Every finding on record at Buckeye Terrace Rehabilitation and Nursing Center

Based on record review, interview, Self-Reported Incident (SRI) review, and facility policy review the facility failed to timely report allegations of abuse. This affected two residents (#40 and #20) of three residents reviewed for abuse. The census was 64.Findings include:1.Review of Resident #40's medical record revealed the resident was admitted on [DATE] with diagnoses to include major depressed disorder, asthma, post traumatic stress disorder and other psychoactive substance abuse. Review of Resident #40's Minimum Data Set 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition.Review of Resident #40's care plan revealed the resident is verbally aggressive related to intimidating threats towards other residents dated 04/15/26.Review of Resident #40's medical record revealed no behaviors were documented from 06/08/26 through 07/01/26.Review of Resident #20's medical record revealed an admission date of 05/08/25. Diagnoses include acquired absence of left foot, restlessness and agitation, essential (primary) hypertension, depression, opioid dependence and bipolar disorder.Review of Resident #20's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Review of Resident #20 medical record revealed an admission date of 05/08/25. Diagnoses include acquired absence of left foot, restlessness and agitation, essential (primary) hypertension, depression, opioid dependence and bipolar disorder.Review of Resident #20's progress notes revealed there was no documented progress note in the resident's medical record regarding the resident to resident verbal abuse on 06/18/26.Review of the facility's Self-Reported Incident (SRI) #276092 with a reporting date of 06/23/26 revealed Resident #20 and Resident #40 were involved in a verbal argument. There were no witnesses listed on the SRI however the SRI indicated a staff member was suspended pending investigation. The SRI review revealed Resident #40 threatened Resident #20 stating he was going to beat his expletive and kill him The SRI indicated the residents were immediately separated and an investigation was immediately initiated. Interview with CNA #400 on 07/01/26 at 5:52 P.M. confirmed they observed the verbal altercation between Resident #20 and Resident #40 on 06/18/26 but did not report it because both residents were participating in the argument. CNA #400 stated if it got physical they would have reported it, stating the residents were just name calling. CAN #400 cnfirmed they did not hear any threats between the two residents. Interview with the Regional Director #800 07/09/26 at 2:53 P.M. confirmed an observed incident of potential abuse was observed by staff on 06/18/26 and the incident was not reported for five days. Review of the facility's policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property dated 10/27/17 confirms the facility will not tolerate abuse, neglect, exploitation of its residents or the misappropriation of resident property. Further noting, facility staff should immediately report all such allegations to the Administrator/designee and to the Ohio Department of Health in accordance with the procedures in this policy. Initial report timing notes all incident and allegations of abuse, neglect, exploitation, mistreatment of resident, or misappropriation of resident property and all injuries of unknown source must be reported immediately to the Administrator or designee. If the event that caused the allegation involves an allegation of abuse or serious injury, it should be reported to ODH immediately, but not later than two hours after the allegation is made.This deficiency represents non-compliance investigated under Complaint Number 3047481.

Based on review of Board of Executives of Long-Term Services and Support (BELTSS) documentation, and staff interview, the facility governing body failed to ensure the facility's Administrator, who was responsible for the management of the facility, had a current license in the State of Ohio. This had the potential to affect all 64 residents residing in the facility. Findings include: Interview on 06/29/26 at 9:00 A.M. with the Administrator confirmed he was the acting Administrator for the facility.Review on 07/07/26 of the BELTSS system revealed the Administrator's license had an issue date of 04/20/11 and an expiration date of 07/01/26. Interview with the Administrator on 07/07/26 at 9:00 AM., verified he was the Administrator of record for the facility, and he was aware his license was not current. Administrator stated he was having technically difficulties when trying to renew his license.

Based on observation, interview, and policy review, the facility failed to maintain a clean, safe, and sanitary environment. This had the potential to affect all 62 residents living in the facility. The facility census was 62.Findings include:Observations on 03/23/26 beginning at 7:43 A.M. revealed in the first-floor dining room there was a mattress against the wall near the corner cabinet. There were two wheelchairs pushed in front of mattress to hold the mattress up. The wall behind the mattress had holes in it where the wallpaper had been torn off. There was a part of a broken chair under the mattress edge. There was a hole in the wall to the right of the entrance door to the dining room. The hole was a streak which ran along the entire wall with the hole measuring approximately seven inches in length and two inches in width at its largest opening. The first-floor hallways had dirt and brown smears throughout the first floor, and the first floor was littered with small pieces of white paper which looked like notebook paper ends pieces. At two of the nursing stations on the first floor, the trash cans had trash which was spilling over the trash cans. The handrail outside of room [ROOM NUMBER] was pulled away from the wall. Outside of room [ROOM NUMBER], the hallway wall was re-plastered with no paint to cover the plaster. On the right side of the soiled utility room near room [ROOM NUMBER], the wall had separated at the corner. Between room [ROOM NUMBER] and the resident/family lounge, the wall had separated at both lower corners of the doorframe. Near the door to the courtyard, the corner of the doorframe wall had separated. In the hallway between the courtyard door and the ambulance door, there were seven cigarette butts. The elevator had multiple brown spots, the size of quarters and dimes throughout the elevator floor. On the second floor, there were white streaks from the elevator to room [ROOM NUMBER] which looked like paint streaks. The second floor had dirty hallways which had brown spots the size of quarters and dimes and was littered with little pieces of white paper which looked like notebook paper ends throughout.Interview on 03/23/26 at 7:52 A.M. with Certified Nursing Assistant (CNA) #40 stated she did not know what the white streaks on the floor were, but that it looked like streaks of paint.Interview on 03/23/26 at 8:13 A.M. with Maintenance #50 who verified the first-floor dining room which had a mattress against the wall near the corner cabinet. There were two wheelchairs pushed in front of mattress to hold the mattress up. The wall behind the mattress had holes in it where the wallpaper had been torn off. There was a part of a broken chair under the mattress edge. There was a hole in the wall to the right of the door. The hole was a streak which ran along the entire wall with the hole measuring approximately seven inches in length and two inches in width at its largest opening. The first-floor hallways had dirt and brown smears throughout the first floor, and the first floor was littered with small pieces of white paper which looked like notebook paper ends pieces. At two of the nursing stations on the first floor, the trash cans had trash which was spilling over the trash cans. The handrail outside of room [ROOM NUMBER] was pulled away from the wall. Outside of room [ROOM NUMBER], the hallway wall was re-plastered with no paint to cover the plaster. On the right side of the soiled utility room near room [ROOM NUMBER], the wall had separated at the corner. Between room [ROOM NUMBER] and the resident/family lounge, the wall had separated at both lower corners of the doorframe. Near the door to the courtyard, the corner of the doorframe wall had separated. In the hallway between the courtyard door and the ambulance door, there were seven cigarette butts. The elevator had multiple brown spots, the size of quarters and dimes throughout the elevator floor. Maintenance #50 stated on the second floor, he had changed the door to room [ROOM NUMBER] which was 300 hundred pounds, and the white streaks from the elevator to room [ROOM NUMBER] were paint streaks from the door. Maintenance #50 verified the overall appearance of the facility was not a homelike manner.Interview on 03/23/26 at 4:11 P.M. with Housekeeping #60 stated the person who used to strip and wax the floors was no longer at the facility as that position was unnecessary. Housekeeping #60 stated the housekeepers have limited hours and the budget only calls for 30 hours per week which means the housekeeper for the day usually only works four hours a day. Housekeeping #60 stated the housekeeper only cleans the important areas such as the bathrooms, the nurses' stations, the main hallways, and about seven to eight resident rooms depending on the housekeeper. Housekeeping #60 stated the housekeeping staff just do what they can when they have limited hours of work. Housekeeping #60 stated the CNAs help clean if there was a spill and the housekeeper isn't in the facility.Subsequent observation on 03/24/26 at 10:07 A.M. of the handrails missing corners on the East Hall and the [NAME] Hall which was verified by the Administrator at the time of the observation.Review of the facility policy titled Floors last revised 12/2009 revealed floors shall be maintained in a clean, safe, and sanitary manner. All floors shall be mopped/cleaned/vacuumed daily in accordance with their established procedures.Review of the facility policy titled Maintenance Service last revised 12/2009 revealed maintenance service shall be provided in all areas of the building, grounds, and equipment. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The functions of the maintenance personnel include, but are not limited to: maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines, maintaining the building in good repair and free from hazards, and providing routine scheduled maintenance service to all areas.This deficiency represents non-compliance investigated under Master Complaint Number 2806051 and Complaint Number 2799222.

Based on medical record review, staff interview, resident interview, and facility policy review, the facility failed to obtain proper justification for decisions on pharmacy recommendations. This affected four (Residents #7, #9, #23 and #25) of five residents reviewed for unnecessary medications. Also, the facility failed to ensure there was proper monitoring/oversight for the use (unuse) of as needed pain medications. This affected one (Resident #23) of five residents reviewed for unnecessary medications. The census was 60.1. Resident #7 was admitted to the facility on [DATE]. His diagnoses were paranoid schizophrenia, muscle weakness, unspecified fracture of right ischium, neuromuscular dysfunction of bladder, dysphonia, hypertension, lack of coordination, insomnia, and xerosis cutis. Review of his minimum data set (MDS) assessment, dated 11/19/25, revealed he was cognitively intact. Review of Resident #7 Consultant Pharmacist Recommendation to Prescriber report, dated 11/23/25, revealed a recommendation for a gradual dose reduction for Risperdal three milligrams (mg) each night. The nurse practitioner reviewed and disagreed with the recommendation on 11/26/25. There was no justification or explanation documented as to why the recommendation was declined. 2. Resident #23 was admitted to the facility on [DATE]. Her diagnoses were type II diabetes, muscle weakness, morbid obesity, major depressive disorder, hyperlipidemia, schizoaffective disorder, psychosis, insomnia, dementia, hallucinations, delusional disorder, and age-related nuclear cataract. Review of her MDS assessment, dated 09/19/25, revealed she was cognitively intact. Review of Resident #23 Consultant Pharmacist Recommendation to Prescriber report, dated 02/06/25, revealed a recommendation for a gradual dose reduction for melatonin six mg at bed time to three mg at bed time for insomnia. The nurse practitioner reviewed and disagreed with the recommendation on 02/07/26. There was no justification or explanation documented as to why the recommendation was declined. Interview with Regional Director of Clinical Services (RDCS) #189 on 12/11/25 at 1:10 P.M. confirmed there were no documented justifications on the above pharmacy recommendations. She confirmed there should be a written justification as to why the recommendations were declined. 3.Review of the medical record for Resident #25 revealed an admission date of 09/05/2024. Diagnoses included generalized anxiety, mood disorder, insomnia, and schizoaffective disorder Bipolar type. Review of Resident #25's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating an intact cognition for daily decision making abilities. Resident #25 was noted to receive antipsychotic and antidepressants on a daily basis. A gradual dose reduction for the antipsychotics received were noted as being clinically contraindicated by the physician. Review of Resident #25's physician orders revealed a current order for Trazadone Hydrochloride (hcl) (a antidepressant often used to treat insomnia and anxiety) 50 milligrams (mg) to be given daily for insomnia. There was also an order noted for Zoloft (a antidepressant) 50 mg to be taken daily for anxiety disorder. Review of the pharmacy review for January 2025 revealed there was a recommendation for Resident #25's Trazodone 50 mg to be re-evaluated to determine the medicinal need of this therapy. Continued review showed the physician (unable to determine who the physician was) noted on 01/13/2025 that they disagreed with this recommendation but not rational was provided as to why. Review of the pharmacy recommendation for September 2025 revealed the pharmacy recommended that Resident #25's Trazodone 50 mg and Zoloft 100 mg be reduced. Please consider a trial dose reduction at this time. If a gradual dose reduction is contraindicated at this time, please document the clinical rational below. This must address the reason(s) why an attempted dose reduction would likely impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder. Continued reviewed revealed the physician (Unable to determine who the physician was) disagreed with this recommendation on 10/12/2025. 4.Review of the medical record for Resident #9 revealed an admission date of 11/05/2025. Diagnosis included cellulitis of the perineum, muscle weakness, and a non-pressure chronic ulcer of the left ankle. Review of Resident #9's admission MDS 3.0 assessment dated [DATE] revealed a BIMS score of 13 out of 15 indicating an intact cognition for daily decision making abilities. Resident #9 was noted to receive antibiotics on a daily basis. Review of Resident #9's current physician orders revealed a order for Daptomycin-sodium chloride (a pre mixed intravenous antibiotic solution to treat serious bacterial infections) intravenous solution, 700-0.9 milligrams per every 100 milliliter. Use 700 mg intravenously daily for right ankle wound infection for 6 weeks. Review of the pharmacy monthly review and recommendations for November 2025 revealed Resident #9 was currently on Daptomycin 700 mg daily. Please consider monitoring CK levels frequently (weekly) until Daptomycin course is finished. Continued review showed a physician (unable to determine who the physician was) noted to disagree with this recommendation on 11/10/2025. 5. Review of Resident #23 current physician orders revealed the following as needed pain medications ordered: Motrin 800 mg by mouth every eight hours as needed for pain, Norco 5-325 mg every eight hours as needed for pain, and Tylenol 650 mg every four hours as needed for pain. Review of Resident #23 medication administration records (MAR), dated July 2025 to December 2025, revealed Motrin and Norco had not been administered during this entire time frame. Review of Resident #23 pharmacy recommendations, dated July 2025 to November 2025, revealed there were no recommendations and/or documentation from the pharmacy to discuss why these two as needed pain medications were still ordered if they were not being administered. Interview with Director of Nursing (DON) on 12/11/25 at 12:45 P.M. confirmed Resident #23 requests to have Tylenol as her as needed pain medication. She is cognitively intact enough to make this decision, even when the pain level is outside the parameters designed for Tylenol. When asked why Motrin and Norco are still available and on her current physician orders if she chooses not to use them, or why pharmacy didn't have a documented review for either unused medication, she stated she didn't have an answer. Interview with Resident #23 on 12/11/25 at 12:55 P.M. confirmed she prefers to have Tylenol as her pain medications, because she said, the medications I'm on don't work as well as Tylenol does, and they would rather receive Tylenol over the other as needed pain medications she has ordered. She confirmed she does not request to have Motrin or Norco. Review of facility Medication Regimen Reviews policy, dated April 2007, revealed the consultant pharmacist shall review the medication regimen of each resident at least monthly. As a part of the medication regimen review, the consultant pharmacist will determine if the resident is receiving the correct medications as ordered, determine if medications are administered in the correct dosage and form, and be alert to medications with potentially significant medication-related adverse consequences and to actual signs and symptoms that could represent adverse consequences. The consultant pharmacist will provide a written report to physicians for each resident with an identified irregularity. If the physician does not provide a pertinent response, or the consultant pharmacist identifies that no action has been taken, he/she will then contact the medical director, or - if the medical director is the physician of record - the administrator. The consultant pharmacist will provide the director of nursing and medical director with a written, signed, and dated copy of the report, listing irregularities found and recommendations for their solutions.

Based on observation, staff interviews and medical record review, the facility failed to ensure the blood glucose meter was sanitized after use for Resident # 39. This had the potential to affect six residents identified by the facility as receiving blood glucose monitoring from the East Hall nurse. The facility census was 60.Review of Resident # 39's medical record revealed he was admitted on [DATE] with diagnoses that included diabetes mellitus type 1, morbid obesity, hypertension and cholecystitis. Review of Resident # 39's Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact and that he required assistance from staff with toileting, transfers, dressing and personal hygiene. Review of Resident # 39's December 2025 physicians orders revealed the following pertinent orders:-Accu Check (type of blood glucose monitor) in the morning every other day for diabetes.-Disinfect glucometer (blood glucose meter) between each use every shift for infection control.-Disinfect glucometer between each use as needed for infection control.Observation of medication administration on 12/10/2025 at 8:30 A.M. with Registered Nurse (RN) # 207 revealed RN # 207 used a glucometer to obtain a blood sugar reading for Resident # 39; she then wiped the glucometer with an alcohol pad. Further observation revealed RN # 207 then wiped the glucometer with a bleach wipe and placed it in the top drawer of the nurse's cart. Interview on 12/10/25 at 8:35 A.M. with RN # 207 revealed the glucometer used was one of two glucometers shared for her assignment. RN # 207 confirmed she wiped the glucometer with a bleach wipe and did not let the glucometer remain visibly wet for 4 minutes as the instructions for disinfecting stated on the bleach wipes. Review of Safety Data Sheet for PDI Sani-Cloth Bleach Germicidal Disposable Wipes dated 08/12/16, revealed it is recommended for use as a disinfectant on hard, non- porous surfaces and should be used only according to label directions. Review of directions for disinfecting revealed to disinfect; allow surface to remain visibly wet for four minutes. Use additional wipes if needed, to ensure continuous four-minute wet contact time. Let air dry.

Based on medical record review and staff interview, the facility failed to maintain hospice notes and records on-site for all residents. This affected one (Resident #31) of one resident reviewed for hospice services. The census was 60.Resident #31 was admitted to the facility on [DATE]. Her diagnoses were hemiplegia, vitamin D deficiency, osteoarthritis of knee, osteoporosis, hypertension, rheumatic heart disease, and dementia. Review of her minimum data set (MDS) assessment, dated 10/02/25, revealed she had a severe cognitive impairment. Review of Resident #31 hospice records in the facility, found there were no hospice notes in their physical hospice binder for the last three months. Review of Resident #31 hospice notes, dated 09/15/25 to 11/26/25, revealed all these hospice notes and records were delivered to the facility by the hospice agency on 12/10/25. Interview with Regional Director of Clinical Services (RCDS) #189 on 12/11/25 at 1:10 P.M. confirmed they received the hospice notes from the hospice agency for Resident #23 on 12/10/25. She confirmed they should have those documents in the facility.

Based on medical record review and staff interview, the facility failed to provide effective pain management for Resident # 18. This affected one (Resident #18) out of four residents reviewed for pain management. The facility census was 60.Review of Resident # 18's medical record revealed she was admitted on [DATE] with diagnoses that included chronic pain syndrome, anxiety, depression, polyneuropathy and irritable bowel syndrome. Review of Resident # 18's Minimum Data Set (MDS) dated [DATE], revealed resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition and required assistance from staff with showering and bathing. Review of Resident # 18's Physician's Orders dated December 2025, revealed the following orders: -Oxycodone (medication used for moderate to severe pain) HCL Oral tablet 5 mg (milligrams); give one tablet every four hours as needed (PRN) for pain level 1-10. -Gabapentin (medication used for nerve pain) Oral tablet 600 mg; give one tablet three times a day for neuropathy (nerve pain) and- Pain Assessment/Pain monitor every shift for pain management. Review of Resident # 18's Medication Administration Records (MAR) dated August 2025 to December 2025, revealed the PRN Oxycodone for Resident # 18 was given and reported to the nurse as ineffective on 08/06/25- pain level 5, 08/09/25- pain level 5, 08/18/25- pain level 6, 08/19/25- pain level 6, 09/14/25- pain level 7, 11/16/25- pain level 7 and 12/08/25- pain level 7. Review of Resident # 18's progress notes dated August 2025 to December 2025 revealed no documentation regarding follow up interventions or physician notification after episodes of ineffective pain management. Interview on 12/11/2025 at 11:41 A.M. with Director of Nursing (DON) revealed her expectation for nurses to manage residents who report PRN pain medication was ineffective, was that they should offer other non-pharmacological interventions and attempt to get to the root cause of pain, then call physician to get a temporary solution to manage the residents' immediate pain. DON confirmed dates for ineffective pain management on the MAR and no follow up documentation in the medical record.

Based on medical record review, resident interview and staff interviews, the facility failed to ensure timely and adequate vision services were provided to Resident #26. This affected one (Resident #26) out of one resident reviewed for communication and sensory problems. Facility census was 60. Review of Resident # 26's medical record revealed an admission date of 06/07/25 with diagnoses that included but were not limited to left femur fracture, asthma, diabetes type 2 with diabetic neuropathy, chronic diastolic heart failure and need for assistance with personal care. Review of Resident #26's Minimum Data Set (MDS) dated [DATE], revealed a BIMS score of 14 out of 15 indicating intact cognition and that she required assistance from staff with toileting, showering/bathing and dressing.Review of Resident # 26's progress notes dated November 2025 to December 2025, revealed no documentation for offering of ancillary services or residents request to be seen by an optometrist.Observation and interview on 12/10/15 at 12:27 P.M. with Resident # 26 revealed resident wearing glasses with a piece of white tape visible on the middle of the frame on the nose pieces. Further interview with Resident # 26 revealed the eye pads on her glasses had been broken for about a month and she requested to an unidentified nurse that she wanted to see the eye doctor to get her glasses fixed, and she was still waiting for someone to come and help her set up an appointment. Interview on 12/11/25 at 9:15 A.M. with the Director of Nursing (DON) revealed she was unaware that Resident # 26 had broken glasses and had requested to be seen by the optometrist. Further interview revealed there was currently no social service director at the facility and scheduling of appointments were handled by the Human Resources Director (HRD) #225Interview on 12/11/25 at 1:15 P.M. with HRD # 225 revealed the facility did not have evidence of tracking residents to be seen for ancillary services or evidence that residents were offered consents for ancillary services. HRD #225 stated that residents need to have signed consent to be seen and after they consent, they are put on the list and seen by the provider on the next visit or facility will schedule with an outside provider. HRD #225 confirmed that Resident # 26 did not have a consent for ancillary services and has never received or assisted with scheduling ancillary services by the facility.This deficiency represents non-compliance investigated under Complaint Number 2676801.

Based on medical record review and staff interview, the facility failed to a psychiatric consult as ordered. This affected one (Resident #43) of four residents reviewed for behavioral services. The census was 60.Resident #43 was admitted to the facility on [DATE]. His diagnoses were chronic obstructive pulmonary disease, depression, hyperlipidemia, hypertension, alcohol abuse, polyneuropathy, and gastro-esophageal reflux disease (GERD). Review of his minimum data set (MDS) assessment, dated 09/15/25, revealed he was cognitively intact. Review of Resident #43 physician orders, dated 08/13/25, revealed there was a psychiatric evaluation that was ordered to be completed. Review of Resident #43 medical records, dated 08/13/25 to 11/24/25 (date of discharge), revealed there was no completed psychiatric evaluation. Interview with Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) #189 on 12/11/25 at 11:38 A.M. and 1:00 P.M. confirmed there was no completed psychiatric consult for Resident #43. RDCS #189 confirmed the psychiatric consult is a standing order that is put into everyone's orders when they are admitted to the facility; she confirmed not all of them are completed. Both confirmed there was no documentation to support a conversation with Resident #43 or his family regarding the psychiatric consult and whether it should or should not be completed. This deficiency represents non-compliance investigated with complaint number 2660184.

Based on observation, resident and staff interview, and medical record review, the facility failed to ensure interventions for pressure relief were administered to residents with pressure ulcers as ordered. This affected one (#30) of three residents reviewed for pressure ulcers. The census was 58.Findings include: Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute kidney failure, muscle weakness, neuromuscular dysfunction of the bladder, and paraplegia.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 13. The resident was assessed to require self-care assistance.Review of the care plan dated 07/14/25 revealed Resident #30 had multiple pressure ulcers due to immobility as a result of his paraplegia. Interventions included assisting the resident with turning and repositioning and weekly monitoring and treatment of his skin breakdown areas.Review of Resident #30's medical record revealed he had an unstageable pressure ulcer (obscured full-thickness skin and tissue breakdown) on his left heel. Review of Resident #30's current physician orders revealed an order for Prevalon boots (padded boots worn to keep the heels elevated to relieve pressure) to be applied every shift to prevent skin breakdown.Observation of Resident #30 on 09/17/25 at 12:30 P.M. and 3:15 P.M., and on 09/18/25 at 7:45 A.M., 12:11 P.M., and 3:03 P.M. revealed he was not wearing the Prevalon boots. During an interview with Resident #30 on 09/18/25 at 3:05 P.M. he confirmed the facility staff have not placed the boots on him in over one month.During an interview with Unit Manager #105 on 09/18/25 at 3:15 P.M. she confirmed Resident #30 was not wearing Prevalon boots as ordered.This deficiency represents non-compliance investigated under Complaint Number OH00167373 (1317249) and Complaint Number OH00166868 (1317247).

Based on observation, medical record review, and staff interview, the facility failed to maintain the facility in a safe, comfortable, and functional manner. This affected one (#22) of three residents reviewed for environment. The census was 58.Findings Include:Review of Resident #22's medical record revealed admission to the facility on [DATE]. Diagnoses included schizophrenia, seizures, morbid obesity, muscle weakness, personal history of transient ischemic attack, gastro-esophageal reflux disease, chronic pain syndrome, and difficulty walking. Review of Resident #22's Minimum Data Set (MDS) assessment, dated 06/16/25, revealed she had a severe cognitive impairment.Observation on 09/17/25 at 10:15 A.M. and 2:00 P.M., and on 09/18/25 at 6:15 A.M. and 9:30 A.M. revealed a large portion of Resident #22's wall was missing beside the right side of her bed. The approximate size of the hole in the wall (missing paint and drywall) was approximately three feet wide by two feet long. On 09/18/25, the facility began maintenance and replacement of the drywall in Resident #22's room.Interview with Certified Nurse Aide (CNA) #136 on 09/18/25 at 9:30 A.M. confirmed the large hole in Resident #22's wall. CNA #136 confirmed it had been that way for a while, but could not say exactly how long. CNA #136 agreed that based on the size of the hole in the drywall, it was something that took a while to happen, and most likely did not happen in a short period of time. She confirmed staff are to report any damage to resident rooms to the maintenance staff in a timely manner.Interview with Maintenance Staff (MS) #162 and the Administrator on 09/18/25 at approximately 1:00 P.M. confirmed the large hole/missing drywall in Resident #22's room. MS #162 and the Administrator confirmed they had no idea how the wall damage occurred and did not know how long it had been that way. MS #162 and the Administrator stated they were told about it by staff on 09/12/25, and they were working on getting the materials to fix it. They stated it could have been caused by staff running the bed into the wall and/or the resident reaching the hole and picking/pulling the drywall away. This deficiency represents non-compliance investigated under Master Complaint Number 2619510 and Complaint Number OH00167251 (1317248).

Based on medical record review, staff interview, and facility policy review, the facility failed to administer medications to residents in a timely manner as prescribed. This effected three (#54, #30, and #27) of five residents reviewed for medication administration. The facility census was 58.Findings include:1. Record review for Resident #54 revealed the resident was admitted to the facility on [DATE] with the diagnoses including intraspinal abscess and granuloma, syphilis, anxiety, and bipolar disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. The resident was assessed to require self-care assistance. Review of Resident #54's current physician orders revealed an order for trazodone 50 milligrams (mg) to treat insomnia, due at 9:00 P.M. Review of Resident #54's medication administration record between 09/01/25 and 09/18/25 revealed trazodone was administered more than 90 minutes late on 09/02/25, 09/06/25, 09/07/25, 09/08/25, 09/09/25, 09/10/25, 09/16/25, and 09/17/25. 2. Record review for Resident #30 revealed the resident was admitted to the facility on [DATE] with the diagnoses including acute kidney failure, muscle weakness, neuromuscular dysfunction of the bladder, and paraplegia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #30 had intact cognition evidenced by a BIMS score of 13. The resident was assessed to require self-care assistance. Review of Resident #30's current physician orders revealed an order for oxycodone 5 mg to treat pain. Review of Resident #30's MAR between 09/01/25 and 09/18/25 revealed oxycodone was administered more than 90 minutes late on the nights of 09/03/25, 09/04/25, 09/05/25, 09/08/25, 09/09/25, 09/10/25, and 09/13/25. 3. Record review for Resident #27 revealed the resident was admitted to the facility on [DATE] with the diagnoses including left femur fracture, muscle weakness, dysphagia, and chronic kidney disease. The resident had allergies to codeine. Review of the admission MDS assessment dated [DATE] revealed Resident #27 had mildly impaired cognition evidenced by a BIMS score of 13. The resident was assessed to require assistance with self-care activities. Review of Resident #27's current physician orders revealed an order for gabapentin 100 mg scheduled for 9:00 P.M. for pain. Review of Resident #27's MAR between 09/01/25 and 09/18/25 revealed gabapentin was administered more than 90 minutes late on 09/08/25 and 09/11/25. Interview with Registered Nurse (RN) #131 stated medications are often administered late at night because of insufficient nursing staff and confirmed the medications were administered late for Resident #54, Resident #30, and Resident #27 on the dates listed for each resident as mentioned above. Review of a facility policy titled, Administering Medications, dated 12/12, revealed medications must be administered within one hour of the prescribed time. This deficiency represents non-compliance identified under Complaint Number OH00167251 (1317248).

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, hospital visit summary review, hospital discharge summary review, review of drainage guidelines for the PleurX, (a thin, flexible tube that's placed in your chest to drain fluid from your pleural space, to make it easier to breathe) and interview, the facility failed to provide necessary and adequate care for Resident #60 who had a PleurX chest tube. The facility failed to ensure nursing staff were properly educated on the tube and failed to ensure the PleurX chest tube was routinely monitored, assessed (for proper placement), monitored for signs/symptoms of infection, accessed, and drained. This affected one resident (#60) of one resident reviewed for chest tubes. The facility census was 58. Findings Include: Review of the closed medical record for Resident #60 revealed an initial admitted [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), edema, depression, insomnia, malignant neoplasm of female breast, shortness of breath, anemia, psychoactive substance abuse and congestive heart failure. The resident was discharged on [DATE] to an acute care hospital and did not return to the facility. Review of the resident's acute care hospital discharge summary on 01/16/25 revealed the resident had Stage IV breast cancer with malignant effusions, brain, bone and soft tissue metastatic cancer. The resident had a PleurX (chest tube) placement on 11/15/24 per interventional pulmonary. The assessment indicated the PleurX chest tube placement was to manage the resident's respiratory symptoms caused from the malignant effusions. Review of the resident's admission assessment dated [DATE] revealed no assessment addressing the PleurX placement to the resident's chest. Review of the progress note dated 01/16/25 at 8:46 A.M. revealed Resident #60 was admitted from the hospital due to shortness of breath and COPD and was on four liters of oxygen via nasal cannula with a history of breast cancer without both breasts. Further review revealed the PleurX drain was not addressed. The assessment and plan included the resident had malignant tumor of breast with metastases to bone, brain, soft tissue, pleural effusions, status post PleurX placement on 11/15/24 with complications. PleurX capped and pulmonary recommended draining intermittently for shortness of breath. The resident's respirations were documented to be even and unlabored. Review of the Nurse Practitioner's (NP) progress note dated 01/17/25 revealed the resident was status post PleurX placement on 11/15/24 and recommended draining intermittently for shortness of breath. The progress note recommended to continue oxygen at two liters per nasal cannula. The progress note indicated the resident had no shortness of breath at this time. Review of the progress note dated 01/17/25 at 11:29 A.M. revealed the resident left the facility for a funeral at 9:00 A.M. The progress note indicated the resident's respirations were even, unlabored and she continued on oxygen continuously. Review of the resident's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The resident required substantial/maximal (staff) assistance with toileting, showers, dressing, transfers and set-up/supervision with eating. The assessment indicated the resident was frequently incontinent of both bowel and bladder. Review of the resident's plan of care revealed no care plan addressing the use of the PleurX chest drain or the potential for infection. Review of the resident's physician orders revealed no physician orders were in place for the care of the PleurX drain during the resident's stay. Review of the care conference form dated 01/21/25 revealed the form was blank. Review of the progress note dated 01/21/25 at 4:40 P.M., revealed the resident had the PleurX drain, however had no drain kit to implement the use of the PleurX. The progress note indicated the resident was short of breath at this time. Review of a situation background assessment recommendation (SBAR) summary dated 01/21/25 at 7:40 P.M. revealed the resident had shortness of breath at the time of the evaluation. The assessment documented the resident's shortness of breath began that afternoon. The resident's vital signs were as follows, blood pressure 98/72 (hypotensive), temperature 97.6, pulse 108, respirations 18 and oxygen saturation rate was 98% with an unspecified liter of oxygen in place via nasal cannula. Review of the respiratory status evaluation contained in the SBAR revealed the resident had shortness of breath and had progressive or persistent shortness of breath. The summary indicated the resident was sent to the local emergency room (ER). Review of the hospital documentation dated 02/01/25 (a discharge summary) revealed Resident #60 was admitted from the extended care facility (ECF) on 01/21/25 with past medical history including breast cancer with metastasis to the brain, bone, and soft tissue, malignant left pleural effusion with PleurX catheter, COPD, and chronic respiratory failure who presented from the ECF with recurrent pleural effusion. The resident reported since her discharge to the ECF on 01/16/25 her PleurX had not been drained (by staff at the ECF). The resident had acute on chronic hypoxic respiratory failure and baseline used two liters of oxygen, however since the draining of the PleurX (in the hospital) she was only requiring one liter of oxygen. The resident was also found to have bilateral lower lobe pneumonia and completed a course of antibiotics during the hospital stay. Resident #60 was status post left PleurX placement on 11/15/24 followed with pulmonology and recommendations against suctioning or hooking up to chest tube; however, it was recommended to intermittently drain catheter on Monday, Wednesday, and Friday. Resident #60 reported that her PleurX had not been drained at the ECF. Resident #60 was transferred to palliative floor while staff worked on discharging her home with hospice services. On 02/14/25 at 2:33 P.M., an interview with Regional Director of Clinical Services (RDCS) #455 confirmed the resident had no assessment, monitoring, respiratory assessment or physician's orders for the care of the PleurX chest tube. She verified staff had not been trained on the use of the PleurX chest tube. Review of the drainage guidelines for the PleurX Catheter System revealed the catheter was to be inspected daily, change the dressing regularly, at least once a week and as needed when it becomes loose, wet or dirty and follow your healthcare provider's instructions for draining the fluid from your pleural space. The deficient practice was corrected on 01/29/25 when the facility implemented the following corrective actions: On 01/21/25 Resident #60 was sent out to the hospital for shortness of breath. On 01/23/25 the facility implemented a Quality Assurance and Performance Improvement Action Plan. The systemic plan was to complete a whole house skin check on all residents to identify anyone that had a medical device. Those residents identified with an implanted medical device were reviewed to ensure care orders were in place. The Director of Nursing (DON) and Wound Nurse #151 were educated by the RDCS #455 on ensuring orders are being transcribed from the hospital after visit summary for implanted medical devices. All licensed nursing staff were educated by the DON on ensuring orders are written timely from the hospital after visit summary for all implanted medical devices. Audits would be conducted on all newly admitted residents hospital after visit summary to ensure orders are transcribed for all implanted medical devices five times a week for eight weeks by the DON and/or designee. Audits will be conducted on all residents that have an implanted medical device to ensure orders are being performed and completed five times a week for eight weeks by the DON and/or designee. On 01/27/25 Staff education on the PleurX chest tube was provided by the DON. On 01/29/25, a whole house skin check was conducted on all residents to identify anyone that had medical device orders in place for the care of the medical devices per the DON. There were no other residents identified. This deficiency represents non-compliance investigated under Complaint Number OH00161852.

Based on medical record review, observation, staff interview and review of a facility policy, the facility failed to provide a dignified dining experience. This affected one (Resident #61) of two residents reviewed for feeding assistance. The facility census was 62 residents. Findings include: Review of Resident #61's medical record revealed an admitted [DATE] with diagnoses that included dementia, dysphagia (difficulty swallowing), and hemiplegia. Review of Resident #61's Minimum Data Set (MDS) dated [DATE] revealed that Resident #61 required partial to moderate assistance with eating. Review of Resident #61's care plan revised 05/09/19 revealed the resident required nursing assistance and supervision to eat. Resident #61's care plan was silent for an intervention that included standing while feeding the resident. Review of Resident #61's speech therapy dysphagia discharge notes on 05/28/24 were silent for recommendations for nursing to stand while feeding the resident her meals. Observation on 10/22/24 at 12:57 P.M. revealed that State tested Nursing Assistant (STNA) #127 was standing while feeding Resident #61 her lunch meal. STNA #127 was observed holding the back of Resident #61's head while he fed her. Observation on 10/23/24 at 12:39 P.M. revealed that STNA #127 fed Resident #61 her lunch meal while standing over her. Interview on 10/22/24 at 1:07 P.M. with STNA #127 confirmed that he was standing while feeding Resident #61. Review of Assistance with Meals policy revised 2017 revealed that residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them with their meals. This deficiency represents non-compliance investigated under Complaint Number OH00158608.

Based on medical record review, resident and staff interview. review of the Electronic Information Dissemination and Collection (EIDC) portal and review of a facility policy, the facility failed to report an incident of alleged sexual abuse to the state survey agency andfailed to implement their abuse policy after an allegation of sexual abuse. This affected one (Resident #23) of three residents reviewed for abuse. The facility census was 62. Findings include: Medical record review revealed Resident #23 was admitted to the facility on [DATE] with a diagnoses of schizophrenia, post traumatic seizures, traumatic brain injury, and depression. Review of Resident #23's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. allegation made on 10/18/24. Interview with Resident #23 on 10/22/24 at 10:20 A.M. revealed on 10/18/24, Resident #38 placed Resident #23's hand on his clothing over his penis. Resident #23 stated that she told Resident #38 no, and he stopped. Resident #23 stated that she felt uncomfortable about it and did not want to be around Resident #38. Resident #23 stated that she told Business Office Manager (BOM) #165, Social Worker #162, and the Administrator about the sexual abuse allegation on 10/18/24. Resident #23 stated that she moved up to the second floor, in a room on a different floor from Resident #38 on 10/21/24. Interview with BOM #165 on 10/23/24 at 11:08 A.M. revealed that she notified Social Woreker #162 and the Administrator about the allegation of sexual abuse reported by Resident #23 on 10/18/24. Interview with the Administrator on 10/23/24 at 11:27 A.M. revealed he interviewed Resident #23 about the allegation on 10/18/24, but he did not recall if he filed a self- reported incident (SRI) with the state survey agency when the allegation was reported. Interview with the the Corporate Nurse on 10/23/24 at 11:29 A.M. confirmed the facility did not file an SRI with the state survey agency for the allegation of sexual abuse on Resident #23 on 10/18/24. Interview with Licensed Practical Nurse (LPN) #142 on 10/23/24 at 3:07 P.M. confirmed that Resident #23 was moved to another floor in a room away from Resident #38 on 10/21/24, three days after the allegation of abuse was made. Interview with State tested Nursing Aide (STNA) #126 on 10/23/24 at 3:08 P.M. confirmed that Resident #23 was moved to another floor in a room away from Resident #38 on 10/21/24, three days after the allegation of abuse was made. Review of the EIDC for online SRI reporting revealed the facility did not have an initial report of the allegation of sexual abuse on 10/18/24. Review of facility policy dated 10/27/17 defines sexual abuse as non consensual sexual contact of any type with a resident. If an allegation of abuse occurs, it should be reported to the Ohio Department of Health immediately, but not later than two hours after the allegation is made. The facility will take action to protect the resident including, but not limited to, preventing access to resident during the investigation. This violation is an incidental finding investigated under Complaint Number OH00158608.

Based on medical record review, resident and staff interview and review of facility policy, the facility failed to implement their abuse policy after an allegation of sexual abuse. This affected one (Resident #23) of three residents reviewed for abuse. The facility census was 62. Findings include: Review of Resident #23's medical record revealed an admitted [DATE] with a diagnosis of schizophrenia, post traumatic seizures, traumatic brain injury, and depression. Review of Resident #23's Minimum Data Set (MDS) assessment on 07/24/24 revealed that Resident #23 had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Review of Resident #23's medical record revealed that the progress notes were silent for an allegation of sexual abuse affecting Resident #23 on 10/18/24. Interview with Resident #23 on 10/22/24 at 10:20 A.M. revealed that on 10/18/24, Resident #38 placed Resident #23's hand on his clothing over his penis. Resident #23 stated that she told Resident #38 no, and he stopped. Resident #23 stated that she felt uncomfortable about it and did not want to be around Resident #38. Resident #23 stated that she told Business Office Manager (BOM) #165, Social Worker #162, and the Administrator about the alleged sexual abuse allegation on 10/18/24. Resident #23 stated that she moved up to the second floor, away from Resident #38 on 10/21/24. Interview with Licensed Practical Nurse (LPN) #142 on 10/23/24 at 3:07 P.M. confirmed that Resident #23 was moved to another floor in a room away from Resident #38 on 10/21/24, three days after the allegation of abuse was made. Interview with State tested Nursing Aide (STNA) #126 on 10/23/24 at 3:08 P.M. confirmed that Resident #23 was moved to another floor in a room away from Resident #38 on 10/21/24, three days after the allegation of abuse was made. Review of facility policy dated 10/27/17 defines sexual abuse as non consensual sexual contact of any type with a resident. Further review of policy revealed that if a third party is accused or suspected of abuse, the facility will take action to protect the resident including, but not limited to, preventing access to resident during the investigation. This deficiency is an incidental finding investigated under Complaint Number OH00158608.

Based on medical record review, resident and staff interviews and policy review, the facility failed to provide appropriate levels of superstition for residents identified as fall risks. This affected one resident (Resident #42) of three residents reviewed for falls. Findings include: Review of the medical record for Resident #42 revealed an admitted [DATE] with diagnoses that included epilepsy, muscle weakness, and post traumatic stress disorder. Review of Resident #42's Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #42 had a Brief Interview for Mental Status of 11, indicative of moderate cognitive impairment, and that Resident #42 needed supervision and/or touch assistance for showering and bathing. Review of Resident #42's care plan initiated 01/13/24 revealed that Resident #42 was at risk of falls due to abnormal posture, impaired gait, muscle weakness, and that he had a decreased awareness of his need for assistance. A care planned intervention is to remove any causes of falls and to educate resident on only taking showers with staff assistance. Review of Resident #42's progress note dated 09/21/24 by Registered Nurse (RN) # 111 revealed that Resident #42 fell on [DATE] in the shower room (he was taking a shower). Resident #42 was assessed for injury and his x-ray was negative for fracture. Review of medical record revealed that follow up nursing assessments for Resident #42 continued for three days with no subsequent injuries or decline in condition and resolved pain. Resident #42's care plan was revised 09/23/24 to include an intervention to remove any causes of falls and to educate resident on only taking showers with staff assistance. Interview on 10/22/24 at 9:47 A.M. with Resident #42 revealed that he fell when an STNA left him alone in the shower room by himself about a month ago. Resident #42 stated that at the time of his fall that his tailbone was sore, but that the pain did not continue. Interview on 10/23/24 at 8:32 A.M. with State tested Nursing Aide (STNA) #129 confirmed that when Resident #42 fell in September 2024, he was alone in the shower room. Interview on 10/23/24 at 1:04 P.M. with RN #111 confirmed that on 09/21/24, Resident #42 fell while he was alone in the shower room. RN #111 stated that she assessed Resident #42, and then that STNA #129 helped her move Resident #42 back into the wheelchair. Family and physician notifications were made. Resident #42 had negative x-ray results, and his pain level was at a five on a scale of one to ten. Resident #42 declined pain medications after the fall on 09/21/24. Review of a facility policy named Falls and Fall Risk Managing dated 2001 revealed that residents should not be unattended in the bathroom until adequate postural stability has been established. This deficiency is an incidental finding investigated under Complaint Number OH00158608.

Based on record review and staff interview, the facility failed to assess pressure ulcers and put treatments in place in a timely manner for Residents #1, #2, and #3. The facility also failed to identify a pressure ulcer Resident #3 developed until it was a Stage III (full-thickness loss of skin, in which adipose (fat) is visible in the ulcer. Slough and/or eschar may be visible) pressure ulcer. This affected three (Resident #1, #2, and #3) out of three residents reviewed for pressure ulcers. The facility census was 59. Findings include: 1. Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses that included anoxic brain damage, chronic obstructive pulmonary disease, metabolic encephalopathy, history of transient ischemic attack, attention deficit hyperactivity disorder, and chronic kidney disease. Review of the nursing admission care plan dated 04/10/24 revealed Resident #3 had a Stage II (partial-thickness skin loss involving the epidermis and dermis) pressure ulcer to sacrum that measured two centimeters (cm) long, one cm wide, and 0.2 cm deep. Review of the Braden scale dated 04/10/24 for predicting pressure sore risk revealed Resident #3 was at high risk. Review of the treatment administration record (TAR) from 04/10/24 to 04/22/24 revealed Resident #3's sacrum was to be cleansed with normal saline, patted dry, covered with barrier cream and a foam dressing every day and as needed. Review of the plan of care dated 04/11/24 revealed Resident #3 had a skin impairment related to a sacrum wound. Interventions included to encourage Resident #3 to float heels as tolerated, encourage to turn and reposition every two hours and as needed, and weekly treatment documentation to include measurement of each skin breakdown's width, lengthy, depth, type of tissue and exudate, and any other notable changes. Review of the wound nurse practitioner (NP) initial consultation note dated 04/15/24 revealed Resident #3 had a Stage III pressure ulcer to left buttock measuring 2.8 cm long, 2.2 cm wide, and 0.2 cm deep. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had a brief interview mental status (BIMS) score of 99 which indicated Resident #3 was unable to complete the interview. The MDS also revealed Resident #3 had a Stage III pressure ulcer upon admission. The wound NP note dated 04/22/24 revealed Resident #3 had a Stage III pressure ulcer to left buttock that measured 0.2 cm long, 0.2 cm wide, and 0.1 cm deep. The TAR revealed triad (a sterile coating that can be used on broken skin, keeping the wound covered and protected from incontinence) paste was applied to wound bed and covered with bordered gauze from 04/24/24 through 05/08/24. The wound NP note dated 04/29/24 revealed Resident #3 had a Stage III pressure ulcer to the left buttock that measured 0.3 cm long, by 0.8 cm wide, by 0.1 cm. in depth. Triad paste was to be applied to the wound and the area was to be left open to air. The treatment was not initiated until 10 days later on 05/09/24. The TAR revealed triad paste was applied to wound bed and left open to air from 05/09/24 through 06/21/24. The wound NP note dated 05/13/24 revealed Resident #3 had a new Stage III pressure ulcer to coccyx that measured 1.2 cm long, 0.7 cm wide, and 0.2 cm deep. The coccyx wound was to have triad paste applied to the wound and left open to air every shift. There was no treatment in place to the coccyx from 05/13/24 until 06/06/24. Review of the TAR for May 2024 revealed no evidence of treatment to coccyx. The TAR revealed a treatment to Resident #3's coccyx of triad paste to wound and wound left open to air was completed from 06/06/24 to 06/12/24. Wound NP note dated 05/20/24 and 05/28/24 revealed Resident #3 had a Stage III pressure ulcer to left buttock and a Stage III pressure ulcer to the coccyx. The Wound NP note dated 06/10/24 revealed Resident #3 had a Stage III pressure ulcer to left buttock. The Stage III pressure to the coccyx was healed. Wound NP note dated 06/17/24 revealed the Stage III pressure ulcer to Resident #3's left buttock was healed. Interview on 07/08/24 at 2:59 P.M. with the Director of Nursing (DON) verified the wound NP note dated 04/29/24 revealed the Stage III pressure ulcer to Resident #3's left buttock was to have triad pasta applied and left open to air and the new treatment was not put in place until 05/09/24. The DON also verified the TAR for May 2024 revealed there was no documentation of treatment to the Stage III pressure ulcer to coccyx identified on 05/13/24. The DON verified the pressure ulcer to Resident #3's coccyx was not identified until it was a Stage III. 2. Review of the medical record revealed Resident #1 was admitted on [DATE] with diagnoses that included acute respiratory failure, cardiac arrest, acute kidney failure, and schizoaffective disorder. The hospital documentation revealed Resident #1 had a unstageable pressure ulcer (Slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) to the coccyx. Review of the admission care plan dated 05/14/24 revealed Resident #1 had an open area to bottom. No measurements or description of the open area was documented. A weekly skin assessment dated [DATE] revealed Resident #1 had a pressure ulcer to coccyx. No measurements or description of the pressure ulcer was documented. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. The MDS revealed Resident #1 did not have any skin impairment. A weekly skin assessment dated [DATE] revealed Resident #1 had a pressure ulcer to coccyx. No measurements or description of the pressure ulcer was documented. A wound NP note dated 05/28/24 revealed Resident #1 had an unstageable pressure ulcer to coccyx that measured 3.4 cm long and 1.1 cm wide. After debridement, the pressure ulcer was 0.2 cm deep. An order was put in place to cleanse the pressure wound with normal saline, pat the wound dry, apply silver alginate and cover with bordered gauze dressing every day. Review of the treatment administration record (TAR) for May 2024 revealed no treatments for the open area to Resident #1's coccyx. A wound NP note dated 06/03/24 revealed Resident #1 had an unstageable pressure to coccyx that measured 3.4 cm long and 1.4 cm wide. A new order was put in place for pressure ulcer to be cleansed with normal saline, Medi honey and calcium alginate applied, and covered with bordered gauze. Review of the TAR revealed the treatment ordered on 06/03/24 was not started until three days later on 06/06/24. A wound NP note dated 06/10/24 revealed Resident #1 had a Stage III pressure ulcer to coccyx that measured 3.1 cm long, and 1.1 cm wide, and 0.4 cm deep. A wound NP note dated 06/17/24 revealed Resident #1 had a Stage III pressure ulcer to coccyx that measured 2.1 cm long, 0.8 cm wide, and 0.4 cm deep. A wound NP note dated 07/01/24 revealed Resident #1 had a Stage III pressure ulcer to coccyx that measured 1.4 cm long, 0.4 cm wide, and 0.1 cm deep. Interview on 07/08/24 at 4:34 P.M. with the Director of Nursing (DON) verified there was no description or measurements of the pressure ulcer to Resident #1's coccyx from 05/14/24 until 05/28/24. The DON also verified no treatments for the pressure ulcer to Resident #1's coccyx was not put in place until 06/06/24. 3. Review of the medical record revealed Resident #2 was admitted on [DATE] with diagnoses that included alcoholic hepatitis, asthma, cirrhosis of the liver, and severe protein-calorie malnutrition. Review of the admission care plan dated 05/04/24 revealed Resident #2 had a pressure ulcer to coccyx. No measurements or description of the pressure ulcer was documented. The weekly skin assessment dated [DATE] revealed Resident #2 had a pressure ulcer to coccyx. No measurements or description of the pressure ulcer was documented. The care plan also revealed Resident #2 had the potential of impairment to skin. Interventions included to encourage Resident #2 to float heels. Review of the TAR revealed the treatment to cleanse Resident #2's pressure ulcer with normal saline, apply triad paste, and leave open to air was started on 05/09/24, three days after identifying the wound to the coccyx. Review of the Medicare five-day MDS assessment dated [DATE] revealed Resident #2 was cognitively intact. Resident #2 had a Stage III pressure ulcer on admission. The wound NP note dated 05/13/24 revealed Resident #2 had a Stage III pressure ulcer to coccyx that measured 1.2 cm long, 0.6 cm wide, and 0.2 cm deep. The Wound NP note dated 05/20/24 revealed Resident #2 had a Stage III pressure ulcer that measured 1.1 cm long, 0.6 cm wide, and 0.2 cm deep. Wound NP note dated 05/28/24 revealed Resident #2 had a Stage III pressure ulcer to coccyx that measured 0.9 cm long, 0.7 cm wide, and 0.2 cm deep. Wound NP note dated 06/03/24 revealed Resident #2 had a Stage III pressure ulcer to coccyx that measured 0.7 cm long, 0.9 cm wide, and undetermined depth. Wound NP note dated 06/10/24 revealed Resident #2 had a Stage III pressure ulcer to coccyx that measured 0.4 cm long, 0.6 cm wide, and undetermined depth. Wound NP note dated 06/17/24 revealed the Stage III pressure ulcer to Resident #2's coccyx was healed. Interview on 07/08/24 at 5:04 P.M. with the DON verified Resident #2 was admitted on [DATE] and a treatment to coccyx was not put in place until 05/09/24. The DON also verified no measurements or description of the wound was documented until 05/13/24 when the pressure ulcer was identified as a Stage III. This deficiency represents non-compliance investigated under Complaint Number OH00154968. This deficiency is an example of continued non-compliance from the complaint survey dated 06/13/24.

Based on record review, observation, and staff interviews, the facility failed to provide nail and skin care for Resident #3, who was dependent on staff for personal hygiene. This affected one (Resident #3) out of three residents reviewed for activities of daily living (ADL). The facility census was 59. Findings include: Review of the medical record revealed Resident #3 was admitted on [DATE]. Diagnoses included anoxic brain damage, chronic obstructive pulmonary disease, metabolic encephalopathy, history of transient ischemic attack, attention deficit hyperactivity disorder, and chronic kidney disease. Review of the plan of care dated 04/11/24 revealed Resident #3 had an ADL self-care performance deficit. Interventions to anticipate needs and explain process. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had a brief interview mental status (BIMS) score of 99 which indicated Resident #3 was unable to complete the interview. Resident #3 was dependent on staff for shower/bathing and personal hygiene. Review of the bathing schedule revealed Resident #3 was scheduled to be bathed on Wednesdays and Fridays on night shift. A shower sheet dated 06/12/24 revealed Resident #3 received a bed bath. Nail care was marked as not done. A shower sheet dated 06/14/24 revealed Resident #3 received a bed bath. Nail care was marked as not done. A shower sheet dated 06/19/24 revealed Resident #3 received a bed bath. Nail care was marked as not done. A weekly skin assessment dated [DATE] revealed Resident #3 had excessive dry flaky skin to bilateral feet. A shower sheet dated 06/21/24 revealed Resident #3 received a bed bath and refused nail care. A shower sheet dated 06/25/24 revealed Resident #3 received a bed bath. Nail care was not marked as being done. A shower sheet dated 06/28/24 was signed but did not reveal what care was provided. A weekly skin assessment dated [DATE] revealed Resident #3 did not have excessive dry skin. Body audit sheets (instead of shower sheets) dated 07/03/24 and 07/05/24 were provided but did not reveal what care was provided. A weekly skin assessment dated [DATE] revealed Resident #3 did not have excessive dry skin. Observation on 07/08/24 at 9:10 A.M. revealed Resident #3 was lying in bed. Resident #3 had long fingernails with a dark substance under the nails. Interview on 07/08/24 at 11:23 A.M. with the Director of Nursing (DON) verified Resident #3 had long fingernails with a dark substance under the nails. The DON removed Resident #3's socks. As Resident #3's socks were removed, large chunks of dry skin were observed falling onto the sheet. The top and bottom of both feet were covered in an excessive amount of dry flaking skin. Observation of Resident #3's left heel revealed a large area of hard, dry skin. The DON stated the wound nurse practitioner would be at the facility on 07/08/24 and would look at Resident #3's heels to see if the hard dry skin was a deep tissue injury. The DON verified there was an excessive amount of dry flaky skin to Resident #3's feet. Interview on 07/08/24 at 3:42 P.M. with Wound Nurse Practitioner #105 revealed they had observed Resident #3's feet and ordered ammonium lactate lotion (to treat dry or scaly skin). Wound Nurse Practitioner #105 stated Resident #3 did not have any wounds or pressure areas to bilateral feet, but Resident #3 did have a lot of dry flaking skin to bilateral feet. This deficiency represents non-compliance investigated under Complaint Number OH00154968.

Based on medical record review, observation, and staff interview, the facility failed to ensure the residents had weekly skin assessments per physician orders, failed to record skin breakdown identified during a bath, and failed to report the skin breakdown to the nurse. This affected one (Resident #57) of three residents reviewed for pressure ulcers. The facility identified seven current residents with pressure ulcers. The facility census was 58. Findings include: Review of the medical record for Resident #57 revealed the resident was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus and neuromuscular dysfunction of bladder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively impaired. Resident #57 was dependent on staff for transfers and toileting. Review of the plan of care dated 12/16/22 revealed Resident #57 was at risk for skin breakdown related to diabetes mellitus type two, impaired mobility, weakness, incontinence, episodes from around the indwelling catheter. Interventions included to apply lotion or moisture barrier cream as needed, encourage to float heels as tolerated, house barrier cream with each incontinence episodes, observe skin for redness or open areas, pressure reducing and relieving mattress, skin assessment as needed, supplements per order, and turn and reposition every two hours as tolerated. Review of the physician order dated 01/08/23 revealed an order for Resident #57 to have weekly skin sweeps. The physician order dated 04/30/23 revealed an order to apply house barrier cream with each incontinent episode. Review of Resident #57's medical record revealed the last recorded weekly skin assessment was completed on 03/04/24. Resident #57's bath sheets dated 05/30/24, 06/04/24, 06/06/24, and 06/11/24, revealed no skin issues for Resident #57. There was a state tested nursing aides (STNA) signature at the bottom of the bath sheet, but there was no nurse signature on the bath sheets where the nurse signature was to be placed. Review of Resident #15's skin risk assessment dated [DATE] revealed Resident #57 was at moderate risk for skin breakdown. Observations on 06/13/24 from 10:20 A.M. through 10:34 A.M. revealed Resident #57 was to receive incontinence care from STNA #200. The Director of Nursing (DON) was in the room for support. There was a reddened open area on the right upper buttocks. STNA #200 confirmed Resident #57 had a skin issue. The DON confirmed Resident #57 had an open area stage two (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) on the right buttocks that measured appropriately 1.5 centimeters (cm) in length by 1.0 cm width and 0.1 cm in depth with a bright beefy pink wound bed. The DON stated she could not remember if Resident #57 was on the facility's current pressure ulcer list or if this was a new pressure ulcer found. Interview on 06/13/24 at 11:44 A.M. with Assistant Director of Nursing (ADON) #121 confirmed the last skin assessment was 03/04/24. ADON #121 confirmed there was no weekly skin assessment for Resident #57. ADON #121 stated the nurses used bath sheets as skin assessments. Interview on 06/13/24 at 2:05 P.M. with STNA #159 stated he worked on 06/11/24 and was the STNA who provided Resident #57 with a bed bath on 06/11/24. STNA #159 stated Resident #57 had a 'scratch' on her upper buttocks but could not remember if it was the left or right side. STNA #159 verified he failed to document the skin issue on Resident #57's bath sheet on 06/11/24 and never reported the skin issue to a nurse. Interview on 06/13/24 at 2:40 P.M. with Corporate Nurse #350 confirmed there was no nurse signature on Resident #57's bath sheets on 05/30/24, 06/04/24, 06/06/24, and 06/11/24. Corporate Nurse #350 verified the nurse should have signed the bath sheets when reviewing the bath sheets. Corporate Nurse #350 verified the STNA should have reported the skin issue to the nurse when he identified it during the bed bath on 06/11/24. This deficiency represents non-compliance investigated under Complaint Number OH00154287.

Based on record review, review of the facility assessment, hospital record review, review of police reports, review of facility policies, and interviews, the facility failed to identify potential risks/hazards for residents with a substance use disorder, develop and implement comprehensive and individualized care plans and provide adequate supervision to prevent unintentional/intentional drug overdoses for residents in the facility. This resulted in Immediate Jeopardy and actual harm/death on [DATE] when Resident #1 overdosed by shooting opioid medications in his peripherally inserted central catheter (PICC) line after he obtained a syringe from the trash bin on the facility medication cart. Resident #1 had a history of intravenous illicit substance abuse prior to admission and had an intravenous line while at the facility. The Immediate Jeopardy and potential for actual harm/death continued on [DATE] when Resident #2 was found unresponsive in his room from a drug overdose. The resident was transferred to the emergency room with altered mental status and unresponsiveness due to an intentional opiate overdose. The toxicology report revealed Resident #2 had overdosed on opiates (prescribed) and Fentanyl (not prescribed). This affected two residents (#1 and #2) of three residents reviewed for substance use disorder. The facility identified 26 residents with a history of substance use disorder. The facility census was 63. On [DATE] at 5:05 P.M., the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Regional Director of Clinical Services (RDCS) #104, and Regional Clinical Director #114 were notified Immediate Jeopardy began on [DATE] when Resident #1, who had been admitted to the facility with a PICC line for intravenous antibiotic and who had been receiving opioid medication daily, was found unresponsive on the bathroom floor due to a drug overdose. The resident subsequently passed away as a result of the overdose. On [DATE], there was a plastic jar with 24 various pills found in Resident #1's nightstand drawer, three used syringes with pink residue, and an unopened syringe. In addition, on [DATE] Resident #2 who had a history of substance abuse disorder was found unresponsive in room from an intentional drug overdose. The resident had obtained medications from a former resident and had stored the medications in his room for several days prior to the incident. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following interventions: On [DATE] at 12:30 P.M. Licensed Practical Nurse (LPN) #100 called emergency medical services (EMS) for possible drug overdose for Resident #1. Police arrived shortly after EMS. On [DATE] at 12:34 P.M., LPN #100 notified Assistant Director of Nursing (ADON) #102 that Resident #1 was being sent out for possible drug overdose. At 12:46 P.M., the LNHA was notified of Resident #1's possible drug overdose. On [DATE] at 3:00 P.M., the facility began their investigation into Resident #1's possible drug overdose. The LNHA spoke to the hospital and obtained an official police report. The LNHA interviewed Resident #67 (roommate of Resident #1) and Resident #29 about any information related to Resident #1's overdose. Resident #67 stated they were not aware of Resident #1 having any visitors. Resident #29 stated Former Resident #3 had drugs delivered in food items brought in from the outside. On [DATE] at 5:30 P.M., LNHA reviewed video footage of the front reception camera from [DATE] at 12:00 A.M. to 2:00 P.M. for any packages being delivered to the facility. This was completed due to information received from an interview with Resident #29. No evidence was observed on camera footage of any packages being delivered. On [DATE] at 2:00 P.M., the DON provided education on the new process changes to five registered nurses (RNs) and twelve LPNS on the following system changes: effective Immediately, all syringes will only be disposed of in a sharp container including all needles syringes and mouth sweeps will be performed on all resident's post medication administration. Any agency nurses would be educated by the DON prior to the start of their shift on the above system changes if needed. On [DATE] at 2:15 P.M., physician orders were written by the DON for all residents to have mouth sweeps after administration of medication. These were to appear on the medication administration record (MAR) for the nurses to sign and validate that this task was performed. On [DATE] at 8:30 A.M., the DON completed writing physician orders for all residents to say, Crush medications if suspected 'cheeking' medications (concealing a medication in the mouth i.e. between the teeth and the cheek, to avoid swallowing it). On [DATE], an audit was initiated by the DON for the disposal of syringes into the appropriate sharp container and not in the medication trash bin on the side of the medication cart. This audit would be completed by the DON/Designee three times per week for two weeks then two times a week for two weeks and then weekly for eight weeks. Results of the audits to be reviewed in monthly QA for further need of monitoring and/or enhancement. On [DATE], an audit was initiated by the DON for mouth sweeps to ensure a mouth sweep was performed post medication administration. The DON/Designee would complete this audit three times a week for two weeks, then twice a week for two weeks, and then weekly for eight weeks. Results would be reviewed in monthly QA for further need of monitoring and or enhancement. On [DATE] and [DATE] the facility reviewed the care plans for all the residents to identify any resident who had a history of substance abuse were identified and to make sure those identified as having a history of substance abuse had an appropriate care plan in place On [DATE] at approximately 5:30 A.M. Resident #2 was noted to be unresponsive by LPN #130. Resident #2's pulse was 55 and oxygen saturation was 66. LPN #130 applied oxygen to Resident #2 per non-rebreather and then called 911. At approximately 5:33 A.M., LPN #130 administered two doses of Narcan (a medication to treat narcotic overdose in an emergency) prior to Emergency Medical Services (EMS) arrival. On [DATE] at approximately 5:40 A.M., Resident #2 was arousing but not yet oriented. Police arrived on the scene and searched Resident #2's room. No medications were found in Resident #2's room. On [DATE] at approximately 5:45 A.M., EMS made the decision to transport Resident #2 to the ED. Resident #2 told the ED staff they he crushed his pain medication that morning and snorted it. On [DATE] at 6:00 A.M., the DON verified with LPN #130 the last time Resident #2 had received a dose of his medication was on [DATE] at 12:00 A.M. and the medication was crushed as physician ordered. On [DATE] at 1:45 P.M., DON drove to the hospital and interviewed Resident #2 about details of the potential drug overdose. Resident #2's statement consisted of the following information: Resident #2 stated that he had gotten the medication from a former resident a while ago. Resident #2 stated he could not remember the name of the former resident. On [DATE] at 3:00 P.M. Facility Department Heads completed a full house sweep of 18 resident's rooms; residents who were on the facility substance use disorder (SUD) program per the contract agreement. No illegal substances were found in this sweep of residents' rooms. These 18 residents had signed a contract allowing staff to conduct room searches because they were identified at high risk. On [DATE] at 3:00 P.M., the facility department heads conducted a room sweep for 24 residents not on the SUD program who gave permission for the room sweep when asked. No illegal substances were found. On [DATE] at 3:00 P.M., an emergency Quality Assessment and Performance Improvement (QAPI) meeting was held with facility department heads and Medical Director #500 to discuss Resident #2's overdose and the facility's plan of correction and steps taken toward an abatement plan. On [DATE], the DON completed education to the facility nurses for policy review of medication storage and for no medication/substance to be kept in the resident's rooms. Five RN's,12 LPNS, and 19 State tested Nursing Assistants (STNAs) were educated on [DATE]. All assigned agency nurses would be educated by the DON prior to the start of their shift on the facility medication storage policy and no medications/substances to be unsecured in resident rooms. On [DATE], the LHNA completed in person education for all 53 residents residing in the facility on this date related to the facility policy for medication storage in the facility and there were to be no medications/substances in resident rooms. On [DATE], the facility initiated random room audits to check for unsecured medications/substances five times a week times for two weeks, then three times a week for two weeks, then times a week for two weeks, and then weekly for six weeks. Results would be reviewed in monthly QA for further need of monitoring and/or enhancement. This audit will be performed by the DON/Designee. On [DATE] at 9:30 A.M., 1:20 P.M. to 1:45 P.M., and 4:00 P.M., onsite surveyor observations revealed the nurses disposed of syringes and needles in the sharp' container. There were no syringes observed in the medication trash bins. On [DATE] at 10:26 A.M. and 2:56 P.M., surveyors noted there were no medications observed in Resident #2's room. On [DATE], surveyor review of Resident #2 and #3's medication administration records (MAR) revealed nursing was completing mouth sweeps after medication administration. On [DATE], surveyor review of the facility's audits for medication sweeps post medication administration, the disposal of syringes into the appropriate sharp container, and checks for unsecured medications/substances revealed no negative findings from the audits completed through this time. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility continued in their process of implementing corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the facility assessment dated [DATE] revealed there were 15 residents with active or current substance use disorders for the first quarter of 2023 and zero behavioral health needs. The assessment reflected the facility managed the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identified, and implemented interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/post-traumatic stress disorder, other psychiatric diagnoses, and intellectual or developmental disabilities. 1. Review of the Resident #1's closed medical record revealed hospital records dated [DATE] noted Resident #1 had history of intravenous drug use with lasted reported use two weeks prior. Resident #1 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis of vertebra, chronic obstructive pulmonary disease, opioid dependence, and anxiety disorder. Review of the plan of care dated [DATE] revealed Resident #1 had a PICC line. Interventions included to change the dressing to PICC site as ordered every seven days, flush both ports every shift and after each administration of antibiotic with 10 milliliters (ml) of normal saline, monitor for signs and symptoms of infection including redness, swelling, temperature, and report any abnormal finding to the physician. Record review revealed there were no interventions initiated to address the resident's history of intravenous drug use. A plan of care dated [DATE] revealed Resident #1 had a substance abuse disorder. No interventions were listed on the plan of care. Review of the five-day Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1's Brief Interview for Mental Status (BIMS) score was 14 which indicated Resident #1 was cognitively intact. The assessment noted Resident #1 was independent with activities of daily living (ADL). Review of Resident #1's medication orders for [DATE] revealed medications included Gabapentin (nerve pain medication) 800 milligram (mg) three times a day, Naloxone (to treat narcotic overdose) liquid one spray to alternating nostrils as needed every two to five minutes until paramedics arrived, and Oxycodone (opiate) 20 mg every four hours as needed for moderate pain. Review of the Medication Administration Record (MAR) for [DATE] revealed Resident #1 received 71 doses of Oxycodone from [DATE] to [DATE]. Resident #1 was administered Oxycodone on [DATE] at 3:00 A.M., 7:47 A.M. and 11:53 A.M. Review of the general progress note dated [DATE] at 12:20 P.M. authored by LPN #100 revealed LPN #100 was called to Resident #1's room by another resident. LPN #100 found Resident #1 on the floor. Resident #1 was lying on his right-side thrashing back and forth. LPN #100 saw Resident #1 had a syringe in his hand. LPN #100 had another nurse obtain Narcan. Resident #1 received Narcan nasally and 911 was called. Resident #1 continued to thrash around, and vitals were not able to be obtained. Resident #1 had a laceration to the left eye that was unable to be assessed due to Resident #1's condition. An ambulance arrived and carried Resident #1 downstairs on a stretcher. Review of the emergency department (ED) notes dated [DATE] revealed Resident #1 was found unresponsive with a syringe in his hand. Upon arrival at the ED, Resident #1 was pulseless and cardiopulmonary resuscitation (CPR) was initiated. Return of spontaneous circulation (ROSC) was achieved twice and Resident #1 was under a total of approximately ten minutes. Cardiac arrest was likely due to drug overdose. Resident #1 had a history of Fentanyl and heroin abuse. Opiate and Oxycodone were detected in Resident #1's drug screen. Review of the police case report dated [DATE] at 12:33 P.M. revealed Resident #1 was found in his bathroom unresponsive. Staff provided the syringe Resident #1 had in his hand. A needle was not attached, and the syringe was empty. The officer searched the immediate area around Resident #1's bed and found no drugs or paraphernalia. Resident #1's roommate reported he was not aware of Resident #1 having any visitors. The police case report revealed on [DATE], an officer met with Assistant Director of Nursing (ADON) #102. ADON #102 reported Resident #1's room was being cleaned out by Head of Housekeeping #103 when a plastic jar with various pills was found in the nightstand drawer. Head of Housekeeping #103 also found three used syringes with pink residue and an unopened syringe. Head of Housekeeping #103 placed the items in a bag and turned them over to ADON #102. ADON #102 stated Resident #1 had been using his PICC line to inject himself with Oxycodone and other unknown drugs. Resident #1 was prescribed Oxycodone but not intravenously. The officer took possession of the pills and syringes. Most of the pills did not have any kind of markings on them. The pills, syringes, and body camera footage were entered into evidence. The 24 pills seized included one round orange pill marked with 022 tentatively identified as Cyclobenzaprine (muscle relaxant), one round orange capsule marked with 214 and tentatively identified as Gabapentin, one round green pill with no markings, one black round pill with no markings, three round scored white pills with no markings, one half round white pill with no markings, one brown round pill with no markings, 15 small white round pills with no markings, three used syringes with pink residue, one unopened syringe, and small plastic jar with a white lid. Interview on [DATE] at 10:53 A.M. with Regional Director of Clinic Services (RDCS) #104 revealed the facility identified Resident #1 was taking used syringes out of the medication trash containers on the side of the medication carts. RDCS #104 stated Resident #1 had told other residents that was where he was getting the syringes. Resident #1 was ordered to receive medications by mouth. The nurses were not doing a mouth sweep after the administration of medications. Partially disintegrated pills were found when Resident #1's room was being cleaned. The police were notified, and the pills were turned over to the police. RDCS #104 stated tape with a serial number/code could be used to indicate if a PICC line had been accessed by someone other than a nurse. There were also locked caps for IV access lines. RDCS #104 stated the tamper tape and locked caps were only used when there was suspicion of tampering with the intravenous access. RDCS verified no antitampering interventions had been placed on Resident #1's PICC line. RDCS #104 stated mouth sweeps were now being done on all residents, and medications were crushed if there was suspicion of a resident hiding medication in their mouth instead of swallowing the medication. All used syringes were now to be placed in sharp containers and unused syringes were to be secured with access to nurses only. RDCS #104 revealed residents on the SUD program had supervised visitations. These visits could be supervised in the lobby by the receptionist or in the hallways by nurses or any staff that were within eyesight. Packages for those on the SUD program were checked by receptionist, but the facility did not check any food that was ordered and brought to the facility. RDCS #104 stated Resident #1 had not exhibited any suspicious behaviors prior to overdose. Since Resident #1 did not exhibit any suspicious behaviors while residing at the facility, there was no increased supervision levels in place. Interview on [DATE] at 12:37 P.M. with SUD Counselor #400 revealed the program provided group sessions Monday through Friday. Residents on the program followed the building rules of no leave of absence without approval and supervision with visitors. Resident #1 attended group nine hours a week. Interview on [DATE] at 2:01 P.M. with LPN #100 revealed she was the first nurse to get to Resident #1. LPN #100 stated a syringe was discovered in Resident #1's hand and it appeared Resident #1 had overdosed. Emergency personnel were called. LPN #100 stated education had been provided to discard syringes in sharp containers and check resident's mouths after administering medications after Resident #1 overdosed. Interview on [DATE] at 2:05 P.M. with Medical Director #500 revealed the facility tried to make things as safe as possible. Medical Director #500 stated there were no specific instructions for residents with intravenous access who had a history of intravenous drug use. A new intervention had been put in place to crush medications for residents as needed when there were concerns of not swallowing medications when administered. Interview on [DATE] at 3:49 P.M. with the DON verified a comprehensive and individualized plan of care had not been developed or initiated for Resident #1 related to his substance abuse disorder prior to his overdose and death in the facility. 2. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, stimulant abuse, and multiple fractures. Review of the plan of care dated [DATE] revealed Resident #2 had a substance abuse disorder with a history of stimulant abuse. Interventions included monitoring Resident #2 for signs and symptoms of intoxication, monitoring for overdose, and report any symptoms of intoxication to the Administrator, DON, and physician. Resident #2 was not allowed a leave-of-absence without a supervised person, all packages must be searched, and visits to be supervised. Review of the MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of 13 which indicated Resident #2 was cognitively intact. The MDS revealed no concerns with Resident #2's mood or behavior. Review of the physician orders revealed Resident #2 was ordered Norco (opiate) ,d+[DATE] mg every six hours at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. On [DATE], a new order was received for Resident #2's medications to be crushed. On [DATE], Resident #2 received Norco ,d+[DATE] mg on [DATE] at 11:30 P.M. Resident #2 did not have a physician order for Fentanyl (synthetic opioid for severe pain). Review of the police case report revealed on [DATE] at 5:49 A.M., Resident #2 overdosed on prescribed medication by taking an extra dose without the nurse's knowledge. Medics administered Narcan and transported Resident #2 to the hospital. Two officers looked around Resident #2's room and did not see any indicators of drug use or any drug related paraphernalia in plain view. An officer went to the hospital and Resident #2 stated he did not take a pill that was administered by the nurse. Resident #2 stated on [DATE] around 2:00 A.M. he crushed and snorted the extra dose of medication without anyone knowing. The nurse found Resident #2 unresponsive when entering the room to administer medication scheduled for 6:00 A.M. A general progress note dated [DATE] at 6:11 A.M. revealed Resident #2 was found unresponsive. Resident #2 had a pulse rate of 55 beats per minute and oxygen saturation of 60-percent. Resident #2 was not able to state name, place, or time. Resident #2 was administered oxygen via a non-rebreather. Resident #2 was transported to the hospital. The hospital summary dated [DATE] revealed Resident #2 had a past medical history of paranoid schizophrenia, substance abuse, and blood clots. Resident #2 presented to the ED on [DATE] with altered mental status and unresponsiveness due to intentional opiate overdose. Resident #2 received Narcan multiple times and recovered. Resident #2's urine toxicology was positive for opiates and fentanyl. Resident #2 reported he had snorted Norco (opioid) the morning of [DATE]. Interview on [DATE] at 10:26 A.M. with Resident #2 revealed drugs taken at the time of overdose had been obtained from a former resident. Resident #2 stated he could not recall the former resident's name. Resident #2 stated if he had a visitor, he had to go to the front lobby so the visit could be supervised. Subsequent interview on [DATE] at 2:56 P.M. revealed he was unsure why nursing crushed his medications starting in [DATE] and stated he did not request his medications to be crushed. Interview on [DATE] at 10:59 A.M. with the LNHA revealed after Resident #2 overdosed, all resident rooms were searched for any drugs or drug paraphernalia. The LNHA stated some over-the-counter medications and lighters were found. No drugs or drug paraphernalia were discovered. Interview on [DATE] at 12:37 P.M. with SUD Counselor #400 revealed the program provided group sessions Monday through Friday. Residents on the program followed the building rules of no leave of absence without approval and supervision with visitors. Resident #2 had not been part of the program until returning from the hospital on [DATE]. Interview on [DATE] at 2:01 P.M. with LPN #100 revealed Resident #2 had an order for medications to be crushed prior to overdose. Interview on [DATE] at 2:05 P.M. with Medical Director #500 revealed the facility tried to make things as safe as possible. A new intervention had been put in place to crush medications for residents as needed when there were concerns of not swallowing medications when administered. Interview on [DATE] at 11:30 A.M. with RDCS #104 verified Resident #2 did not have a diagnosis of substance abuse, but a plan of care dated [DATE] was in place for substance abuse disorder. RDCS #104 verified Resident #2 was not on the SUD program prior to the overdose on [DATE]. RDCS #104 verified Resident #2 had requested medications to be crushed prior to overdose and nurses reported they crushed Resident #2's medications. Review of the facility undated Medication Storage policy and procedure revealed all drugs and biologicals would be stored in locked compartments. Only authorized personnel would have access to the keys to locked compartments. Review of the facility undated Resident Self-Administration of Medication policy revealed bedside medication storage was permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication. For bedside storage to occur the manner of storage prevents access by other residents and medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy. All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage. This deficiency represents non-compliance investigated under Complaint Number OH00153228 and Complaint Number OH00153109.

Based on medical record review, review of physician notes, review of administration time reports, review of a concern form and interview the facility failed to ensure residents were free of significant medication errors when intravenous (IV) antibiotic therapy was not provided as ordered for the treatment of infections and to prevent complications. This affected three residents (#13, #16, and #61) of three reviewed for IV antibiotics. Actual Harm occurred to Resident #16 when the facility failed to ensure IV antibiotics were administered as ordered and failed to ensure laboratory testing (Vancomycin trough levels) were completed as ordered to determine proper dosing of the antibiotic to effectively treat the resident's infection resulting in the resident requiring an additional 15 days of IV antibiotic therapy and the resident's nursing home placement being extended. Findings included: 1. Record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra, discitis, opioid dependence, arteritis, intervertebral disc disorder, low back pain, and difficulty walking. A concern form, dated 02/21/23 revealed Resident #16 reported he was not receiving (the antibiotic) Vancomycin. Review of Resident #16's antibiotic therapy plan of care, dated 02/22/23 revealed to administer antibiotics medication as ordered and to report any pertinent lab results to the physician. a. Review of Resident #16's physician's orders and Medication Administration Records (MAR) revealed on 02/09/23 an order to start Vancomycin IV 1000 milligrams (mg) twice daily (every 12 hours) for spine and heart valve infection for 20 days. The administration times were 9:00 A.M. and 9:00 P.M. On 02/19/23 the administration times were changed to 2:00 A.M. and 2:00 P.M. Review of a Vancomycin administration time report (dated 03/02/23) revealed no evidence the resident received a dose of Vancomycin on 02/09/23. On 02/10/23 the resident received three doses at 1:09 A.M., 10:16 A.M., and 9:24 P.M. Further review of the administration times and dates for Vancomycin revealed: On 02/11/23 he received a dose at 12:01 P.M. and 10:35 P.M. On 02/12/23 he received a dose at 6:23 P.M. and 8:44 P.M. (only a few hours apart). On 02/13/23 he received a dose at 8:45 A.M. and 10:21 P.M. On 02/14/23 he received a dose at 8:25 A.M. and 9:44 P.M. On 02/15/23 he received a dose at 10:29 A.M. and 9:29 P.M. On 02/16/23 he received a dose at 12:02 P.M. and 9:06 P.M. On 02/17/23 he received one dose at 1:51 P.M. On 02/18/23 he received a dose at 4:18 A.M. and 12:06 P.M. On 02/19/23 he received a dose at 12:02 A.M. and 5:19 P.M. (dose times changed to 2:00 A.M. and 2:00 P.M.). On 02/20/23 he received a dose at 2:00 A.M. and 3:59 P.M. On 02/21/23 he received a dose at 1:43 P.M. The A.M. dose was not administered and referenced to see progress note. The note indicated to hold one time. On 02/22/23 he received a dose at 1:02 A.M. and 4:57 P.M. On 02/23/23 he received a dose at 1:13 P.M. The A.M. dose was not administered and referenced to see progress notes. The note indicated to hold due to new dose. On 02/24/23 he received a dose at 2:18 P.M. The note indicated the resident refused A.M. dose. On 02/25/23 he received a dose at 4:15 A.M. and 2:28 P.M. On 02/26/23 he received a dose at 2:15 A.M. and 2:30 P.M. On 02/27/23 he received a dose at 2:59 P.M. There was a note the resident refused A.M. dose. On 02/28/23 he received a dose at 3:16 A.M. and 4:10 P.M. Interview on 02/28/23 at 11:38 A.M., with Resident #16 and the resident's spouse revealed on admission (02/09/23) they were told the Vancomycin was available prior to admission. However, when he arrived, he did not receive the Vancomycin until the following day around 2:00 A.M. The resident and spouse reported concerns the administration times had been off. The resident reported he hadn't refused the medication, however he had requested for the administration time to be changed to later times since it was to be given every 12 hours and staff were not administering the IV on the correct time schedule. The resident/spouse acknowledged the need to check blood levels for the antibiotic and reported the nurses could use the resident's peripherally inserted central catheter (PICC) line to draw blood because they were told they don't have the equipment, so they have to stick him for blood draws. The resident/spouse also reported the laboratory testing was not being done properly as blood was to be drawn 30 minutes prior to the administration, however staff were obtaining the blood sample only afterwards. The resident indicated most of the staff were from an agency and they were not IV certified. The resident indicated he had missed one dose of antibiotics due to there not being a nurse available who was IV certified. The resident reported LPN #135 had thrown a bottle of Vancomycin in the trash because it had appeared to be tampered with and the next nurse who came on shift took the vial out of the trash and administered it. The resident indicated the nurse reported that pharmacy only sends so many vials. The resident stated he then unhooked the IV and took the medication and took the vial to the Director of Nursing (DON) and reported the incident. The resident reported half of the time he had to hook and unhook his IV once the antibiotic was completed due to staff forgetting to check it. Interview on 03/01/23 at 8:50 A.M., with Unit Manager Licensed Practical Nurse (LPN) #137 revealed she was aware the resident had concerns with missed doses and times of the IV Vancomycin. LPN #137 revealed there was an incident the nurse could not find the Vancomycin and did not administer the medication. Interview on 03/01/23 at 1:53 P.M., with Resident #16 and the resident's spouse revealed the infection disease physician ordered the resident to continue on the Vancomycin for an additional 15 days (past the normal completion date scheduled) due to inconsistencies with the Vancomycin administration by facility staff. The resident revealed the need for additional days of IV therapy also extended the time he had to stay at the nursing home. Review of Resident #16's infection disease physician note, dated 03/01/23 revealed the resident presented for a follow up related to infection. The resident had a complicated spinal infection then aortic graft infection requiring surgery. He had been on Vancomycin. Notes multiple issues with getting Vancomycin in a timely fashion. Notes at one time a bag of Vancomycin was removed from the garbage and hooked up. The resident had a cat (CT) scan scheduled for 03/13/23 and then CT surgery on 03/15/23. The resident was fairly stable but still had discomfort in his chest. He has had issues with getting all of his Vancomycin dosing. New orders to continue IV Vancomycin through 03/16/23 and weekly labs. Interview on 03/02/23 at 10:55 A.M., with the Director of Nursing (DON) confirmed on 02/09/23 the resident did not receive his 9:00 P.M. dose of Vancomycin. The dose was not administered until 02/10/23 at 1:09 A.M. The DON confirmed Vancomycin 1000 mg was available in the stock medication, however it was not administered until it arrived from the pharmacy resulting in a late dose and also resulting in the resident receiving three doses in 24 hours, even though the order was for every 12 hours/twice daily. The DON reviewed the administration times and confirmed the Vancomycin was not administered at the scheduled times the majority of the days as noted above. The DON also confirmed the resident had voiced concerns regarding the administration times and the infection physician had seen the resident yesterday (03/01/24) and ordered the Vancomycin to be continued for an additional 15 days. Interview on 03/02/23 at 1:52 P.M., with the Infection Disease Nurse #200 revealed Resident #16 had seen the infection disease physician yesterday and the physician ordered to continue the Vancomycin for 15 more days due to the resident missing doses and still having chest discomfort (indicative of infection). The resident had also reported to the physician that staff had removed a vial of Vancomycin from the trash and administered it after it had appeared to be tampered with and it had been thrown in the trash by a previous nurse. b. Review of Resident #16's physician's orders revealed an order, dated 02/2023 to obtain Vancomycin trough level every Tuesday and fax to the pharmacy on Wednesday. Review of Resident #16's lab result dated 02/14/23 revealed the resident's Vancomycin trough was collected on 02/14/23 at 10:46 A.M. The results were 10.3 (normal range 10-20). Review of Resident #16's administration records dated 02/14/23 revealed the resident received the Vancomycin at 8:25 A.M. and 9:44 P.M. Review of Resident #16's lab result dated 02/21/23 revealed the resident's Vancomycin trough was collected on 02/21/23 at 2:26 P.M. The results were 20.9 (normal range 10-20) Review of Resident #16's administration records dated 02/21/23 revealed the resident received the Vancomycin at 1:52 A.M. and 1:43 P.M. Review of Resident #16's lab result dated 02/28/23 revealed the resident's Vancomycin trough was collected on 02/28/23 at 9:24 A.M. The results were 15.5 (normal range 10-20). Review of Resident #16's administration records dated 02/28/23 revealed the resident received the Vancomycin at 3:16 A.M. and 4:10 P.M. Interview on 03/02/23 at 12:33 P.M., with the Director of Nursing confirmed the Vancomycin trough levels should be collected 30 minutes before the administration of the next dose. The DON confirmed the above dates were not collected 30 minutes prior to administering the next dose. Vancomycin trough levels are recommended to predict Vancomycin efficacy, and inaccurate levels may lead to inappropriate clinical actions. Laboratory testing, including trough levels are particularly useful for therapeutic drug monitoring, which is the process of measuring drug concentrations at intervals to ensure a consistent concentration of a medication remains in an individual. 2. Closed record review revealed Resident #61 was admitted to the facility on [DATE] on with diagnoses including methicillin susceptible staphylococcus aureus infection, bacteremia, septic arterial embolism, chronic viral hepatitis C, substance abuse, and acute and subacute endocarditis. Review of Resident #61's nursing note, dated 02/23/23 revealed the resident arrived at the facility at 2:30 P.M. The resident was alert and oriented times four. He had a peripherally inserted central catheter (PICC) line for intravenous antibiotics Cefazolin continuous and Vancomycin every eight hours. Pharmacy was called to have the correct IV tubing shipped promptly. The resident had a history of IV drug abuse (heroin and methadone). The resident last use was 12/20/22. Review of Resident #61's medication administration records dated 02/2023 revealed the resident's continuous Cefazolin was not initiated until 9:00 P.M. on 02/23/23 and on 02/25/23 at 9:00 P.M. the Cefazolin was not available and was not administered again until 02/26/23 at 9:00 A.M. The Vancomycin was ordered every eight hours. However, there was no evidence the Vancomycin was administered on 02/24/23 at 8:00 A.M. or 02/25/23 at 10:00 P.M. Review of Resident #61's medication administration note dated 02/23/23 to 02/27/23 revealed the antibiotics was not administered as ordered on 02/25/23. The pharmacy was notified on 02/26/23 at 12:29 A.M. the Cefazolin and Vancomycin were not available. Review of Resident #61's infection and antibiotic plan of care dated 02/24/23 revealed to administer antibiotics as ordered. Interview on 03/01/23 at 8:00 A.M., with Resident #16 revealed around 10:00 P.M. on 02/26/23, a facility staff member had approached him and inquired when he had last seen Resident #61 last. The resident reported he had seen Resident #61 going down the steps at 6:30 P.M. Resident #16 indicted Resident #61 was upset with the facility and made comments he was leaving because the facility did not have his intravenous medications and he was supposed to be on IV's twenty-four hours a day. Resident #61 did not return to the facility. Interview on 03/02/23 at 10:55 A.M., with the DON confirmed there was no evidence Resident #61 received IV antibiotics on 02/24/23 and 02/25/23 as ordered. 3. Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, discitis, extradural and subdural abscess, bacteremia, and methicillin resistant staphylococcus aureus infection (MRSA). Review of Resident #13's orders dated 02/2023 revealed the resident was ordered Vancomycin 1,000 mg every twelve hours. Review of Resident #13's MAR dated 02/2023 revealed the resident did not receive his Vancomycin 1,000 mg on 02/19/23. Interview on 03/02/23 at 10:55 A.M., with the DON confirmed Resident #13 did not receive his Vancomycin as ordered on 02/19/23. This deficiency represents non-compliance investigated under Complaint Number OH00140216.

Based on record review, staff interview, and review of facility Self-Reported Incidents (SRIs), the facility failed to ensure Resident #28 was free from physical abuse by Resident #61. Actual harm occurred to Resident #28 when the facility failed to implement interventions for Resident #61 after a previous incident of resident to resident abuse involving Resident #44. This resulted in the behavior continuing and Resident #28 was struck in the head multiple times with a shoe horn/reacher device causing a [MEDICAL CONDITION] requiring an emergency room visit and staples to close the laceration. The facility also failed to implement the planned and physician ordered interventions to prevent resident to resident abuse after the incident involving Resident #28. This affected two of three residents reviewed for resident to resident altercations. Findings include: Review of Resident #61's medical record revealed an original admission date of [DATE] with the latest readmission of 04/08/17 with [DIAGNOSES REDACTED]. Review of Resident #61's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she had clear speech, understood others and made herself understood. This assessment indicated she was alert and oriented and had no cognitive deficits. Review of Resident #61's plan of care dated 04/22/19 revealed she was/had the potential to be physically aggressive towards others due to poor impulse control. Interventions included, every 15 minute checks and a stop sign placed on the room entrance. The resident's triggers for physical aggression were due to other residents intruding on her personal space. When the resident became agitated, staff were to intervene before the agitation escalated, guide her away from the source of distress and engage her calmly in conversation. If her response is aggressive, walk away calmly and approach later. Record review for Resident #44 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his current care plan revealed he had short and long term memory impairments and exhibited wandering behaviors. The MDS assessment dated [DATE] revealed he had clear speech, usually understood others, made himself understood and had severe cognitive deficits. Review of Resident #61's progress notes dated 03/08/19 at 10:02 A.M., authored by Licensed Practical Nurse (LPN) #17, revealed she was notified by another facility staff member that Resident #61 had been physically aggressive towards Resident #44. Resident #61 reported she hit Resident #44 with her aluminum reacher because he came into her room. Record review for Resident #61 revealed no evidence that any interventions were implemented to attempt to prevent further abuse towards other residents. Review of the facility's SRI's reported to the State Agency revealed no SRI was completed for the incident occurring on 03/08/19 when Resident #61 struck Resident #44. Additional review of Resident #61's progress notes dated 04/14/19 at 7:17 P.M., authored by LPN #17, revealed a staff member notified her Resident #61 was physically aggressive towards Resident #28. Resident #61 reported Resident #28 came into her room and she told him to go away but he refused. Resident #61 said she hit him on the back of his head with her shoe horn. Review of the progress note dated 04/14/19 at 10:21 P.M., authored by Registered Nurse (RN) #48,revealed the staff heard Resident #61 screaming for a staff member. Two staff members immediately went to the room and saw Resident #28, who has severe cognitive deficit and wandering behaviors, bleeding from the back of his head. Resident #61 said she struck Resident #28 multiple times in the head with her shoe horn because he would not get out of her room. Review of the SRI, tracking number 2, dated 04/14/19 and timed 7:30 P.M. revealed Resident #28 entered Resident #61's room and she pushed him away from her and asked him to leave her room multiple times. She said he then threw a glass of water on her and raised his fists in a threatening manner. She said she then hit Resident #28 in the head with an aluminum therapy reacher, which she described as a shoe horn. The staff immediately separated the residents and called emergency medical services (EMS) for Resident #28. Resident #28 was transferred to the local emergency room for sutures to the laceration to his head. Review of Resident #28's acute care hospital discharge instructions dated 04/14/19 revealed he required staples to close the laceration to his head. Review of Resident#28's progress note dated 04/15/19 at 2:55 A.M. revealed the resident returned from the emergency room with six staples to the back of his head. The laceration measured 3.0 centimeters (cm) long by 0.3 cm wide and he was to be checked by staff every 15 minutes. Review of Resident #61's monthly physician's orders for (MONTH) 2019 revealed an order initiated on 04/14/19 for her to have one on one supervision until further notice. On 04/24/19 at 10:00 A.M. and 2:00 P.M. Resident #61 was observed sitting in her wheelchair in her room watching television, the resident's physician ordered for one on one supervision was not being provided. There were no staff in the room. There was no stop sign on the door/entrance to her room. On 04/25/19 at 9:15 A.M. and 1:05 P.M. Resident #61 was observed in her room in her wheelchair watching television. The resident was not receiving one on one staff supervision as ordered by the physician and there was no stop sign on the door/entrance to her room. Interview on 04/25/19 at 10:15 A.M. with the Administrator verified the facility failed to investigate, report and implement interventions to prevent further resident to resident abuse/altercations after Resident #61 struck Resident #44 on 03/08/19. The Administrator verified Resident #61 was care planned to have a stop sign on her door to deter other residents from wandering into her room after the incident with Resident #28, but it had not been installed. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 12/27/17, revealed it is the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation and misappropriation of resident property. Facility staff should immediately report all such allegations to the Administration/designee and to the Ohio Department of Health. This deficiency substantiates Complaint Number OH 902.

Based on medical record review, staff and physician interview, and review of facility procedure, the facility failed to provide care and services to prevent dehydration and a hospitalization for a resident receiving nutrition and hydration through a feeding tube. This affected one of two residents reviewed tube feeding (Resident #47). This resulted in actual harm when Resident #47 was found unresponsive and was discharged to the hospital resulting in the [DIAGNOSES REDACTED]. Findings include: Closed medical record review of Resident #47 revealed an admission date of [DATE], a discharge date from the facility of 11/10/15 and [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Resident #47 also had a diet order of puree with honey thick liquids. Review of Resident #47's Certified Nursing Aide (CNA)- Activities of Daily Living (ADL) tracking form for 10/01/15 until 10/07/15 revealed that Resident #47 required extensive assistance with eating and drinking. Review of nurses notes dated 10/06/15 revealed that Resident #47's urinary catheter was draining amber urine. Review of a physician telephone order dated 10/06/15 revealed an order for [REDACTED].#47's water flushes to 200 ml six times daily. Nurses note dated 10/07/15 at 5:00 A.M. revealed that a lab was drawn from the resident, the resident was talking gibberish and the peg tube was functioning properly. Laboratory test dated 10/07/15 revealed a sodium level of 157 and a blood urea nitrogen level of 44 indicating high values. Nurses note dated 10/07/15 at 12:00 P.M. revealed that Resident #47 was found unresponsive to a sternal rub and his pupils were non-reactive. Vitals were taken, the physician and power of attorney were notified and the physician ordered the resident to be sent to the emergency room . Resident #47 returned to the facility on [DATE]. Review of Resident #47's medical administration record (MAR) revealed a document titled Enteral Feeding Record. The Enteral Feeding Record from 09/25/15-09/30/15 revealed a 200 ml water flush every shift and 10 out of 18 opportunites were missing documentation of flushes. The Enteral Feeding Record from 10/12/15-10/31/15 revealed a flush of 200 ml every six hours and 30 out of 80 opportunities for flushes had missing documentation of flushes. Readmission physician orders [REDACTED]. One order stated 200 ml of water every six hours and the other order stated 200 ml of water every four hours. No noted clarification was found in the nurses notes or physician orders. The Enteral Feeding Record from 11/01/15-11/10/15 revealed a flush of 200 ml every four hours and 38 of 60 opportunities for flushes had missing documentation of flushes. Interview on 01/21/2016 at 4:15 P.M. with Director of Nursing (DON) #6 confirmed she could not locate the Enteral Feeding Record from 10/01/15-10/07/15 which was the documentation of Resident #47's flushes prior to being sent out to the hospital. Review of hospital records revealed a consultation for the reason of [MEDICAL CONDITION] (high sodium) dated 10/08/15 and a conclusion of dehydration was documented. The consultation pointed out improved mental status after water was administered to Resident #47. The physician who performed the consultation also recommended the resident go home on maintenance free water replacement program so Resident #47 did not become dehydrated again. The consulting physician did not see any issues with ongoing fluid losses, such as diarrhea or high insensible losses. Interview 01/21/2016 at 5:42 P.M. with Resident #47's physician at time of admission to the facility (Physician #67) revealed his expectation was that water flush orders were to be given and needed to be documented. Interview on 01/22/16 with DON #6 at 9:55 A.M. verified the water flushes should have been documented on the Enteral Feeding Record and if they were not given for any reason, the reason why should have been documented. DON #6 verified there were several missing initials on the Enteral Feeding Records for administration of water flushes for Resident #47 from 09/2015-11/2015. Interview on 01/22/16 at 1:55 P.M. with DON #6 revealed the facility did not have a policy on proper MAR indicated [REDACTED]

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to provide adequate nutrition support to prevent unplanned significant weight loss for Resident #72 and #84. This resulted in actual harm for Resident #72 when the facility's registered dietitian made three separate recommendations for nutrition support that were not implemented by the facility which resulted in further unplanned weight loss for the resident. This affected two (Resident #72 and #84) of three residents reviewed for nutrition. The facility census was 56. Findings include: 1. Closed medical record review revealed Resident #72 was admitted to the facility on [DATE]. The resident was sent out to the hospital on [DATE] and was readmitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment, required extensive assistance of one person with eating, weighed 163 pounds (#), had no significant weight loss or gain, and was on a mechanically altered and therapeutic diet. The MDS also revealed Resident #72 had an unstageable pressure ulcer (slough and/or eschar present but not stageable due to coverage of wound bed by slough and/or eschar) measuring 9.0 centimeters (cm.) wide and 3.0 cm. long. Review of Resident #72's nutrition plan of care revealed the resident was at nutrition and hydration risk due to poor intake, reduced intake, and inadequate intake. One of the goals was for the resident to maintain adequate nutritional status as evidenced by maintaining weight within the resident's usual body weight. Review of the resident's weight history revealed weights as follows: 163# on 09/23/15. 136.4# on 09/28/15. 124.4# on 10/06/15. 121.8# on 10/12/15. 120# on 10/19/15. This revealed Resident #72 lost 26.6# and 16.3 percent (%) on 09/28/15; 38.6# and 23.7% on 10/06/15; 41.2# and 25.3% on 10/12/15, and 43# total and 26.4% on 10/19/15. Review of the Nutrition Evaluation dated 09/29/15 revealed Resident #72's current body weight was 163# and his usual body weight was 160's. Review of the back of the Nutrition Evaluation form revealed the Registered Dietitian (RD) completed the assessment on 10/02/15 and indicated Resident #72 had inadequate oral food and beverage intake. The RD indictaed to rule out dysphasia and increased nutrient needs as evidenced by variable meal intakes. The RD stated the goal for weight maintenance was desired during the healing process (of pressure areas) and recommended to add 120 milliliters (ml.) of the house nutritional supplement to provide an additional 200 kilocalorie's (kcal's) and 6 grams of protein per day and start weekly weights for close monitoring. This nutrition evaluation did not address the weight loss that was indicated by the weight of 09/28/15. Review of physician orders [REDACTED]. Resident #72 lost another 10.4# in one week oas indicated by the weight of 10/06/15. Review of the medication administration record (MAR) revealed the nutritional supplement that was ordered on [DATE] was not recorded. The delay in the supplement being ordered by the recommendation of the RD, the resident losing further weight, and the house supplement never being administered was confirmed with the Director of Nursing (DON) during interview on 01/21/16 at 4:20 P.M. Review of the Nutrition Services Progress Note dated 10/14/15 revealed the resident's current body weight was 121.8#. Yhe weight was noted with a downward trend and weight loss was possibly due to decreased meal intake. The RD recommended another nutritional supplement, Med Pass, to be administered at 120 ml three times per day and to increase the house supplement named Mighty Shake to four ounces three times a day. Review of the medical record revealed the recommendations by the RD were not ordered and there was no notification to the physician and/or family of the significant weight loss. Interview with the DON on 01/21/16 at 4:20 P.M. verified the recommended supplements were not ordered and notification to the physician and/or family of the significant weight loss was not made. Review of the thirty day assessment on the Nutritional Review form dated 10/19/15 revealed the resident's current body weight was 120#. The resident had a 12% significant weight loss in one month. Meal intakes were 25 to 50%. The RD noted the Med Pass nutritional supplement and Mighty Shakes were recommended and would continue to monitor. Further review of the medical record revealed the Med Pass and Mighty Shakes were never ordered and there was no notification to the physician and/or family of the significant weight loss. This was verified during interview with the DON on 01/21/16 at 4:20 P.M. Resident #72 was discharged from the facility on 10/26/15. Interview with RD #66 on 01/21/16 at 3:47 P.M. revealed she started working at the facility in January, 2016 and the previous RD no longer worked at the facility. She stated that when she made a recommendation she documented in the medical record and wrote a note to the nurse and put the note in the nurse's box located on the units. She said that house supplements like Med Pass get administered through the nurses. The only nutritional supplement that goes through the dietary department's meal tracker was Magic Cup. Review of the facility's policy and procedure regarding Nutritional Supplements dated 11/30/14 revealed supplements were available 24 hours per day for any resident who requested or required additional calories due to inadequate meal consumption, need for weight gain or maintenance, need for additional protein, or other therapeutic considerations. The procedure included that all supplements, including both commercial and house supplements, would be provided by physicians order only. Review of the facility's policy on Weighing the Resident dated 11/30/14 revealed the procedure included if there was a significant variance from the previous recorded weight the scale should be re-balanced and the resident should be re-weighed and a licensed nurse to validate. The weight should be recorded and to alert the nurse to any significant change, and nursing would notify the physician of any significant weight change, consult with the Director of Dietary Services and/or dietitian, and update the plan of care accordingly. 2. Medical record review of Resident #84 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of Resident #84's January, 2016 physician orders [REDACTED]. Review of Resident #84's quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #84 as cognitively intact. Review of Resident #84's weights located on the Vital Signs and Weight Record revealed the following dated weights: 10/08/15- 197 pounds (#), 11/04/15- 203.8#, 12/08/15- 174.4#, 12/30/15- 168.8#, and 01/02/16- 155.8#. The most current weight on 01/02/16 of 155.8# indicated a 8.3% significant weight loss over 30 days. Review of Nutrition Services Progress Note dated 01/05/16 by Registered Dietitian (RD) #66 revealed Resident #84's diet as Regular with Magic Cup at lunch and dinner and that nursing reported the resident was not eating his supplement. RD #66 revealed continued weight loss. RD #66 recommended to give Resident #84 fruit in place of his Magic cup based upon an interview with the resident. Review of Resident #84's January 2016 physician orders [REDACTED]. The physician orders [REDACTED].#84 was to get Mighty shakes with trays. Observation on 01/21/16 at 8:32 A.M. revealed Resident #84 received a breakfast tray in his room. Review of Resident #84's breakfast tray card revealed that he was on a Regular diet and was to receive a fruit cup as an additional breakfast item. Observation revealed no fruit cup on the tray. Interview at the time of the observation with Resident #84 verified that he did not have a fruit cup on his tray. Resident #84 stated he could not recall if he received supplements on his trays. Observation also revealed no Mighty Shake on the resident's breakfast tray. Interview on 01/21/16 at 9:50 A.M. with Dietary Manager (DM) #68 revealed that Special Requests Detail Report provided included all supplements to be on Resident #84's tray. DM #68 verified that Resident #84 did not have Mighty shakes listed to be on his trays and was not aware that he had a physician order [REDACTED]. Observation of January 2016 MAR on 01/21/16 at 12:15 P.M. revealed that the nurse had recorded 50% intake of a Mighty Shake for breakfast, after observation revealed no Mighty shake on Resident #84 ' s breakfast tray. Interview on 01/21/16 with Registered Nurse (RN) #60 at 12:45 P.M. verified that the Mighty Shake had not been on Resident #84's breakfast tray as ordered; however, RN #60 stated that she had provided the resident with one herself. Interview on 01/21/16 at 3:47 P.M. with RD #66 revealed that when she made a recommendation, she filled out a recommendation sheet at the nurse ' s box on the unit for the nurses to transcribe the recommendation to a physician order. When asked about following up on a recommendation to ensure it was transcribed to a physician order, RD #66 stated she was new and could not really say about the follow up on a recommendation. Interview on 01/22/16 at 9:03 A.M. with Director of Nurse (DON) #6 revealed that Resident #84's diet order said mechanical soft and was to be a regular diet. DON #6 verified that all supplement acceptances were to be recorded on the MAR. Interview on 01/22/16 at 1:55 P.M. with DON #6 revealed that the facility did not have a policy on proper MAR documentation. Review of the policy titled Nourishment and Supplements dated 11/30/14 revealed that all supplements, including both commercial products and house supplements, would be provided by physicians order only.

Based on observation, record review, resident interview and staff interview the facility failed to ensure dressing changes were completed as ordered and interventions were implemented to prevent the deterioration of a pressure ulcer. This affected two residents (Resident #56 and #60) of three residents reviewed for pressure ulcers. The total facility census was 57. Findings include: 1. A review of Resident #56's medical record revealed the resident was admitted to the facility on [DATE] with a medical [DIAGNOSES REDACTED]. The area was assessed on 12/08/15 and the measurements were 5.0 centimeters (cm) in length by 4.5 cm width with an undetermined depth. Record review revealed no interventions related to pressure ulcer care or treatment were implemented on 12/08/15 when the area was discovered on admission. On 12/11/15 the area was assessed as measuring 5.5 cm in length by 4.2 cm width with a depth of 0.1 cm. The wound bed was documented as being red with granulation tissue present. The pressure ulcer was assessed as being a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) pressure ulcer because the area was open and had a small amount of serous drainage. A review of the physician orders [REDACTED]. A review of the Minimum Data Set (MDS) 3.0 assessment, completed on 12/16/15 revealed the a Brief Interview of Mental Status (BIMS) score of 14 which reflected the resident was cognitively intact. Further review revealed the resident was dependent on staff for all activity of daily living (ADL) care including oral care and showers. On 12/19/15 the pressure ulcer to the right buttocks was assessed to measure 5.5 cm in length by 3.5 cm width. The wound bed was documented as being red with granulation tissue present. The area was documented as having a small amount of yellow serous drainage. A review of the physician's orders [REDACTED]. A review of the treatment administration record (TAR) revealed the dressing ordered on [DATE] was to be changed every three days. Record review revealed the dressing change ordered for 12/28/15 had not been signed off as being completed for this date. An observation on 12/29/15 at 10:59 A.M. revealed Resident #56 was in the shower room. The dressing to the right buttocks was not dated as to when it was applied. Observation revealed the dressing in place was not an [MEDICATION NAME] dressing. This was confirmed with Licensed Practical Nurse (LPN) #600 at 11:00 A.M. An interview on 12/29/15 at 11:05 A.M. with Resident #56 revealed the staff had not changed the dressing on the right buttocks for at least two days. On 12/29/15 at 1:10 P.M. LPN #600 entered Resident #56's room to change the dressing to the right buttocks. LPN #600 further confirmed during the observation that the dressing that was in place was not dated and was not the dressing that was ordered. The measurements obtained by LPN #600 during the dressing change revealed the pressure ulcer to the right buttock measured 6.0 cm in length by 3.0 cm width. The area was cleansed with wound cleanser and covered with an [MEDICATION NAME] dressing. An interview on 12/29/15 at 12:01 P.M. with the Director of Nursing (DON) confirmed the weekly measurements were not performed as directed by the pressure ulcer protocol and the dressing was not signed off as completed on 12/28/15. The DON further confirmed no interventions were implemented for the resident when the area was first discovered on 12/08/15. A review of the Pressure Ulcer Protocol undated revealed that weekly skin assessments and weekly pressure ulcer measurements were to be completed. 2. A review of Resident #60's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident was admitted with a Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer to the coccyx. A review of the weekly pressure ulcer measurements beginning on 11/17/15 revealed the area was assessed on 11/17/15, 11/24/15, 12/01/15 and 12/08/15. The assessment dated [DATE] was not fully completed. Only the measurements were documented. No description of the area and no signature as to who completed it were included on the assessment form. An interview on 12/29/15 at 12:01 P.M. with the DON confirmed the assessment on 12/15/15 was incomplete. This deficiency substantiates Complaint Number OH 054.