-hour plan of care effective [DATE] at 4:11 P.M. revealed Resident #3 had a confused mental status, was disoriented times three, and non-verbal. Resident #3 received a tube feeding through a gastric tube and was totally dependent upon staff with all activities of daily living. Resident #3 received [MEDICATION NAME]and did not have any routine blood sugar monitoring. The residents' behavior was documented as combative and severely agitated. Review of the hospital discharge instructions revealed Resident #3 was admitted to the hospital from [DATE] to [DATE] and diagnosed with [REDACTED]. Resident #3 had a history of [REDACTED]. Resident #3 was an insulin dependent brittle diabetic and was prescribed [MEDICATION NAME], eight units twice daily for diabetes. Blood sugar results in the past 24 hours while hospitalized , prior to admission to the facility, included: 400 mg/dL on [DATE] at 9:25 A.M.; 453 mg/dL on [DATE] at 11:06 A.M.; 245 mg/dL on [DATE] at 12:49 P.M.; 32 mg/dL on [DATE] at 4:27 P.M.; 29 mg/dL on [DATE] at 4:31 P.M.; 77 mg/dL on [DATE] at 4:48 P.M.; 123 mg/dL on [DATE] at 5:05 P.M.; 194 mg/dL on [DATE] at 7:48 P.M.; and 188 mg/dL on [DATE] at 6:47 A.M. Advanced directives were documented as pre-existing Do Not Resuscitate (DNR), notify physician for order. Review of the admission physician orders [REDACTED].#3 was prescribed nothing by mouth, 240 milliliters (ml) of Glucerna (1.2 calories per ml) tube feeding five times a day until [MEDICATION NAME] HN arrived, and [MEDICATION NAME] insulin, eight units twice daily at 6:00 A.M. and 9:00 P.M. There were no orders for blood glucose monitoring. DNR Comfort Care (DNRCC) was written on the physician order [REDACTED]. Review of the Medication Administration Record [REDACTED].M. nor on [DATE] at 6:00 A.M or 9:00 P.M. [MEDICATION NAME], eight units was administered at 9:00 P.M. on [DATE] at which time Resident #3's blood sugar was documented as HI (greater than 600 mg/dL). Review of the nursing progress note dated [DATE] at 11:54 P.M. revealed Resident #3 was resistive to all care, combative, kicking, and screaming. Blood sugar was tested and results were HI. Medical Doctor (MD) #125 (the on-call physician) was notified and a one-time order for eight units of [MEDICATION NAME] was obtained as the [MEDICATION NAME]hadn't been delivered from the pharmacy yet. There was no further monitoring of blood sugars to ensure effectiveness of the insulin given. Review of the nursing progress note dated [DATE] at 4:00 P.M. revealed Resident #3 was assessed at 3:45 P.M. upon request of the family due to unusual sedation. The resident's blood sugar was obtained and registered HI. MD #130 was notified and ordered 10 units of [MEDICATION NAME]now, recheck blood sugar in two hours and call physician with results. Additionally, MD #130 ordered to administer one bag of normal saline at 100 ml per hour via intravenous line, fingerstick blood sugar every six hours and cover with Humalog insulin sliding scale. The bolus tube feeding was ordered to be held until the fingerstick blood sugar was back within normal range. Resident #3's fingerstick blood sugar was rechecked at 6:15 P.M. and remained HI. A message was left for MD #130, awaiting a return call. Review of the nursing progress note dated [DATE] at 9:15 P.M. revealed at 6:45 P.M. report was received from the day shift nurse regarding current medical condition. The day shift nurse reported Resident #3's family informed facility staff that Resident #3 was a Full Code. Awaiting call back from physician for continued HI blood sugar results. At 7:00 P.M., Resident #3 was assessed and had a respiration rate of 12 breaths per minute, skin was pale and cool, eyes were open, head moved slightly to verbal prompts, and radial pulse rate was 62 beats per minute. Continued to wait for call back from physician. At 7:10 P.M., the family once again requested the nurse assess the resident. The assessment revealed oxygen saturation was 72 % and respiration were eight to 10 per minute. Oxygen was applied at five liters per minute. The family requested Resident #3 be transported to the hospital. Nine-one-one (911) was notified, message was left for the physician, EMT's arrived at the facility and Resident #3's respirations were slow and shallow. Report was given to the EMTs. The EMTs began cardiopulmonary resuscitation (CPR) and pronounced Resident #3 expired at 7:35 P.M., (per paramedic report Resident #3 expired at 7:53 P.M., see below). Review of the paramedic incident report dated [DATE] revealed the unit was dispatched at 7:20 P.M. for an unconscious, unresponsive, not breathing resident. Upon arrival at 7:25 P.M., Resident #3 was unresponsive, without any spontaneous respirations, in [MEDICAL CONDITION], with a blood sugar which registered HI. CPR was initiated by EMS and Resident #3 was pronounced dead at 7:53 P.M. Interview on [DATE] at 1:08 P.M. with LPN #91 revealed on [DATE] around 3:45 P.M., Resident #3's family requested the resident's blood sugar be assessed as it was unusual for the resident to sleep so much and reported the resident typically thrashed about. Resident #3's blood sugar was obtained and registered HI. LPN #91 reported Resident #3 received routine insulin and didn't have any routine blood sugar monitoring ordered so it had not been obtained prior. MD #130 was notified and ordered 10 units of [MEDICATION NAME]to be administered immediately, recheck the blood sugar in two hours and call back with the results, intravenous fluids, and routine fingerstick blood sugars four times daily with sliding insulin coverage in addition to routine insulin twice daily. The fingerstick blood sugar was rechecked around 6:00 P.M. and remained HI. A message was left for MD #130 to call the facility. Interview on [DATE] at 4:13 P.M. with RNC #75 revealed the facility did not have any policies related to diabetic management, just notify the physician of any HI or LO blood sugar results. Interview on [DATE] at 9:11 P.M. with LPN #93 revealed Resident #3's family requested the residents breathing be assessed on [DATE] around 7:10 P.M. at which time oxygen was applied due to low oxygen saturation level. The family reported Resident #3 was a Full Code and requested the resident be transported to the hospital. Nine-one-one was called. Upon EMS arrival to the facility, EMS assessed Resident #3, began CPR, and pronounced the resident dead in the facility. LPN #93 reported Resident #3 was breathing upon arrival of EMS at the facility or CPR would have been initiated. During an interview on [DATE] at 10:50 A.M. with MD #125, he stated he was the on-call physician and was contacted on [DATE] as Resident #3's long acting insulin wasn't available so an order was given to substitute with another long acting insulin. MD #125 reported upon admission, Resident #3 should have had blood sugar monitoring ordered, and assumed the resident was already on routine blood sugar checks. Interview on [DATE] at 12:14 P.M. with EMT Lieutenant #50 revealed services were requested on [DATE] for a resident who was unresponsive and having trouble breathing. Upon arrival to the facility, the LPN #93 was at the far end of the room with the family, nobody was monitoring or doing anything for the resident, and Resident #3 was in [MEDICAL CONDITION] with a blood sugar of HI, over 600 mg/dL. The medical record had a sticker which indicated Resident #3 was a DNR but there was not a signed authorization form in the medical record and LPN #93 reported the resident was a Full Code. EMT Lieutenant #50 reported attempts were made to revive Resident #3 for 30 minutes without success and the resident was pronounced dead at the scene. Interview on [DATE] at 4:50 P.M. with RNC #76 revealed orders were transcribed by a nurse upon admission who does not necessarily review all accompanying hospital records. Interview on [DATE] at 6:02 P.M. with RNC #75 revealed a physician was in the facility at least every two weeks. New admissions were seen within three days. Resident #3 had not been seen by a physician since admission to the facility but would have been seen within the next day or two. The protocol was for all new admission charts to be reviewed by clinical staff in morning meeting and this did not occur for Resident #3. An additional interview on [DATE] at 7:02 P.M. with LPN #93 revealed on [DATE] around 6:30 P.M. report was received from the off going nurse that Resident #3 had started vomiting around lunchtime. Upon assessment, around 7:10 P.M., at the request of the family, Resident #3 was unresponsive, oxygen saturation levels were dropping rapidly, and the family requested the resident be transported to the hospital. Nine-one-one was called, LPN #93 went back into the resident's room to talk to the family, and then out into the hall to direct EMS responders. LPN #93 reported she did not have time to reassess Resident #3 after the oxygen was applied as everything happened so rapidly, but reported Resident #3 was breathing when last assessed. Review of the Blood Glucose Monitoring System User's Guide revealed a test result of HI indicated blood glucose reading was above 600 mg/dL and a physician or healthcare professional should be contacted immediately. This deficiency substantiates Complaint Number OH 802.

Based on closed medical record review, review of hospital records, staff and emergency medical technician (EMT) interviews, review of the paramedic incident report, and review of the blood glucose monitoring system user's guide, the facility failed to ensure one resident received appropriate monitoring and treatment for [REDACTED]. This resulted in Immediate Jeopardy when Resident #3 did not receive ordered insulin for over 24 hours after admission to the facility, blood sugars were not routinely monitored, and Resident #3 became unresponsive and expired at the facility three days after admission. This affected one (#3) of five residents reviewed with insulin dependent diabetes. The facility identified a total of 12 residents prescribed insulin for diabetes. The facility census was 59. On [DATE] at 4:37 P.M., Regional Nurse Consultants (RNCs) #75 and #76 were notified Immediate Jeopardy began on [DATE] at 7:30 P.M. when Resident #3 was admitted to the facility without any plan in place to monitor her JODM. Hospital records revealed Resident #3 was a brittle diabetic, received a tube feeding and nothing by mouth, and blood sugars for the 24 hours prior to admission to the facility ranged from 29 milligrams per deciliter (mg/dL) to 453 mg/dL. [MEDICATION NAME] insulin, eight units subcutaneous (SQ), was prescribed twice daily at 6:00 A.M. and 9:00 P.M. The [MEDICATION NAME]was not available for administration on [DATE] and [DATE]. On [DATE] at 9:00 P.M., Resident #3's blood sugar was obtained and registered HI, above 600 mg/dL. Medical Doctor (MD) #125 (the on-call physician) was contacted and an order was obtained to administer [MEDICATION NAME], eight units SQ for one dose, as the [MEDICATION NAME]still had not been delivered by pharmacy. The facility failed to further monitor Resident #3's blood sugar to ensure the administered treatment was effective. Resident #3's blood sugar was not monitored again until the family requested the nurse assess the resident's blood sugar on [DATE] at 3:45 P.M. as Resident #3 was unusually sedated. The blood sugar results measured HI. MD #130 was notified and 10 units of [MEDICATION NAME]was administered. Additionally, normal saline was administered via an intravenous line, the tube feeding was placed on hold until the blood sugar was within normal range, routine blood sugars were ordered every six hours with Humalog insulin sliding scale prescribed, and blood sugar was to be repeated in two hours with the results telephoned to the physician. Resident #3's blood sugar was rechecked at 6:15 P.M. and remained HI. A message was left for MD #130. On [DATE] at 7:10 P.M., the family once again requested the nurse to assess Resident #3's breathing. Resident #3's oxygen saturation was at 72 percent (%) and respirations were eight to 10 per minute. Oxygen was applied and nine-one-one (911) was called at the family's request. Resident #3 was in [MEDICAL CONDITION] when the paramedics arrived and was pronounced expired at the facility at 7:53 P.M. The Immediate Jeopardy was removed on [DATE] at 3:30 P.M. when the facility implemented the following corrective actions: · On [DATE] at 10:00 A.M., the Director of Nursing (DON) began educating all facility Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) on diabetic care and monitoring. All education was completed on [DATE] at 3:30 P.M. by RNC #75 and #76 after the surveyor informed them staff were working who had not been educated, including LPN #93 who was directly involved with the incident of Resident #3. · On [DATE], the DON, RNC #75 and #76, and Social Service Coordinator (SSC) #78 completed an audit of 100% of diabetic residents to ensure orders were in place for blood sugar monitoring. There were no issues noted at the time of the audit. · Review of the medical records for Residents #10, #32, #48 and #55 who were insulin dependent diabetes revealed no concerns with the availability of insulin and of the monitoring of blood sugars. · Interviews were conducted on [DATE] between 6:42 P.M. and 6:52 P.M. and on [DATE] between 5:28 P.M. and 5:38 P.M. of RN #201, LPN's #94, #97, #230 and #234 and STNA's #62 and #69 revealed all were knowledgeable on diabetic care and monitoring. · The DON or designee will monitor diabetic care of residents including medication orders, availability of medication, blood sugar results and parameters, and physician notification five times a week for 90 days and discuss during clinical review Monday through Friday. Audit results will be reviewed with the Quality Assessment & Assurance Committee monthly for three months. Facility will also review all new admission records the following business day after admission during clinical review Monday through Friday and this will be ongoing. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (No actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of monitoring their corrective action plan to ensure on-going compliance. Findings include: Closed medical record review revealed Resident #3 was admitted to the facility on [DATE] at 7:30 P.M. with [DIAGNOSES REDACTED]. Review of the 48-hour plan of care effective [DATE] at 4:11 P.M. revealed Resident #3 had a confused mental status, was disoriented times three, and non-verbal. Resident #3 received a tube feeding through a gastric tube and was totally dependent upon staff with all activities of daily living. Resident #3 received [MEDICATION NAME]and did not have any routine blood sugar monitoring. The residents' behavior was documented as combative and severely agitated. Review of the hospital discharge instructions revealed Resident #3 was admitted to the hospital from [DATE] to [DATE] and diagnosed with [REDACTED]. Resident #3 had a history of [REDACTED]. Resident #3 was an insulin dependent brittle diabetic and was prescribed [MEDICATION NAME], eight units twice daily for diabetes. Blood sugar results in the past 24 hours while hospitalized , prior to admission to the facility, included: 400 mg/dL on [DATE] at 9:25 A.M.; 453 mg/dL on [DATE] at 11:06 A.M.; 245 mg/dL on [DATE] at 12:49 P.M.; 32 mg/dL on [DATE] at 4:27 P.M.; 29 mg/dL on [DATE] at 4:31 P.M.; 77 mg/dL on [DATE] at 4:48 P.M.; 123 mg/dL on [DATE] at 5:05 P.M.; 194 mg/dL on [DATE] at 7:48 P.M.; and 188 mg/dL on [DATE] at 6:47 A.M. Review of the admission physician orders [REDACTED].#3 was prescribed nothing by mouth, 240 milliliters (ml) of Glucerna (1.2 calories per ml) tube feeding five times a day until the Two Cal HN arrived, and [MEDICATION NAME] insulin, eight units twice daily at 6:00 A.M. and 9:00 P.M. There were no orders for blood glucose monitoring. Review of the Medication Administration Record [REDACTED].M. nor on [DATE] at 6:00 A.M. and at 9:00 P.M. [MEDICATION NAME], eight units was administered at 9:00 P.M. on [DATE] at which time Resident #3's blood sugar was documented as HI (greater than 600 mg/dL). Review of the nursing progress note dated [DATE] at 11:54 P.M. revealed Resident #3 was resistive to all care, combative, kicking, and screaming. Blood sugar was tested and results were HI. MD #125 was notified and a onetime order for eight units of [MEDICATION NAME] was obtained as the [MEDICATION NAME]hadn't been delivered from the pharmacy yet. There was not any further monitoring of blood sugars to ensure effectiveness of the insulin given. Review of the nursing progress note dated [DATE] at 4:00 P.M. revealed Resident #3 was assessed at 3:45 P.M. upon request of the family due to unusual sedation. The resident's blood sugar was obtained and registered HI. MD #130 was notified and ordered 10 units of [MEDICATION NAME]now, recheck blood sugar in two hours and call physician with results. Additionally, MD #130 ordered to administer one bag of normal saline at 100 ml per hour via intravenous line, fingerstick blood sugar every six hours and cover with Humalog insulin sliding scale. The bolus tube feeding was ordered to be held until the fingerstick blood sugar was back within normal range. Resident #3's fingerstick blood sugar was rechecked at 6:15 P.M. and remained HI. A message was left for the physician, awaiting a return call. Review of the nursing progress note dated [DATE] at 9:15 P.M. revealed at 7:00 P.M., Resident #3 was assessed and had a respiration rate of 12 breaths per minute, skin was pale and cool, eyes were open, head moved slightly to verbal prompts, and radial pulse rate was 62 beats per minute. Facility staff continued to wait for a call back from the physician. At 7:10 P.M., the family once again requested the nurse assess Resident #3. The assessment revealed Resident #3's oxygen saturation was 72 % and respirations were eight to 10 per minute. Oxygen was applied at five liters per minute. The family requested Resident #3 be transported to the hospital. Nine-one-one (911) was notified, EMT's arrived at the facility and began cardiopulmonary resuscitation (CPR) and pronounced the resident expired at 7:35 P.M. (Paramedic report documented 7:53 P.M., see below). Review of the paramedic incident report dated [DATE] revealed the unit was dispatched at 7:20 P.M. for an unconscious, unresponsive, not breathing resident. Upon arrival at 7:25 P.M., Resident #3 was unresponsive, without any spontaneous respirations, in [MEDICAL CONDITION], with a blood sugar which registered HI. CPR was initiated without success and Resident #3 was pronounced dead at 7:53 P.M. Interview on [DATE] at 1:08 P.M. with LPN #91 revealed on [DATE] around 3:45 P.M., Resident #3's family requested the resident's blood sugar be assessed as it was unusual for the resident to sleep so much and the family reported the resident typically thrashed about. Resident #3's blood sugar was obtained and registered HI. LPN #91 reported Resident #3 received routine insulin and didn't have any routine blood sugar monitoring ordered so it had not been obtained prior. MD #130 was notified and ordered 10 units of [MEDICATION NAME]to be administered immediately, recheck the blood sugar in two hours and call back with the results, intravenous fluids, and routine fingerstick blood sugars four times daily with sliding insulin coverage in addition to routine insulin twice daily. The fingerstick blood sugar was rechecked around 6:00 P.M. and remained HI. A message was left for the physician to call the facility. Interview on [DATE] at 4:13 P.M. with RNC #75 revealed the facility did not have any policies related to diabetic management, just to notify the physician of any HI or LO blood sugar results. Interview on [DATE] at 9:11 P.M. with LPN #93 revealed Resident #3 was not on routine blood sugar monitoring. LPN #93 obtained a finger stick blood sugar on the resident once, based upon nursing judgement, due to the residents [MEDICATION NAME]being unavailable. LPN #93 reported she assumed routine blood sugar monitoring was not ordered due to Resident #3's combative behavior as it was extremely difficult to even administer the insulin. During an interview on [DATE] at 10:50 A.M. with MD #125 he stated he was the on-call physician and was contacted on [DATE] as Resident #3's long acting insulin wasn't available so an order was given to substitute with another long acting insulin. MD #125 reported upon admission, Resident #3 should have had blood sugar monitoring ordered, and assumed the resident was already on routine blood sugar checks. Interview on [DATE] at 12:14 P.M. with EMT Lieutenant #50 revealed services were requested on [DATE] for a resident who was unresponsive and having trouble breathing. Upon arrival to the facility, LPN #93 was at the far end of the room with the family, nobody was monitoring the resident, and Resident #3 was in [MEDICAL CONDITION] with a blood sugar of HI, over 600 mg/dL. EMT Lieutenant #50 reported attempts were made to revive Resident #3 for 30 minutes without success and the resident was pronounced dead at the scene. Interview on [DATE] at 4:50 P.M. with RNC #76 revealed orders were transcribed by a nurse upon admission who does not necessarily review all accompanying hospital records. Interview on [DATE] at 6:02 P.M. with RNC #75 revealed a physician was in the facility at least every two weeks. New admissions were seen within three days. Resident #3 had not been seen by a physician since admission to the facility but would have been seen within the next day or two. The protocol was for all new admission charts to be reviewed by clinical staff in morning meeting and this did not occur for Resident #3. Review of the Blood Glucose Monitoring System User's Guide revealed a test result of HI indicated blood glucose reading was above 600 mg/dL and a physician or healthcare professional should be contacted immediately. This deficiency substantiates Complaint Number OH 802.

Based on closed medical review, staff and pharmacy interviews, review of pharmacy shipment detail and review of the blood glucose monitoring system user's guide, the facility failed to ensure residents were free of significant medication errors. This resulted in actual harm to Resident #3 who missed three doses of her prescribed insulin and after missing the insulin doses her blood sugar registerd HI. This affected one (#3) of five Residents reviewed for diabetic care and treatment. The census was 59. Findings include: Closed medical record review revealed Resident #3 was admitted to the facility on [DATE] at 7:30 P.M. with [DIAGNOSES REDACTED]. Review of the admission physician orders [REDACTED].#3 was prescribed [MEDICATION NAME]eight units twice daily at 6:00 A.M. and 9:00 P.M. Review of the Medication Administration Record [REDACTED].M. or on [DATE] at 6:00 A.M. and at 9:00 P.M [MEDICATION NAME] eight units was administered at 9:00 P.M. on [DATE] at which time Resident #3's blood sugar was documented as HI. The MAR indicated [REDACTED].M. and 9:00 P.M. and on [DATE] at 6:00 A.M. Resident #3 expired prior to the dose due on [DATE] at 9:00 P.M. Review of the nursing progress note dated [DATE] at 3:00 P.M. revealed pharmacy was contacted due to the [MEDICATION NAME]pen wasn't delivered as stated on the shipment detail form. Pharmacy reported it would be delivered tonight. Requested [MEDICATION NAME]in a vial instead of the pen and pharmacy reported a new physician order [REDACTED].M., the physician was notified and a new order was obtained to change the [MEDICATION NAME] pen to [MEDICATION NAME]eight units subcutaneous (SQ) at 6:00 A.M. and 9:00 P.M. Review of the nursing progress note dated [DATE] at 11:54 P.M. revealed Resident #3 was resistive to all care, combative, kicking, and screaming. Blood sugar was tested and results were HI. Medical Doctor (MD) #125 was notified and a one time order for eight units of [MEDICATION NAME] was obtained as the [MEDICATION NAME]hadn't been delivered from pharmacy yet. Review of the 48-hour plan of care effective [DATE] at 4:11 P.M. revealed Resident #3 had a confused mental status, was disoriented times three, and non-verbal. Resident #3 received a tube feeding through a gastric tube and was totally dependent upon staff with all activities of daily living. Resident #3 received [MEDICATION NAME]and didn't have any routine blood sugar monitoring. Behavior was combative and severely agitated. Review of the nursing progress note dated [DATE] at 4:00 P.M. revealed Resident #3 was assessed at 3:45 P.M. upon request of the family due to unusual sedation. Blood sugar was obtained and registered HI. The physician was notified and ordered 10 units of [MEDICATION NAME]now, recheck blood sugar in two hours and call physician with results, administer one bag of normal saline at 100 ml per hour via intravenous line, fingerstick blood sugar every six hours and cover with Humalog insulin sliding scale, hold [MEDICATION NAME] bolus tube feeding until fingerstick blood sugar was back within normal range. Interview on [DATE] at 1:08 P.M. with LPN #91 reported on [DATE] around 3:45 P.M., Resident #3's family requested the residents blood sugar be assessed as it was unusual for the resident to sleep so much and reported the resident typically thrashed about. Resident #3's blood sugar was obtained and registered HI. LPN #91 reported Resident #3 received routine insulin and didn't have any routine blood sugar monitoring ordered so it had not been obtained prior. The physician was notified and ordered 10 units of [MEDICATION NAME]to be administered immediately, recheck the blood sugar in two hours and call back with the results, intravenous fluids, and routine fingerstick blood sugars four times daily with sliding insulin coverage in addition to routine insulin twice daily. An additional interview with LPN #91 on [DATE] at 9:21 A.M. reported Resident #3 never had any insulin delivered from the pharmacy during admission to the facility. The [MEDICATION NAME]was obtained from another resident but LPN #91 was unable to recall from which resident it was obtained. Interview on [DATE] at 2:47 P.M. with the Director of Nursing (DON) reported the pharmacy never delivered any insulin for Resident #3 and it was not available in the facility emergency box. The DON reported the pharmacy shipment detail dated [DATE] at 2:34 P.M. indicated three [MEDICATION NAME] flextouch pens were delivered but the DON reported interviewing the nurse on duty whom received the shipment and the shipment did not include any insulin for Resident #3. Per the DON, Pharmacy was immediately contacted and informed the insulin was not included in the shipment. This was also documented in Resident #3's nursing progress notes. Review of pharmacy shipment detail dated [DATE] at 2:34 P.M. revealed three [MEDICATION NAME] Flextouch pens were delivered for Resident #3. Interviews on [DATE] at 7:02 P.M. and on [DATE] at 5:42 A.M. with LPN #93 reported Resident #3 never received any insulin from pharmacy while at the facility. A fingerstick blood sugar was obtained on [DATE], based upon nursing judgement, due to the residents [MEDICATION NAME]being unavailable. The physician was notified and ordered a one time dose of eights units of [MEDICATION NAME], which LPN #93 reported was borrowed from Resident #32 for administration to Resident #3. LPN #93 reported it was then discovered Resident #48 received [MEDICATION NAME]and reported she would have LPN #95 fill syringes full of Resident #48's [MEDICATION NAME]for administration to Resident #3. Interview on [DATE] at 2:51 P.M. with pharmacist #710 reported delivery records revealed [MEDICATION NAME] and oral medications were delivered to the facility for Resident #3 on [DATE] and intravenous medications were delivered on [DATE]. Upon informing Pharmacist #710 that the [MEDICATION NAME] was not included in the shipment and pharmacy was notified about this error, Pharmacist #710 reported she did not have access to that information, would email pharmacy to investigate the issue, and inform the surveyor about the results of the investigation. No further information was provided by the Pharmacist as of [DATE]. Review of the Blood Glucose Monitoring System User's Guide revealed a test result of HI indicated blood glucose reading was above 600 mg/dL and a physician or healthcare professional should be contacted immediately. This is an incidental deficiency and was discovered during the course of the investigation of Complaint Number OH 802.

Based on observation, record review, and staff interviews, the facility failed to ensure one resident maintained nutritional status and implemented interventions to prevent the continued weight loss of the resident. This resulted in actual harm when Resident #9 was identified as having a 5.8% significant weight loss in one month with no additional interventions implemented to prevent further weight loss. In addition, the facility failed to serve a physician ordered therapeutic diet to Resident #29. This affected two (#9 and #29) of four residents reviewed for nutrition. The facility census was 59. Findings include: 1. Review of Resident #9's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE], documented the resident had adequate hearing, clear speech, sometimes made self understood, sometimes understood others, and had impaired vision with corrective lenses. The assessment documented the resident as having problems with long and short term memory, moderately impaired cognitive skills for decision making, inattention and disorganized thinking. The assessment further documented the resident required extensive assist of one staff person for bed mobility and transfers, supervision with set-up only for eating and total dependence for toileting. Not receiving hospice service. Review of the nutritional care plan with a revision date of 09/19/17, documented the resident had potential for compromised nutrition/hydration status related to [DIAGNOSES REDACTED]. The long term goal indicated the resident would consume at least 50% of meals, maintain ability to participate in self feeding, and have no significant weight change from the current weight of 90 pounds. Interventions included: providing a diet as ordered, monitoring and recording meal intake, monitoring the need for increased assistance, and monitoring weights monthly and as needed. Review of the December 2017, Clinical Weights and Vitals record revealed the resident's height was 57 inches. The weights for the past six months included: July 2017-89 pounds, August 2017-88 pounds, September 2017- 88 pounds, October 2017-87 pounds, November 2017- 86 pounds and December 2017- 81 pounds. This was a 8.99% weight loss for six months and 5.81% for one month. Review of the dietary progress note dated 12/21/17 at 2:40 P.M., documented the resident's weight was 81 pounds, was a significant weight loss of 5.8% from November 2017 to December 2017. The resident also had a seven pound (8%) weight loss over the last 90 days. The note indicated the resident's intake varied from 0-75%, and staff would provide Mighty Shakes (a nutritional supplement) with meals to provide additional calories and protein. Review of the December 2017 and January 2018 physician's orders [REDACTED]. There was no order for Mighty Shakes or any other nutritional supplement to provide additional calories and protein, as indicated in the dietary progress note. Review of the Meal Intake sheet dated December 2017 revealed the resident experienced a decline in meal intake, eating only 25% to 50% of meals. Review of the Meal Intake sheet with dates of 01/01/18 through 01/05/18 revealed the resident ate only 25-75% of meals with two meals documented as refusal. Review of a nurse's progress note dated 01/04/18 documented, Poor dietary intake. Staff tries to feed her and she is somewhat resistive. Taking small amount of extra fluids. Frequently napping. The note indicated that the physician was informed. There was no documented change in orders related to this communication. Observation of the breakfast meal on 01/04/18 at 8:49 A.M., revealed the resident in the dining room. The resident appeared very thin and frail, and was being fed by State tested Nurse Aide (STNA) #52. There was no nutritional supplement provided with the meal. Interview with STNA #52 on 01/04/18 at 9:20 A.M. revealed the resident ate only 10% of breakfast meal, and reported would report this information to the nurse. STNA #52 verified the resident was not offered a supplement at the meal. Observation of the dinner meal on 01/05/18 at 5:28 P.M., revealed the resident in the dining room with the meal on the table but was not feeding herself. At 5:42 P.M., STNA #39 arrived and began feeding the resident. The resident had two cups of fruit punch provided with the meal, but there was no nutritional supplement provided. Interview with STNA #39 on 01/05/18 at 6:00 P.M., revealed the resident ate 25% of the dinner meal and the resident was not offered additional supplements. Interview with Licensed Practical Nurse (LPN) #44 on 01/05/18 at 8:25 P.M., verified there was no order for a Mighty Shake or any other nutritional supplement or fortified food substance on the resident's physician's orders [REDACTED].#44 reported a doctor's order was required in order to give the resident a fortified food supplement. Interview with the Administrator and corporate Regional Reimbursement Coordinator on 01/05/18 at 9:28 P.M., verified the resident's current weight obtained on 01/05/19 at the surveyor's request was down to 70 pounds. This represented a 13.58% (11 pound) severe weight loss from the previous month's weight of 81 pounds. 2. Review of Resident #29's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE], revealed the resident had moderate difficulty with hearing, clear speech, rarely understood others, and had adequate vision with corrective lenses. The assessment documented the resident had problems with long term memory and severely impaired cognitive skills for daily decision making. The assessment documented the resident had no signs and symptoms of possible swallowing disorder and was not on a therapeutic diet. The assessment further documented the resident was independent with set-up assist only for eating. Review of the nutritional care plan revised 10/31/17, documented the resident had potential for compromised nutrition/hydration status related to a medical [DIAGNOSES REDACTED]. Interventions included providing a diet as ordered. Review of a telephone order dated 12/04/17, revealed an order for [REDACTED]. Observation of the breakfast meal on 01/04/18 at 8:51 A.M., revealed Resident #29 in the dining room. The resident was served a meal which consisted of regular consistency scrambled eggs and oatmeal and fortified chocolate milk which was not thickened to honey consistency. The meal ticket on the resident's tray indicated a diet of puree with honey thickened consistency liquids. Interview on 01/04/18 at 8:51 A.M., with STNA #52 verified the resident's meal ticket provided with the breakfast tray indicated puree consistency with honey thickened liquids. STNA #52 verified the food served to the resident was regular consistency and not pureed and that the chocolate milk served to the resident was not thickened to honey consistency.

Based on closed medical record review, staff interview and review of emergency medication supply policy the facility failed to ensure a hospice resident remained comfortable during the end stages of life. This resulted in actual harm to Former Resident #5 whom did not have medications in place for pain or anxiety, the physician and hospice were not contacted until eight hours after the resident displayed signs of discomfort, medication was not administered for another nine hours which was nine minutes prior to the residents death, and the hospice nurse arrived for continuous care seven hours after the resident had been evaluated for continuous care and nineteen minutes before the resident died . This affected one (Former Resident #5) of three terminally ill residents reviewed for pain management. The facility identified two residents whom received hospice services and 38 Residents on a pain management program. The facility census was 51. Findings include: Closed medical record review revealed Former Resident #5 was admitted to the facility on [DATE] and expired on [DATE] with [DIAGNOSES REDACTED].#5 was rarely/never understood and had moderately impaired cognitive skills for daily decision making, and extensive assistance was required with all activities of daily living. Review of the physician order [REDACTED].#5 was admitted to hospice on [DATE] with a terminal [DIAGNOSES REDACTED]. Former Resident #5 didn't have any current orders for pain or anxiety medication prior to [DATE]. Review of care plans for Former Resident #5 revealed hospice services dated [DATE] with the goal for Former Resident #5 to remain comfortable without any signs or symptoms of discomfort. Interventions included to administer pain medications as needed, to notify the physician of any changes in condition, position for comfort, and monitor vital signs and for signs and symptoms of discomfort. Former Resident #5 was at risk for pain dated [DATE] with the goal that the resident wouldn't display any signs or symptoms of pain. Interventions included to assess effects of pain (e.g., disturbances in sleep, activity, self care, appetite, psychosocial), position for comfort, monitor and record any non-verbal signs of pain (e.g., crying guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal). Former Resident #5 displayed signs and symptoms of depression dated [DATE] as evidenced by isolating self in her room throughout the day. Former Resident #5 didn't have any other care plans related to behaviors or problems with sleep and the medical record did not contain any record of behavior monitoring. Review of the nursing progress note dated [DATE] at 7:43 A.M. revealed Former Resident #5 was in bed yelling help me. Former Resident #5 was placed in a wheelchair and transported to the dining room. On [DATE] at 3:22 P.M. the family expressed concerns about the former resident being lethargic. Vital signs were obtained and revealed blood pressure ,[DATE], pulse 79, and respirations 16. Oxygen saturation was unable to be obtained. Hospice was contacted upon family request. On [DATE] at 3:41 A.M. upon completion of a dressing change to Former Resident #5's left shin area the left foot and ankle were noted to be purple in color and cold to touch with no pedal pulses. Former Resident #5 had also been up all night yelling out baby. When staff asked the former resident if was in pain she would only yell out baby. The notes indicated the staff would inform the oncoming nurse to call hospice for pain medication and something to calm the resident. There weren't any documented progress notes from [DATE] to [DATE]. On [DATE] a summary progress note of day shift included: at 10:00 A.M., Former Resident #5 was noted with signs and symptoms of discomfort. Blood pressure was ,[DATE], pulse 98, respirations 24, and oxygen saturation level 92 percent. Former Resident #5 was repositioned and bilateral lower extremities elevated with effect. At 11:45 A.M., Former Resident #5 again displayed signs and symptoms of discomfort as evidenced by moaning, yelling out, and moving her legs around. Blood pressure was ,[DATE], pulse 109, respirations 24, and oxygen saturations level was unable to be determined. Lung sounds were abnormal in upper lobes. Oxygen was applied at two liters per nasal cannula. The medical doctor and hospice were notified for changes in condition. At 12:15 P.M. new orders were obtained to give [MEDICATION NAME] 0,5 mg and [MEDICATION NAME] 5 mg every four hours as needed. Pharmacy was notified of new orders at 12:30 P.M. and they reported the need for a prescription. The physician was notified at 1:00 P.M. and instructed to fax the prescription to the pharmacy. At 2:30 P.M., the former resident was resting without signs of discomfort. At 3:00 P.M. hospice was in to evaluate for continuous care but reported they didn't have anyone available to provide continuous care at that time. Pharmacy was contacted again at 4:00 P.M. and reported they had just received the prescription from the physician and would send over the medications immediately. The pharmacy was contacted again at 7:00 P.M. as the medication had not been received and the pharmacy reported the medication was available in the emergency box at the facility. Necessary forms were faxed to the pharmacy at 7:30 P.M. to receive authorization to obtain medication from the emergency box. Between 7:30 P.M. and 8:00 P.M., hospice delivered a new bed and oxygen concentrator. At 8:00 P.M., the pharmacy was contacted again and reported they had sent a fax with the authorization code to obtain the medications from the emergency box but the facility had not received the fax. At 8:30 P.M., the pharmacy was contacted again and gave the emergency box authorization code over the phone and the medication was obtained from the emergency box. Former Resident #5 was assessed and blood pressure was ,[DATE], pulse 49, and respirations 10. Oxygen continued to be administered at three liters. At 10:10 P.M. on [DATE], [MEDICATION NAME] 0.25 ml was administered for increased discomfort and signs of pain. The family and hospice nurse were at the bedside and at 10:19 P.M., Former Resident #5 was pronounced dead. Hospice documentation provided by the Director of Nursing (DON) did not include the plan of care for Former Resident #5 or any service records for the month of [DATE]. An interview on [DATE] at 2:15 P.M. with the DON reported both [MEDICATION NAME] and [MEDICATION NAME] were available in the emergency box at the facility. An interview on [DATE] at 3:59 P.M. with Licensed Practical Nurse (LPN) #50 reported around 10:00 A.M. on [DATE] she heard staff reporting Former Resident #5 was in pain at which time the former resident was repositioned and oxygen was applied which was effective. The nurse contacted the physician and hospice to obtain orders for pain medication. Around 11:45 A.M., Former Resident #5 displayed signs of discomfort again as evidenced by moaning. The family was present at bedside, the physician had already given orders for pain medication, and hospice was contacted to come to the facility and assess the former resident. The former residents daughter was informed about the former residents condition and asked if she wanted to contact any other family members, the daughter reported they were all working. Pharmacy was contacted at 12:30 P.M. and the physician was contacted at 1:00 P.M. to ensure the prescription was faxed to the pharmacy. Former Resident #5 was assessed around 2:30 P.M. and was without signs of discomfort. Hospice came in to evaluate the former resident at 3:00 P.M. At 4:00 P.M., the pharmacy was contacted, they reported they had received the prescription, and would send the medication immediately. At 7:00 P.M., the pharmacy was contacted again as the medication was never received and the pharmacy reported the medication was available and should be obtained from the emergency box. Approval was received to obtain the medication from the emergency box around 7:30 P.M. Hospice arrived at the facility with a new mattress and oxygen concentrator around 7:30 P.M. and Former Resident #5 was placed on the new mattress without any signs of discomfort. The pharmacy was again contacted at 8:00 P.M. and again around 8:30 P.M. or 9:00 P.M. for the code to access the emergency box. The medication was administered to Former Resident #5 around 9:30 P.M. at the request of the family. The former resident didn't appear to be in pain at this time. Former Resident #5 had displayed symptoms of anxiety, shortness of breath, and distress which was relieved by the oxygen. An interview on [DATE] at 4:09 P.M. with LPN #51 reported she arrived for duty on [DATE] at 6:30 P.M. at which time LPN's #50 and #53 reported Former Resident #5 was actively dying and they were waiting for [MEDICATION NAME], which the prescription was received by pharmacy around 3:30 P.M., to be delivered. The family felt the former resident was in pain and they were notifying other family members to come to the facility as they were aware the former resident was actively dying. LPN #53 was brand new and probably didn't realize the [MEDICATION NAME] was in the emergency box. LPN #51 reported the hospice nurse arrived at the facility around 10:00 P.M., the [MEDICATION NAME] was administered to Former Resident #5 at 10:10 P.M. at the request of the family although the former resident didn't appear to be in pain at that time. LPN #51 reported limited contact with Former Resident #5 prior to the administration of the [MEDICATION NAME] but reported LPN #53 reported the former resident had been in pain earlier. An interview on [DATE] at 5:22 P.M. with LPN #52 reported Former Resident #5 was up during the night on [DATE] and was calling out baby which wasn't typical behavior and this concerned her as the former resident had lost a baby in the past. LPN #52 reported she informed day shift to contact hospice about getting orders for [MEDICATION NAME] for pain and [MEDICATION NAME] for anxiety. LPN #52 reported she didn't contact hospice, the physician, or the family as it was 3:00 A.M. and she didn't feel the change in the former resident's behavior indicated any distress but felt it would be nice to have medication on hand if needed. An interview on [DATE] at 5:59 P.M. with the DON and the Administrator reported Former Resident #5 was at the facility the entire month of February 2017 until her death in [DATE] and there weren't any documented progress notes available from [DATE] to [DATE] as there wasn't anything pertinent to document. A telephone interview on [DATE] at 8:17 P.M. with LPN #53 on [DATE] at 8:17 P.M. reported when she reported for work on [DATE] the night shift nurse reported Former Resident #5 had been up all night but didn't relay any other information. She reported later in the morning Former Resident #5 began to moan as if she was in pain at which time she was repositioned and oxygen was applied which seemed effective. Hospice was contacted for pain management recommendations, the physician was contacted and an order was obtained for [MEDICATION NAME] and [MEDICATION NAME]. The orders were sent to the pharmacy and LPN #53 called them to ensure they received the order at which time they reported they hadn't received the script. Pharmacy was instructed to call the physician for the prescription and LPN #53 also called the physician. Pharmacy reported they received the prescription around 4:00 P.M. at which time LPN #53 informed them to send the medication immediately. LPN #53 reported the family was at the former resident's bedside but she had limited contact with the family. The family were monitoring the former resident's vital signs, reported the former resident was in pain, and insisted the facility obtain the ordered medication. LPN #53 reported Former Resident #5 appeared comfortable after the oxygen was administered. Hospice came out to the facility at 3:00 P.M. to evaluate for continuous care but reported Former Resident #5 was third on the waiting list and they didn't have anybody available but would send somebody as soon as possible. The nurse arrived shortly before the former resident died . Review of facility Emergency medication Supplies policy last revised [DATE] revealed in order to request authorization from the pharmacy to remove a schedule II - V controlled substance from Facility's Emergency Medication Supply, facility staff should complete Request for Removal of Controlled Substance from Contingency Supply form and fax it to the Pharmacy and/or call the Pharmacy to request authorization. Once the facility staff receives the completed written authorization release from the Pharmacy, the facility staff may access the medically necessary controlled substance from the facility's Emergency Medication Supply. This deficiency substantiates Complaint Number OH 085.