Every finding on record at Capri Gardens

Based on observation, record review, and staff interviews, the facility failed to ensure medications were stored securely. This had the potential to affect one (#60) of five residents reviewed for medications. The facility census was 78. Findings include: Record review for Resident #60 revealed an admission date of 05/22/26 with diagnoses including hemiplegia and hemiparesis, type 2 diabetes mellitus, diffuse traumatic brain injury, seizures, chronic kidney disease, chronic systolic heart failure and anxiety.Review of the Quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #60 was moderately cognitively impaired. Review of a physician order dated 07/25/25 revealed Tresiba FlexTouch Subcutaneous Solution Pen Injector 200 UNIT/ML (Insulin Degludec). The order directed to inject 54 units subcutaneously at bedtime for diabetes mellitus and to decrease the dose to 48 units if blood sugar was less than 80. Blood sugar was to be checked prior to administration.Observation on 05/26/26 at 11:40 A.M. of Resident #60's room revealed a Tresiba long acting insulin pen with an expiration date of 07/21/26 and no open date documented. The insulin was sitting out on a small dining room table in the resident's room. Resident #60 was unable to confirm if he had received the medication that morning or if it was left by night shift.Interview and observation on 05/26/26 at 11:44 A.M. with Licensed Practical Nurse (LPN) #227 confirmed the Tresiba insulin was sitting unattended in the resident's room on the dining table. LPN #227 stated she believed the insulin had been returned to the room by the resident's daughter after the resident left for a leave of absence on the night of 05/25/26.Interview on 05/26/26 at 11:57 A.M. with the Director of Nursing confirmed the facility did not have a medication storage policy and acknowledged that insulin should not be left out unsecured.

Based on resident record review, observation and staff interview, the facility failed to ensure that bedside table was in good repair to prevent a possible injury. This affected one (#59) out of two residents reviewed for environment. The facility census was 78 residents.Findings include:Review of a resident medical record revealed that Resident #59 was admitted to the facility on [DATE] and had diagnoses that included cerebral infarction, schizophrenia and acute embolism. Review of Resident #59's Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #59 was assessed as having moderate cognitive impairment. He was assessed as having no upper body impairment and being on an anticoagulant. Review of Resident #59's care plan dated 10/20/23 revealed that Resident #59 was at risk for bleeding related to use of anticoagulant medications. Observation on 05/26/26 at 9:43 A.M. revealed Resident #59's bedside table was within reach of the resident. The bedside table's edge was observed to be unfinished, broken, and had approximately three inches of exposed particle board with splinters and wood chips on the tabletop. Interview with Certified Nursing Aide (CNA) #205 on 05/26/26 at 10:02 A.M. confirmed Resident #59's bedside table was broken with rough, exposed particle board and wood chips, within reach of Resident #59.

Based on record review and staff interviews, the facility failed to ensure pharmacy recommendations were completed accurately. This affected two (#3 and #17) out of five residents reviewed for pharmacy recommendations. The facility census was 78.Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 01/28/26 with diagnoses of metabolic encephalopathy, depression, cognitive communication deficit, anxiety and psychotic disorder with hallucinations due to a known physiological condition. Review of the care plan dated 02/09/26 revealed the resident has an alteration in sleep pattern and takes trazodone for insomnia. Interventions included administering medication as specified, monitoring for effectiveness, side effects, and adverse reactions and notifying the physician as appropriate. Review of a physician order dated 02/16/26 with a discontinue date of 03/12/26 revealed Trazodone HCl 100 milligram (mg) tablet. The order directed staff to give 1.5 tablets by mouth at bedtime for insomnia. Review of nursing/prescriber recommendations dated 02/20/26 revealed please adjust the trazodone order for this resident. Facility needs to ensure they are documenting exactly what is being administered. Reports supplier is sending both one x 50 mg tablet and one x 100 mg tablet for a total dose of 150 mg. Those pills will have to enter as two separate orders with the instructions total dose = 150 mg for both orders. Review of a physician order dated 03/13/26 with a discontinue date of 03/17/26 revealed Trazodone HCl 100 mg tablet with instructions to give 1.5 tablets by mouth at bedtime for insomnia. Review of nursing/prescriber recommendations dated 03/16/26 revealed please adjust the trazodone order for this resident. Facility needs to ensure they are documenting exactly what is being administered. Appears supplier is sending one x 150 mg tablet. Review of a physician order dated 03/17/26 with a discontinue date of 05/21/26 revealed Trazodone HCl 100 mg tablet. The order directed staff to give 1.5 tablets by mouth at bedtime for insomnia to equal 150 milligrams. Review of a single day physician order dated 05/25/26 revealed Trazodone HCl 100 mg tablet with instructions to give 1.5 tablets by mouth at bedtime for insomnia to equal 150 mg. Review of a physician order dated 05/27/26 revealed Trazodone HCl oral tablet 150 mg with instructions to give one tablet by mouth at bedtime for insomnia. Interview on 05/27/26 at 3:08 P.M. with the Director of Nursing revealed the resident always received a 150 mg tablet from the medication supplier. The Director of Nursing stated the initial recommendation from 02/20/26 was to separate the trazodone doses, both fifty milligram and one hundred milligram tablets, into separate orders but document they were both to be given at night. The Director of Nursing stated that on 03/16/26 the pharmacy again recommended the facility change the order to reflect what was actually being administered. The Director of Nursing confirmed the order should have been updated to reflect the medication being supplied as Trazodone HCl oral tablet 150 mg, one tablet by mouth at bedtime, when the pharmacy recommendation was first made on 02/20/26 and again on 03/16/26. The Director of Nursing stated the order was not accurately changed until 05/27/26 to reflect what was actually being administered. 2. Record review for Resident #3 revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction, diabetes mellitus, hypertension, dementia, anxiety, major depressive disorder, and heart failure Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had severely impaired cognition. Review of Resident #3's physician orders revealed the following orders: Latanoprost Solution 0.005 % Place one drop in both eyes every day at bedtime; Systane Ultra Ophthalmic Solution 0.4-0.3 % Instill 2 drop in both eyes two times a day for dry eyes; Timoptic Solution 0.5 % Instill 1 drop in both eyes two times a day; Trusopt Solution 2 % Instill 1 drop in both eyes two times a day. Review of Resident #3's pharmacist recommendation dated 03/17/26 revealed a recommendation to add the instruction allow 5 minutes between administration of different drops to all eye drop orders. Review of Resident #3's physician orders did not reveal the added instructions to allow five minutes between administration of different drops to any of the applicable orders. During an interview on 05/28/26 at 4:11 P.M. with the Director of Nursing, she confirmed the instructions had not been added to any of the eye drop orders. She explained that she did provide education to all of the nurses in March of 2026 concerning allowing five minutes between eye drop administrations.

Based on record review and staff interview, the facility failed to ensure a urine specimen was collected, processed, and submitted to the laboratory in a timely manner. This affected one (#6) out of one residents reviewed for urinary tract infections. The facility census was 78.Findings include:Review of the medical record for Resident #6 revealed an admission date of 11/13/25, with diagnoses of type 2 diabetes mellitus, thrombocytopenia, retention of urine, transient ischemic attack and anxiety.Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 is cognitively intact, dependent on toileting hygiene and always incontinent of urine.Review of a physician order dated 05/21/26 at 4:15 P.M. revealed an order to complete a urine culture and urinalysis.Review of a progress note dated 05/21/26 at 4:17 P.M. revealed urine results were previously received, the laboratory did not perform a sensitivity and was unable to perform one on the current specimen. The nurse practitioner was notified and ordered recollection due to abnormal leukocytes in the urinalysis.Review of a progress note dated 05/21/26 at 6:17 P.M. revealed the resident refused urine sample collection multiple times.Review of a progress note dated 05/22/26 at 5:26 P.M. revealed the nurse attempted urine collection multiple times. The resident refused despite education.Review of a progress note dated 05/22/26 at 6:09 P.M. revealed urine was collected by Registered Nurse (RN) #201 and kept in the refrigerator. The laboratory was contacted, but there was no answer.Review of progress notes from 05/22/26 through 05/26/26 revealed no documentation lab was contacted for specimen pickup. Review of the urinalysis report received by laboratory 05/26/26 at 11:32 A.M., reported 05/28/26 at 12:57 P.M., revealed three or more isolates were present, suggesting contamination.Review of a progress note dated 05/27/26 at 3:22 P.M. revealed a urine specimen was collected, the specimen was contaminated and results could not be obtained. The resident was assessed and denied pain and dysuria. The nurse practitioner discontinued the order for urinalysis.Review of a progress note dated 05/27/26 at 4:14 P.M. revealed Resident #6's daughter expressed concern about resident confusion and requested that a urinalysis and culture and sensitivity be completed for a possible urinary tract infection. The nurse practitioner's order was reviewed.Interview on 05/28/26 at 11:21 A.M. with RN #201 confirmed she was able to collect Resident #6's urine on 05/22/26. She stated it was unusual for the resident to refuse collection. RN #201 reported RN #274 was notified the lab would need to be contacted for pickup.An attempted interview on 05/28/26 at 12:49 P.M. with RN #274, was unsuccessful.Interview on 05/28/26 at 12:53 P.M. with RN #249 confirmed he worked 05/23/26 during the day shift and denied night shift staff informed him the laboratory needed to be contacted to pick up Resident #6's urine.Interview on 05/28/26 at 2:30 P.M. with the Director of Nursing confirmed the facility was unable to determine whether the urine specimen was picked up by the laboratory in a timely manner, and no evidence was found in the medical record supporting additional attempts to contact laboratory services for pickup.

Based on record reviews and staff interviews, the facility failed to maintain complete, accurate, and readily accessible medical records. This affected two (#7 and #8) out of two records reviewed for availability of records. The facility census was 78. Findings include:1. Review of the medical record for Resident #7 revealed an admission date of 01/28/26 with diagnoses of metabolic encephalopathy, type 2 diabetes mellitus, gastroesophageal reflux disease without esophagitis, anxiety, and psychotic disorder with hallucinations. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was severely cognitively impaired, exhibited no rejection of care, had experienced a five percent or greater weight loss in the past month and was not on a physician prescribed weight loss regimen. a. Review of physician orders dated 04/02/26 revealed weekly weights were ordered to be obtained every Thursday due to significant weight loss. Review of the shower sheet dated 04/09/26 received 05/28/26 to support refusal of weight revealed the resident refused the scheduled weekly weight. Review of the electronic medical record for 04/09/26 showed no documentation of the refusal or any reattempt to obtain the weight. Review of a physician order dated 05/06/26 revealed weekly weights were to be obtained every Wednesday. Review of the electronic medical record for 05/13/26 (Wednesday) revealed no documentation that the weekly weight was completed, refused or attempted. The medication administration record displayed N/A for the scheduled weight, and no supporting documentation existed in the medical record to explain the entry. Review of the dietician's significant weight change report for the week of 05/07/26 through 05/13/26 received upon request on 05/28/26 revealed the dietician documented that Resident #7 refused the weekly weight. This refusal was not documented anywhere in the resident's medical record. Interview on 05/28/26 at 9:40 A.M. with the Director of Nursing and the Director of Clinical Services #351 revealed the resident was refusing multiple care tasks during the week of 04/09/26. They confirmed there was no documentation showing staff reattempted the weight, and staff could have attempted the weight on another day or used an alternative method. They stated the N/A entry on 05/13/26 was not supported by any documentation in the resident's medical record. Interview on 05/28/26 at 9:54 A.M. with the Director of Nursing confirmed the refusal on 04/09/26 was not captured in the electronic medical record and that no documentation existed to indicate staff attempted to obtain the weight again. Interview on 05/28/26 at 10:13 A.M. with the Director of Nursing confirmed refusals were not readily accessible in the medical record. She stated she had to provide the surveyor a bathing sheet and a dietary report because the medical record did not contain documentation of refusals or weight attempts. She confirmed staff did not document refusal of care under the required behavior task for the two days in question. Interview on 05/28/26 at 10:27 A.M. with Dietician #355 revealed she could provide evidence of refusals through the weekly dietician report. She confirmed that the resident's medical record did not contain documentation or evidence that the weekly weights were refused or reattempted. b. Review of a progress note dated 05/25/26 at 7:00 P.M. revealed the resident was readmitted to the facility from the hospital. Review of a physician order dated 05/26/26 at 6:00 A.M. revealed the resident was to receive Accu Checks (a test to check blood sugar levels) two times daily. Review of the electronic medical record for 05/25/26 through 05/26/26 received 05/28/26 revealed only two blood glucose results were documented: on 05/25/26 at 7:16 P.M., measuring 163 milligrams per deciliter (mg/dL) and on 05/28/26 at 10:18 A.M., measuring 149 mg/dL. Review of nursing handwritten report sheets dated 05/26/26 revealed morning and evening blood glucose results of 186 and 167. Review of nursing handwritten report sheets dated 05/27/26 revealed morning and evening blood glucose results of 162 and 174. Interview on 05/28/26 at 8:18 A.M. with Nurse Practitioner #350 confirmed Resident #7 was ordered to receive twice daily blood sugar checks following readmission from the hospital. Interview on 05/28/26 at 8:20 A.M. with the Director of Nursing (DON) revealed she had been informed blood sugar records for 05/26/26 and 05/27/26 were not located in the medical record and requested that staff attempt to locate them. Interview on 05/28/26 at 8:41 A.M. with the DON reported the medication administration record did not generate a documentation field for glucose results. She confirmed nursing did not enter the values into the vitals tab, as required per physician order. Interview on 05/28/26 at 10:08 A.M. with the DON revealed she located some day shift results on handwritten report sheets, but night shift results had not been located. Interview on 05/28/26 at 12:22 P.M. with the DON revealed she located the night shift results on handwritten report sheets. The DON confirmed that none of the blood glucose results from 05/26/26 or 05/27/26 were documented in or accessible through the resident's electronic medical record. 2. Review of a resident medical record revealed that Resident #8 was admitted to the facility on [DATE] and had diagnoses that included cerebral infarction, chronic back pain and fibromyalgia. Review of Resident #8's MDS assessment dated [DATE] revealed intact cognitive status. Resident #8 was assessed as using opioid medications. Review of Resident #8's physician orders dated 02/17/26 through 03/25/26 revealed that Resident #8 was prescribed Hydromorphone HCl, an opioid pain reliever, 4 milligrams (mg) one tablet every eight hours as needed for pain. Review of Resident #8's physician orders starting 03/25/26 revealed that Resident #8 was prescribed Hydromorphone HCl, 4 mg, 1 tablet every eight hours as needed for moderate to severe pain. Review of Resident #8's care plan dated 01/20/26 revealed that Resident #8 was at risk for alteration in comfort related to fibromyalgia, generalized pain and spinal stenosis. An intervention listed was to administer medications as ordered. Review of Resident #8's March 2026 hydromorphone narcotic count sheet revealed that Hydromorphone HCl 4 mg one tablet was administered to Resident #8 on 03/03/26 at 10:00 A.M., 03/04/26 at 1:00 P.M., 03/07/26 at 7:30 A.M. and 3:00 P.M., 03/08/26 at 7:00 A.M. and 2:30 P.M., 03/11/26 at 5:31 P.M., 03/12/26 at 6:00 A.M. and 2:00 P.M., 03/13/26 at 6:00 A.M. and 1:30 P.M., 03/17/26 at 6:35 A.M., 03/18/26 at 2:15 P.M., 03/20/26 at 2:00 P.M., 03/21/26 at 1:00 P.M., 03/26/26 at 12:30 P.M., and on 03/27/26 at 12:00 P.M Review of Resident #8's March 2026 Medication Administration Record (MAR) revealed that on 03/03/26 at 10:00 A.M., 03/04/26 at 1:00 P.M., 03/07/26 at 7:30 A.M. and 3:00 P.M., 03/08/26 at 7:00 A.M. and 2:30 P.M., 03/11/26 at 5:31 P.M., 03/12/26 at 6:00 A.M. and 2:00 P.M., 03/13/26 at 6:00 A.M. and 1:30 P.M., 03/17/26 at 6:35 A.M., 03/18/26 at 2:15 P.M., 03/20/26 at 2:00 P.M., 03/21/26 at 1:00 P.M., 03/26/26 at 12:30 P.M., and on 03/27/26 at 12:00 P.M., the MAR did not reflect that Hydromorphone HCl 4 mg 1 tablet was administered to Resident #8. Review of Resident #8's April 2026 hydromorphone narcotic count sheet revealed that Hydromorphone HCl 4 mg 1 tablet was administered to Resident #8 on 04/01/26 at 1:00 P.M. and 9:00 P.M., 04/04/26 at 8:00 A.M. and 4:10 P.M., 04/05/26 at 8:00 A.M. and 4:00 P.M., 04/09/26 at 8:00 A.M. and 3:30 P.M., 04/10/26 at 8:00 A.M. and 4:00 P.M., 04/14/26 at 2:00 P.M., 04/18/26 at 8:00 A.M. and 4:00 P.M., 04/19/26 at 8:00 A.M. and 4:00 P.M., 04/20/26 at 12:00 A.M., 04/23/26 at 8:00 A.M. and 4:00 P.M., 04/24/26 at 8:00 A.M. and 4:00 P.M., 04/25/26 at 12:00 A.M., 04/27/26 at 11:00 A.M., 04/28/26 at 12:30 P.M., 04/29/26 at 2:00 P.M., and 04/30/26 at 3:00 P.M. Review of Resident #8's April 2026 MAR revealed that on 04/01/26 at 1:00 P.M. and 9:00 P.M., 04/04/26 at 8:00 A.M. and 4:10 P.M., 04/05/26 at 8:00 A.M. and 4:00 P.M., 04/09/26 at 8:00 A.M. and 3:30 P.M., 04/10/26 at 8:00 A.M. and 4:00 P.M., 04/14/26 at 2:00 P.M., 04/18/26 at 8:00 A.M. and 4:00 P.M., 04/19/26 at 8:00 A.M. and 4:00 P.M., 04/20/26 at 12:00 A.M., 04/23/26 at 8:00 A.M. and 4:00 P.M., 04/24/26 at 8:00 A.M. and 4:00 P.M., 04/25/26 at 12:00 A.M., 04/27/26 at 11:00 A.M., 04/28/26 at 12:30 P.M., 04/29/26 at 2:00 P.M., and 04/30/26 at 3:00 P.M., the MAR did not reflect that Hydromorphone HCl 4 mg 1 tablet was administered to Resident #8. Review of Resident #8's May 2026 hydromorphone narcotic count sheet revealed that Hydromorphone HCl 4 mg 1 tablet was administered to Resident #8 on 05/02/26 at 8:00 A.M. and 4:00 P.M., 05/03/26 at 8:00 A.M. and 3:00 P.M., 05/04/26 at 9:00 A.M., 05/06/26 at 11:00 P.M., 05/07/26 at 8:00 A.M. and 4:00 P.M., 05/08/26 at 8:00 A.M. and 3:30 P.M., 05/16/26 at 8:00 A.M. and 3:30 P.M., 05/17/26 at 8:00 A.M. and 4:00 P.M., 05/21/26 at 12:00 A.M., 8:00 A.M. and 4:00 P.M., 05/22/26 at 7:30 A.M. and 4:00 P.M., 05/23/26 at 9:30 A.M. and 5:11 P.M., and on 05/26/26 at 6:30 P.M. Review of Resident #8's May 2026 MAR revealed that on 05/02/26 at 8:00 A.M. and 4:00 P.M., 05/03/26 at 8:00 A.M. and 3:00 P.M., 05/04/26 at 9:00 A.M., 05/06/26 at 11:00 P.M., 05/07/26 at 8:00 A.M. and 4:00 P.M., 05/08/26 at 8:00 A.M. and 3:30 P.M., 05/16/26 at 8:00 A.M. and 3:30 P.M., 05/17/26 at 8:00 A.M. and 4:00 P.M., 05/21/26 at 12:00 A.M., 8:00 A.M. and 4:00 P.M., 05/22/26 at 7:30 A.M. and 4:00 P.M., 05/23/26 at 9:30 A.M. and 5:11 P.M., and on 05/26/26 at 6:30 P.M., the MAR did not reflect that Hydromorphone HCl 4 mg 1 tablet was administered to Resident #8. An interview with the Director of Nursing (DON) on 05/28/26 at 2:20 P.M. confirmed that the nurses were not accurately documenting hydromorphone administration on the MARs after medication administration. The DON confirmed that it is her expectation that medication administration would be immediately documented accurately on the MAR after administration.

Based on closed medical record review, review of the hospital records, staff and physician interviews, review of facility letters, and review of the facility policy, the facility failed to ensure Resident #80's continuity of care from the hospital to the facility was thoroughly reviewed and implemented. This resulted in Immediate Jeopardy and the potential for serious life-threatening injuries, negative health outcomes and/or death on [DATE] when Resident #80 received Coumadin (anticoagulation medication) despite hospital orders and recommendations to stop anticoagulation therapy until seen by the neurosurgeon. Consequently, this resulted in Resident #80 being sent to the hospital and admitted to the neuro critical care unit on [DATE] due to an increased subdural hemorrhage (a collection of blood between the brain and the skull that can be life-threatening) and a craniotomy (a surgical procedure that involves removing a portion of the skull to access the brain) for subdural evacuation (a surgical procedure to remove subdural hematoma). This affected one (Resident #80) of four residents reviewed for continuity of care upon admission to the facility. The facility census was 77. On [DATE] at 3:43 P.M., the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), and Director of Clinical Services #300 were notified Immediate Jeopardy began on [DATE] when Certified Nurse Practitioner (CNP) #205 ordered four milligrams (mg) of warfarin (generic for Coumadin) for Resident #80. Resident #80 was admitted to the facility on [DATE] with a primary diagnosis of acute bilateral subdural hemorrhage. Hospital discharge recommendations from neurology stated to hold off on anticoagulation therapy until the resident follows up with the neurosurgeon and schedule a neurology appointment as soon as possible (ASAP). The hospital discharge orders stated to discontinue the use of Coumadin. On [DATE], CNP #205 ordered to start Coumadin for atrial fibrillation. CNP #205 did not discuss this order to restart the medication Coumadin for Resident #80 with the physician or a neurosurgeon or cardiologist. Resident #80 continued with the use of Coumadin until he was discharged to the hospital. On [DATE], Resident #80 had voiced complaints of a headache that would not go away with medication and had weakness in his hands, and Resident #80 was sent to the hospital. On [DATE], while in the hospital, Resident #80 had an increase in subdural hemorrhage and required a craniotomy for subdural evacuation. Interviews with Physician #200 and CNP #205 stated they would not have started Resident #80 on Coumadin if it said in the hospital discharge orders not to. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], the DON and designee reviewed all residents receiving Coumadin with Physician #200. One resident (#37) was identified to be currently on Coumadin and no new orders received. The DON or designee performed a head-to-toe assessment on Resident #37 and no adverse findings were noted. The appropriate dose was ordered, there was indication for use, and the facility implemented the physician's orders accurately. On [DATE], the DON and designee completed an initial audit to ensure the hospital after visit summaries were available, accurate, and implemented for all residents residing in the facility. No negative findings were noted. On [DATE], the DON re-educated all 24 licensed nurses on Coumadin best practices, new admission procedures, thoroughly reviewing the hospital after-visit summary to ensure continuity of care, order clarification and indications for use. On [DATE], the facility's Quality Assurance (QA) Committee, including Medical Director #200, held an impromptu QA Committee meeting to review the facility's Immediate Jeopardy, investigation, corrective actions, and audits. On [DATE], CNP #205 was re-educated by Medical Director #200 on ensuring residents receive the continuity of care upon admission to the facility, including following physician orders and recommendations following a hospital stay. Beginning [DATE], daily for four weeks, the DON will audit all new hospital after visit summaries to ensure accurate review and implementation; and all new orders, including new admission and Coumadin orders, to ensure accurate order transcription, indication for use, and implementation per the physician's order. The DON will be responsible for ongoing compliance. 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 is in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #80 revealed the resident was admitted to the facility on [DATE]. Diagnoses included nontraumatic acute subdural hemorrhage, chronic obstructive pulmonary disease, longstanding persistent atrial fibrillation, heart failure, and a personal history of transient ischemic attack. Review of the admission Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #80 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 14 (out of 15). Review of the hospital after visit summary dated [DATE] revealed Resident #80 was admitted to the hospital with small acute bilateral subdural hemorrhage (SDH) on [DATE]. Resident #80 was admitted to the neuro intensive care unit (ICU). The hospital course was complicated by seizures and acute stroke. Hospital discharge recommendations included for the treatment of nontraumatic SDH, recommended to hold off on anticoagulation therapy until the resident followed up with neurosurgery and to schedule a neurology appointment ASAP. The after-visit summary also stated to stop taking warfarin two milligrams (mg). There were no anticoagulants listed under the Expected Medication List at Discharge. Review of Resident #80's admission physician orders dated [DATE] revealed there were no physician orders for anticoagulation medications. The admission assessment and baseline care plan confirmed admission orders have been verified with the physician. Review of CNP #205's progress note dated [DATE] revealed Resident #80 was seen for a follow-up on allergies, hypertension and SDH. Resident #80 was in the hospital from [DATE] to [DATE] for a headache and was found to have a small acute bilateral SDH. The hospital course and complications were noted. Under Assessment and Plan, it stated to continue beta blockers and anticoagulants for the treatment of atrial fibrillation; however, there were no anticoagulants ordered to continue at this time. The history of present illness stated the electronic medical record and hospital records were reviewed. There was no mention of the recommendation to hold off on anticoagulants until seen by neurosurgery as directed in the hospitals after visit summary dated [DATE]. The note addressed that Resident #80's medications were reviewed and reconciled, and it listed medications, which did not include any anticoagulants. There was no mention to start anticoagulants and any discussion with the physician or neurosurgeon to start anticoagulants. Review of the physician orders dated [DATE], revealed CNP #205 ordered Coumadin four mg for Resident #80. Review of Resident #80's Treatment Administration Record (TAR) dated [DATE] revealed the neurology appointment was scheduled for [DATE] at 12:30 P.M. Review of the physician's History and Physical dated [DATE] revealed Resident #80 was in the hospital from [DATE] to [DATE] for a headache. Resident #80 was found to have a small acute bilateral SDH. Under the Assessment and Plan, for the diagnosis of SDH, Resident #80 was sent to the hospital by the Coumadin Clinic on [DATE] due to headache. The Computed Tomography (CT) scan of his head and neck revealed acute bilateral SDH. Warfarin (Coumadin) managed per Coumadin clinic. For the diagnosis of atrial fibrillation, it stated to continue with beta blockers and anticoagulation therapy. Under medications reviewed and reconciliation completed, medications were listed, and they did not include anticoagulation medications. There was no mention of the hospital's after-visit summary recommendation to hold off on anticoagulation medications and if it was discussed with a neurologist or cardiologist. The History and Physical was electronically signed by Physician #200. There were no other physician progress notes or assessments in Resident #80's medical record. Review of CNP #205's progress notes dated [DATE], [DATE], and [DATE] revealed the CNP followed up on Resident #80. There was mention anticoagulation therapy was discussed with the physician and neurosurgeon during these visits. The notes did not address the recommendation to hold off on anticoagulants until seen by neurosurgery as noted in the hospital after visit summary dated [DATE]. Review of Resident #80's progress notes revealed on [DATE] at 11:36 A.M., a family member of Resident #80 said she had to feed Resident #80 because he was having trouble controlling his fingers well enough to hold or handle utensils. On [DATE] at 11:45 A.M., Resident #80 had a headache that medication was not helping. A neuro assessment was completed with no other abnormalities other than weakness in his hands. Physician #200 was made aware, and he said to send Resident #80 to the emergency room for evaluation. Review of Resident #80's Medication Administration Record (MAR) dated [DATE] revealed Resident #80 did not receive Coumadin on [DATE], [DATE], and [DATE]. From [DATE] to [DATE] (except [DATE]), Resident #80 received Coumadin daily per physician orders. Review of the hospital records dated [DATE] revealed Resident #80 was admitted to the Neuro ICU from the emergency department. The history and physical documentation of the plan was to hold anticoagulation in the setting of new subdural hematomas. The CT scan showed an increase in size of bilateral SDH since [DATE]. The left side did not warrant intervention. The physician discussed with the family the recommendation would be a reversal of his anticoagulation, and the resident will be at high risk to resume anticoagulation given his SDH and right craniotomy. The family consented to surgery and on [DATE], Resident #80 had a right craniotomy with evacuation. On [DATE], the family was concerned about Resident #80 returning to the facility after hospitalization because of the medication error. On [DATE], Resident #80 was transferred to a neuro rehabilitation facility. Telephone interview on [DATE] at 11:01 A.M. with Physician #200 stated he doesn't remember reviewing Resident #80's discharge orders. Physician #200 stated it would make sense to hold the anticoagulants due to the diagnosis of SDH. Physician #200 stated he wouldn't have recommended starting Resident #80 on Coumadin if he saw it in the hospital discharge orders and after-visit summary. Physician #200 stated the documentation where he or the on-call physician would review medications would be in the nursing notes. Physician #200 stated he does not recall CNP #205 calling him the next day ([DATE]) to discuss starting Resident #80 on Coumadin. Telephone interview on [DATE] at 11:10 A.M. with CNP #205 stated the discharge orders she saw for Resident #80 were from the cardiologist that said to just be careful restarting Coumadin considering the atrial fibrillation. CNP #205 stated Physician #200 talked to the family about the risk and benefits of Coumadin; however, there was no documentation of this discussion in Resident #80's medical record. CNP #205 said the discharge orders she saw were from the cardiologist and not about the Coumadin. CNP #205 also stated if she saw the hospital discharge orders to hold anticoagulants until seen by the neurosurgeon dated [DATE], she would not have ordered the Coumadin for Resident #80 unless cardiology said to do it. CNP #205 verified she did not consult with Physician #200 or cardiology. A subsequent telephone interview on [DATE] at 1:10 P.M. was held with CNP #205 along with the DON present. CNP #205 stated she was at the facility on [DATE] and Licensed Practical Nurse (LPN) #154 had the medication administration record and said Resident #80 was on Heparin (anticoagulant) at the hospital and Coumadin prior to the hospital. CNP #205 said Resident #80's wife was at bedside and she went in to talk to Resident #80's family. CNP #205 said she got the doses Resident #80 was on at the Coumadin clinic from the family. CNP #205 said she was going to be careful and restart it as it made sense to CNP #205 from the critical care standpoint. CNP #205 said Resident #80 could throw a clot due to therapy. CNP #205 said the hospital after-visit summary dated [DATE] was not available at that time or it wasn't uploaded into Resident #80's medical record. CNP #205 said she went by a cardiology note. CNP #205 reiterated that she went by a cardiology note as she did not have access to the after-visit summary at that time. CNP #205 stated if she had access to the after-visit summary at that time, she would not have started Resident #80 on the Coumadin. CNP #205 stated she went by the information she had at that time which was the cardiology notes and talking to the family. CNP #205 stated she goes by discharge orders. The DON said the after-visit summary was always there for them to review. CNP #205 said Physician #200 and she did not see it at that time. The DON said CNP #205, or Physician #200 typically asked for the after-visit summary and CNP #205 asked LPN #154 for it that day. The DON said she was not aware that CNP #205 did not have it. Interview on [DATE] at 1:43 P.M. with LPN #154 stated the floor nurse reviews the new admission's after-visit summary. LPN #154 stated she asks for clarification if she sees a new order that contradicts the after-visit summary. LPN #154 stated she told CNP #205 on [DATE] that she saw Resident #80 had a history of atrial fibrillation and he wasn't on atrial fibrillation medication at the time. LPN #154 said she told CNP #205 why Resident #80 was admitted to the hospital and asked her if the facility needed to continue Coumadin therapy. LPN #154 said it was her understanding that CNP #205 had access to the after-visit summary documentation. Interview on [DATE] at 12:06 P.M. with the DON stated the floor nurse, unit managers, or DON read and review an after-visit summary when a resident was admitted . The DON also stated when new orders come in, they get verified and signed off by CNP #205 or Physician #200 before going in the computer system. When CNP #205 or Physician #200's order contradicts discharge orders from a newly admitted resident, the nurse was to question the discrepancy and then document if the order still stands or needs to be changed. The DON doesn't believe she saw the documentation of Resident #80 when his order was questioned. Interview on [DATE] at 4:30 P.M. with Manager of Clinical Services #350 confirmed there was no cardiology note for Resident #80 from the hospital records dated [DATE] to [DATE] (in reference to CNP #205 stating she went by the cardiology note to start Resident #80 on Coumadin on [DATE]), and they don't have it. Manager of Clinical Services #350 stated the facility does not have a continuity of care policy. Review of a letter dated [DATE] from the [NAME] President of Post-Acute Operations #600 revealed CNP #205 had access to hospital records via MedOne's electronic medical record and the facility's electronic medical record on [DATE] for Resident #80. Review of a letter dated [DATE] from Physician #200 revealed he did have access to the medical records provided by the hospitals who refer residents. The access was via uploaded documents to the facility's electronic medical record software maintained by the facility. Review of the facility's policy titled Coumadin Best Practice dated [DATE] revealed upon admission, the nurse accepting the resident will call the attending physician/CNP and verify the orders for the residents Coumadin dose. This deficiency represents non-compliance investigated under Complaint Number OH00159587.

Based on observation, record review, staff interview, and facility policy review, the facility failed to appropriately store, date, and maintain food safety in the kitchen. This affected 74 of 76 residents who receive food from the kitchen (Residents #3 and #34 do not receive food from the kitchen). The facility census was 76. Findings include: Observations on 07/25/22 from 7:35 A.M. to 8:00 A.M. of the kitchen revealed a plastic bag of chicken strips in the walk-in refrigerator that was not dated to when it was opened or when the chicken strips should be used by. Also in the walk in refrigerator, there was an opened bag of lettuce/salad with the perceived date of 06/25/22. The date on the lettuce was fading and very difficult to read. Also, there were brown pieces of lettuce, visible on the bottom of the bag. Then, in the walk-in freezer, the following items were opened without a used by or opened date on them: plastic bag of hash browns, plastic bag of pancakes, plastic bag of waffles, a package of diced ham, and a plastic bag of sausage links. Interview with Dietitian #3 and Dietary Manager #4 on 07/25/22 at 7:50 A.M. and 8:00 A.M. confirmed the bag of chicken strips and all the breakfast items in the basket were opened, did not have opened dates, and should have either had an opened date or a date to use by and confirmed the bag of lettuce should have been thrown out. Review of the facility's list of residents' diets revealed Resident #3 and #34 did not receive food from the kitchen. Review of facility's policy titled Food Storage-Labeling and Dating, dated July 2018, revealed all food must have a date that includes month, date, year on the package indicating the date in which it entered the facility. All items removed from the original packaging must be dated. Items must be dated after opening with an open date and a use by date. The use by date will be seven days (today plus six), unless the original manufacturer expiration date is before the seven days.

Based on review of the facility's policy, review of the Bristol [NAME] Squibb Prescribing Information document, observations, staff and staff interviews, and record review, the facility failed to properly store medications in a safe manner. This affected three of four medication carts and two of four medication rooms observed for medication storage. This affected one resident (#18) who was allowed to self-administer some of her medications. This had the potential to affect five residents who were identified by the facility as being cognitively impaired and at risk for wandering. Additionally, this had the potential to affect three residents (#18, #28, and #61) who received [MEDICATION(S)] 25 milligrams (mg), seven residents (#15, #125, #224, #225, #226, #274, and #276) who received a [CONDITION(S)] skin test test in the last three months, and eight Residents (#1, #4, #5, #8, #36, #38, #50, #54) who received an influenza vaccine in the last six months. The facility identified there were no residents who received the Vitamin E 180 mg or the [MEDICATION(S)] peroxide ear drops. The facility census was 76. Findings include: 1. Review of the medical record for Resident #18 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had no communication impairment, was cognitively intact, and had no behaviors. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was also an order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #18 did not have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the self-administration skills assessment dated [DATE] revealed Resident #18 was given permission to self-administer [MEDICATION(S)] (treats [CONDITION(S)]), [MEDICATION(S)] (supplement), cranberry tablet (supplement), and the [MEDICATION(S)] sodium medication. The assessment also revealed the resident had demonstrated the proper way to secure the medication. The assessment did not specify how the medications were to be stored in the resident's room. Review of the clinical plan of care last revised on 07/20/22 revealed Resident #18 self-administered some of her medications. The plan of care did not provide details about what medications would be self-administered and how they would be stored in the resident's room. Review of the self-administration skills assessment dated [DATE] revealed Resident #18 was given permission to self-administer medications however it did not specify which medications could be self-administered. The assessment also revealed Resident #18 had demonstrated the proper way to secure the medication. Again, it did not specify how the medications should be stored in the resident's room. Observation and interview on 07/25/22 at 10:40 A.M. with Resident #18 revealed an observation of the top part of an open drawer her nightstand revealed a small yellow plastic bag that contained medications. Resident #18 stated the medications were her [CONDITION(S)] drug ([MEDICATION(S)] sodium). Resident #18 stated she had permission to keep it in her medication in her room because no one else was allowed to touch it since it cost $1,000 per pill and could not be handled by anyone but herself. In addition, there were were two round white pills sitting in a clear plastic cup on the bedside table. Resident #18 further stated the staff give her the Tylenol at night and sit them on her nightstand for her to take when she needs them. Interview with Licensed Practical Nurse (LPN) #87 on 07/25/22 at 11:05 A.M. confirmed the medication on Resident #18's bedside table was Tylenol but was not sure how long they were there. LPN #87 also stated to Resident #18 that the Director of Nursing (DON) wanted to see the pills in the yellow bag. Resident #18 refused to give the bag to LPN #87 and the yellow bag remained in the open top nightstand drawer. Interview and observation on 07/26/22 at 8:45 A.M. with Resident #18 revealed the yellow bag containing the [MEDICATION(S)] sodium remained in the same spot which was on top of the open nightstand drawer. The two Tylenol tablets were no longer on the bedside table. Resident #18 stated she was given a lock box by the previous DON a long time ago and pointed to the top of her miniature refrigerator. Resident #18 stated she doesn't use the lock box because she can't open it herself and she could not reach it anyway. An interview with the Administrator on 07/27/22 at 5:30 P.M. confirmed the medication in Resident #18's room should have been securely stored. Review of the document titled Bristol [NAME] Squibb Prescribing Information, dated November 2020, revealed for [MEDICATION(S)] sodium, the drug is to be kept out of reach of children and the capsule should be handled with as little exposure as possible. Review of the facility's policy titled Medication Storage, dated 07/23/19, revealed all medications and biologicals are to be stored safely, securely, and properly following the manufacturer's instructions. 2. Observation on 07/27/22 at 8:02 A.M. with Registered Nurse (RN) #82 of the 200 hall medication storage room revealed the following concerns: an opened and undated bottle of [MEDICATION(S)] liquid (treats nerve pain) with Resident #34's name on it, an opened vial of [MEDICATION(S)] (PPD) that was undated, and an opened and undated bottle of [MEDICATION(S)] liquid (treats anxiety) for Resident #5. Interview on 07/27/22 at 8:02 A.M. with Registered Nurse (RN) #82 confirmed the opened and undated medications in the 200 hall medication storage room. 3. Observation on 07/27/22 at 9:20 A.M. with RN #82 of the 100 hall medication storage room revealed the following concerns: 18 [MEDICATION(S)] 25 milligram (mg) bottles expired May 2022, 10 Vitamin E 180 mg bottles expired May 2022, three [MEDICATION(S)] Peroxide ear drop bottles expired May 2022, and one Influenza Vaccine expired 06/07/22. Interview on 07/27/22 at 9:20 A.M. with RN #82 confirmed the expired medications in the 100 hall medication storage room. Review of the facility's list of medications used by residents revealed Residents #18, #28, and #61 received [MEDICATION(S)] 25 milligrams (mg), Resident #15, #125, #224, #225, #226, #274, and #276 received a [CONDITION(S)] skin test test in the last three months, and Residents #1, #4, #5, #8, #36, #38, #50, and #54 received an influenza vaccine in the last six months. The facility identified there were no residents who received the Vitamin E 180 mg or the [MEDICATION(S)] peroxide ear drops. Review of the facility's policy titled Medication Storage, dated 07/23/19, revealed outdated medications are immediately removed from stock and disposed of accordingly.

Based on observation, medical record review, review of Medscape guidance and U.S. Pharmacist guidance, and staff interview, the facility failed to ensure a medication error rate below five percent (%). Out of 32 opportunities, there were three errors to equal an error rate of 9.4%. This affected one (Residents (#5) of three residents observed for medication administration. The facility census was 76. Findings include: Review of the medical record for Resident #5 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 07/11/22, revealed Resident #5 had adequate vision and corrective lenses. Review of Resident #5's care plan dated 07/25/22, revealed the resident may require assistance with activities of daily living (ADL) and may be at risk of developing complications associated with decreased ADL self performance with interventions for glasses. Review of Resident #5's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] and Brimonide medications were due upon rising and at bedtime, the [MEDICATION(S)] was due upon rising, lunch, dinner, and bedtime. Observation on 07/27/22 at 8:59 A.M. with Licensed Practical Nurse (LPN) #628 revealed she administered Resident #5's three separate eye drops within a one minute period. At 8:59 A.M. one drop of the Brimonide was administered to the left eye, at 9:00 A.M. one drop of the [MEDICATION(S)] medication was administered to the left eye, and at 9:00 A.M. one drop of the [MEDICATION(S)] medication was administered to both eyes. Interview on 07/27/22 at 9:11 A.M. with LPN #628 revealed there was no specified time on the eye drop order so it was acceptable to give them without a waiting period in between. She stated she made sure the whole eye was saturated with the drop, but if the order specified to wait between drops she would do that. Subsequent interview on 07/27/22 at 9:15 A.M. with LPN #628 revealed the time to wait between eye drops was five minutes and she confirmed she did not wait that time frame to administer the eye drops to Resident #5. Review of the Medscape guidance found at medscape.com revealed if administering [MEDICATION(S)] and another opthalmic product is being administered, wait five minutes between instilling eye drops. Review of the U.S. Pharmacist guidance titled How to Use Eye Drops Properly, dated 03/14/03, found at https://www.uspharmacist.com/article/how-to-use-eye-drops-properly, stated if another drop of eye medication is needed, wait at least five to 10 minutes before administering the second eye drop so the first drop will not be washed out of the eye.

Based on medical record review, review of Medscape guidance, and staff interview, the facility failed to provide proper justification for the use of [CONDITION(S)] medications. This affected one (Resident #14) of five residents reviewed for unnecessary medications. The facility census was 76. Findings include: Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia, anxiety disorder, anorexia, and mood disorder. Review of the Minimum Data Set (MDS) assessment, dated 05/06/22, revealed Resident #14's cognitive status was not assessed due to her inability to answer the questions appropriately. Review of Resident #14's medical records revealed she had a physician order for [MEDICATION(S)] (antipsychotic) five milligrams (mg) with the justification for the medication being for the diagnoses of agitation and [CONDITION(S)]. Neither of those diagnoses were listed in Resident #14's diagnoses list. Interview with Director of Nursing (DON) on 07/27/22 at 2:30 P.M. confirmed the current diagnoses listed for her [MEDICATION(S)] were not appropriate for the use of the medication. The DON stated she would have to review her diagnoses and other medical records to determine what the actual justification would be for [MEDICATION(S)]. No proper justification from the pharmacy or physician was found for the physician order of [MEDICATION(S)]. Review of the Medscape guidance found at medscape.com revealed [MEDICATION(S)] is used for [CONDITION(S)], Agitation-Associated with [CONDITION(S)] and [CONDITION(S)], [CONDITION(S)] depression, and [CONDITION(S)].

Based on medical record review, observations, and staff interview, the facility failed to provide and document activities for a resident. This affected one (Residents #13) of two residents reviewed for activities. The facility census was 76. Findings include: Review of the medical record for Resident #13 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 has unclear speech and has severely impaired cognition. Resident #13 required extensive assistance for mobility, locomotion, and eating. Review of the activities plan of care, last revised on 02/04/22, revealed Resident #13 was unable to pursue her interests due her physical and cognitive condition, was willing to interact with others and participate in activities that relate to her interests. The following activities were documented as important to Resident #13: gardening, music, pet visits, religious activities, spending time outside, watching TV, and movies. Review of the June 2022 activity log for Resident #13 revealed she attended a 1:1 visit on 06/04/22 and 06/11/22 and attended sensory stimulation on 06/10/22, 06/14/22, 06/19/22, and 06/21/22. The July 2022 activity log for Resident #13 revealed she had not attended any activities from 07/01/22 to 07/26/22. Observation on 07/25/22 at 8:55 A.M. revealed Resident #13 was observed to be sitting in the common area adjacent to the 400-hall dining area and nurse's station. Resident #13 was sitting in a chair, was not participating in any activities. At the time of the observation, Daily Chronicle activities was scheduled on the calendar. On 07/25/22 at 3:51 P.M., Resident #13 was observed to be in a sitting in the common area adjacent to the 400-hall dining area and nurse's station. Resident #13 was yelling come here over and over. An unidentified nurse who was sitting behind the nurse's station stated she couldn't because she was doing paperwork. At the time of the observation, bible study was on the activities calendar, but Resident #13 was not in attendance. On 07/26/22 at 11:36 A.M., Resident #13 was observed to be in a sitting in the common area adjacent to the 400-hall dining area and nurse's station. Resident #13 had a plastic puzzle toy in her hand but appeared to not know what to do it with. At the time of the observation, about seven unidentified residents were attending Group Trivia but Resident #13 had not been invited or in attendance. On 07/26/22 at 2:30 P.M., Resident #13 was observed to be in a sitting in the common area adjacent to the 400-hall dining area and nurse's station. Resident #13 still was holding the plastic puzzle but not engaging with it. At the time of the observation, bingo was occurring, but Resident #13 had not been invited and was not participating. No staff approached Resident #13 to assist her with the puzzle. On 07/27/22 at 3:15 P.M., Resident #13 was observed to be in a sitting in the common area adjacent to the 400-hall dining area and nurse's station. Resident #13 sitting in the chair sleeping. At the time of the observation, a music performance was occurring, but Resident #13 was not in attendance. On 07/26/22 at 4:35 P.M., Resident #13 was observed to be in a sitting in the common area adjacent to the 400-hall dining area and nurse's station. Resident #13 was still sitting in same chair, sleeping, and leaning to the left. Interview with the Activities Director #6 on 07/27/22 at 2:30 P.M. revealed she normally does 1:1 visits with Resident #30 twice per week when she had the time. Activities Director #6 also confirmed the activities logs for Resident #13 showed very little evidence of activity participation in June and no documentation in July. Activities Director #6 stated she was getting used to the new documentation system and she was the only activities staff at the time. Interview with the Administrator on 07/28/22 at 10:00 A.M. revealed another Activity Staff was in the process of being hired.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observations, review of an employee file, review of a Self-Reported Incident (SRI), review of the facility's investigation and witness statements, review of medical records, review of the State of Ohio Board of Nursing's Complaint Form, review of the coroner's report, review of the facility's policy on Respiratory: [CONDITION(S)] Care, staff interviews, interview with the Medical Director and interview with the local police detective, the facility failed to ensure necessary life-sustaining respiratory services were provided for one (#78) resident. This resulted in Immediate Jeopardy and serious life-threatening harm for Resident #78 when the [CONDITION(S)] (a hole in the front of the neck and into the windpipe) tubing was found on the floor with no [CONDITION(S)] mask and had gone unnoticed by any of the facility staff. Consequently, Resident #78 was found unresponsive, cold, with blue lips and without pulse and had expired. This affected one (#78) of two (#24 and #78) residents identified by the facility to have tracheostomies requiring supplement oxygen. The facility census was 77. On [DATE] at 11:52 A.M., the Administrator, Director of Nursing (DON), and Clinical Director #600 were notified Immediate Jeopardy began on [DATE] at approximately 7:50 A.M., when Resident #78 was found unresponsive with his [CONDITION(S)] tubing lying on the floor by Registered Nurse (RN) #164. The resident had blue lips, was cool to the touch, and had no pulse or apical heartbeat. RN #164 asked for help and License Practical Nurse (LPN) #137 came into the room and confirmed the [CONDITION(S)] tube was on the floor and was not attached to a [CONDITION(S)] mask, and the resident had blue lips, no pulse, no apical heartbeat, and was cool to the touch. Multiple staff members were unable to find a [CONDITION(S)] mask in the resident's room. Staff did locate a [CONDITION(S)] mask in the supply drawer in the resident's room. The Immediate Jeopardy was removed on [DATE] and the deficiency continued at a Severity Level 2 (no harm with the potential for more than minimal harm that is not immediate jeopardy) until the deficiency was corrected on [DATE], when the facility implemented the following corrective actions: · On [DATE], the facility immediately suspended LPN #133 who had provided [CONDITION(S)] care to Resident #78, pending investigation. · On [DATE], the facility's DON observed all residents with a [CONDITION(S)] to ensure oxygen was being delivered per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] · On [DATE], the facility's DON reviewed all residents with a [CONDITION(S)] and/or receiving supplemental oxygen to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . · On [DATE], the facility's DON and/or designees began auditing all licensed nurses and required a return demonstration competency to ensure competence with [CONDITION(S)] care and applying oxygen via the correct source. By [DATE], all licensed nurses completed return demonstration competency. · On [DATE], the facility's DON and Assistant Director of Nursing (ADON) began inservicing all licensed nursing staff on procedures relative to oxygen use, [CONDITION(S)] mask use, abuse/neglect, care plan implementation, documentation, and reporting of change in condition. By [DATE], all staff had completed in-service content. · On [DATE], the facility's Administrator submitted a self-reported incident to the Ohio Department of Health of the incident and their investigation involving potential neglect. · On [DATE], the Administrator and/or the DON interviewed all pertinent staff. · On [DATE], an ad hoc Quality Assurance (QA) Committee meeting was held to review the incident investigation, internal action plan, and audit plan. Additional QA committee meetings were held on [DATE] and [DATE] to validate the effectiveness of the action plan and audits. · On [DATE], the Ohio Board of Nursing was notified of a potential nurse practice concern by the DON. · On [DATE], the facility terminated LPN #133. Review of the personnel file for LPN #133 revealed the reason for termination according to the Disciplinary Action Form was documented as Failed to comply with standard nursing practice or facility policy and procedures. · Beginning on [DATE], the facility's DON and/or designee began audits of all residents with a [CONDITION(S)] and/or receiving supplemental oxygen to ensure oxygen was delivered per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Negative findings will be corrected immediately and communicated to the QA Committee for review and recommendations. · Beginning on [DATE], the facility's DON or designee will audit three to five licensed nurses and require a return demonstration competency to ensure competence with [CONDITION(S)] care and applying oxygen via the correct source weekly for four weeks or until otherwise directed by the QA Committee. Negative findings will be corrected immediately and communicated to the QA Committee for review and recommendations. · Beginning [DATE], the facility's DON and/or designee will conduct interview audits of staff to validate understanding of in-service content. Random audits will continue three to five times weekly for four weeks, or until otherwise directed by the QA committee. · On [DATE] at 12:48 P.M., an observation of RN #115 revealed she provided [CONDITION(S)] care for Resident #24. The RN demonstrated competency in the provision of [CONDITION(S)] care. Findings include: Review of the closed medical record for Resident #78 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had severely impaired cognition and was assessed as requiring oxygen therapy, suctioning, and [CONDITION(S)] care. Resident #78 was assessed as total dependence on staff for bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. Review of the plan of care, dated [DATE], revealed the resident was oxygen dependent due to a [CONDITION(S)]. Interventions included administering oxygen as ordered, monitoring lung sounds, and oxygen saturations. Review of the physician orders, dated [DATE], revealed orders for oxygen administration to be via [CONDITION(S)] mask at six to ten liters per minute. [CONDITION(S)] suctioning was to be conducted every two to four hours. Review of the nursing progress notes, dated [DATE] at 7:50 A.M., revealed RN #164 entered Resident #78's room and found Resident #78 in bed, cyanotic, and unresponsive with no palpable pulse. The DON was notified. RN #164 checked with another nurse for a sign of life. Review of the facility's SRI submitted to the state agency revealed Resident #78 died after being found in his room with no oxygen supplied to his [CONDITION(S)]. [CONDITION(S)] tubing was found on the floor and the [CONDITION(S)] mask was not present. The allegation of abuse, neglect or misappropriation was not substantiated by the facility due to the evidence being inconclusive. Review of State tested Nursing Aide (STNA) #122's witness statement, dated [DATE], revealed STNA #122 last performed incontinence care for Resident #78 and the nurse changed the resident dressing. There were no other issues noted. The statement was signed at the bottom by STNA #122. Review of LPN #133's witness statement, dated [DATE], revealed LPN #133 last observed Resident #78 around 6:45 A.M. and stated she went into his room to assist STNA #133 with incontinence care. She took the resident's vital signs and they were within normal limits, and fasting blood sugar was 206 milligrams per deciliter (mg/dL). She administered four units of [MEDICATION(S)] insulin. LPN #133 provided [CONDITION(S)] care, changed the [CONDITION(S)] ties, suctioned the resident, and removed the [CONDITION(S)] mask due to being soiled. She then threw the [CONDITION(S)] mask in the trash. The [CONDITION(S)] dressing was changed, and a cool mist aerosol canister was refilled with distilled water and his tubing was rearranged. The statement was signed at the bottom by LPN #133. Review of RN #164's witness statement, dated [DATE], revealed the nurse entered Resident #78's room at approximately 7:40 A.M. to 7:45 A.M., and found the resident cyanotic and his oxygen tubing was on the floor. The resident was unresponsive, with no pulse. A second nurse was called into the room to verify absence of vital signs. The Code Status for Resident #78 was Do No Resuscitate Comfort Care (DNRCC). The statement was signed at the bottom by RN #164. Review of LPN #137's witness statement, dated [DATE], revealed the nurse entered Resident #78's room after hearing the hall nurse yell I need you now. Resident #78 was found in his bed, cyanotic with no vital signs. His [CONDITION(S)] tubing with oxygen was laying on the floor with no [CONDITION(S)] mask. There was no [CONDITION(S)] mask in the room. The statement was signed at the bottom by LPN #137. Review of the DON's interview with LPN #133, dated [DATE] at 8:30 A.M., revealed when LPN #133 was asked what she did with the [CONDITION(S)] tubing, LPN #133 was unsure. When asked again, LPN #133 stated she placed the tubing in the bed and threw the [CONDITION(S)] mask into the trash, then removed the trash from the room. LPN #133 did not remember if she replaced the [CONDITION(S)] mask, and stated she thinks she forgot. This statement was signed at the bottom by the DON. Review of the State of Ohio Board of Nursing's Complaint Form, dated [DATE], revealed the Administrator filed a complaint against LPN #133 for an incident dated [DATE]. The incident resulted in the death of Resident #78 due to a [CONDITION(S)] mask not being reapplied after care was performed. The facility terminated the employee on [DATE]. It indicated the clinical reasoning was a factor in the practice breakdown and the LPN did not follow orders, without considering specific patient condition. The LPN did not follow standard protocol order and failed to advocate for patient stability and clinical ability. Review of Occupational Therapist (OT) #300's statement, dated [DATE], revealed Resident #78 had significant contractures and limited passive range of motion in both upper arms. The resident was noted to not have functional movement in his upper extremities. In OT #300's opinion, Resident #78 did not have the active range of motion required to remove a [CONDITION(S)] mask if appropriately place onto the resident's neck. Review of the coroner's report, dated [DATE], revealed the preliminary gross anatomic findings were status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the employee file for LPN #133 revealed her LPN license was obtained on [DATE]. She was hired to work in the facility as an LPN on [DATE]. Checklist for competency was reviewed, with [CONDITION(S)] care competency covered under the oxygen supplies and care section and was completed on [DATE]. Interviews on [DATE] from 10:09 A.M. to 11:06 A.M., with LPN #135, RN #115, STNA #112, and Non-Certified Nursing Assistant #22 revealed Resident #78 was bed bound, nonverbal, with limited to no movement in arms and head. Interview on [DATE] at 12:27 P.M. with the DON stated she entered Resident #78's room around 8:05 A.M. on [DATE] and noticed the [CONDITION(S)] tubing was on the floor with no mask attached. The [CONDITION(S)] mask was not in the room. The DON notified the Administrator of the findings. LPN #133 and STNA #122 were interviewed. LPN #133 was suspended and terminated on [DATE] and the Ohio Board of Nursing was notified. Resident #78 died on [DATE], when he was found unresponsive by RN #164. Resident #78's [CONDITION(S)] tubing was found on the ground with no mask attached. Interview with Detective #900 on [DATE] at 9:28 A.M., revealed he was notified of this incident on [DATE] and has been assigned this case. He stated he was investigating it and considering this a felony three charge for reckless homicide. He stated the coroner's office was preliminarily reporting this was an accidental death because they could not prove LPN #133 willfully did not try to kill him. Subsequent interview with the detective on [DATE] at 12:40 P.M., revealed he completed his interview with LPN #133. He showed the LPN her written statement the facility provided and asked if the events were written in correct order and everything was correct to the statement she made to the facility. The LPN verified her statement was correct, it was signed and there were no changes that needed to be made. The LPN told the detective if she had remembered she forgot to replace the [CONDITION(S)] mask then she would have gone back to the room and applied it. The LPN said she felt her assignment at the facility was not hectic and was not distracted at the time of providing [CONDITION(S)] care for Resident #78 on [DATE]. Interview on [DATE] at 2:30 P.M. with LPN #133 revealed she worked the 7:00 P.M. to 7:00 A.M. shift. She stated she provided [CONDITION(S)] care to Resident #78 every two hours during her shift. On the morning of [DATE] around 6:45 A.M., she gathered her supplies from the supply closet and completed suctioning, and [CONDITION(S)] care for the resident. She then assisted STNA #122 with cleaning the resident after a bowel movement and completed the dressing change on his buttocks. LPN #133 stated she thought she had replaced the resident's [CONDITION(S)] mask. LPN #133's interview was inconsistent with her written statement and what she told Detective #900. Her statement and what she told the detective was that she completed incontinence care and the dressing change and then completed [CONDITION(S)] care. Interview on [DATE] at 3:37 P.M. with RN #164 revealed she worked the 7:00 A.M. to 7:00 P.M. shift, and her usual assignment was the 200 Hall. Resident #78 resided on the 200 Hall. On the morning of [DATE], RN #164 received morning report from LPN #133, and nothing was mentioned regarding Resident #78 not being connected to his oxygen. She started passing her 7:00 A.M. medications. At around 7:40 A.M. to 7:45 A.M., she gathered her [CONDITION(S)] supplies from the supply room to stock Resident #78's room for the day. Upon entering the room, she noticed Resident #78's lips were blue, and the [CONDITION(S)] tubing was on the floor. She called the resident's name with no response and checked for a pulse. She then called for another nurse to help. LPN #137 came into the room along with several STNAs. His code status was confirmed, the resident was a DNRCC. LPN #137 confirmed there was no pulse, no vital signs or apical heartbeat, and resident was cool to touch. Postmortem care was started. No [CONDITION(S)] mask was found on the tubing. The room was searched, and an unopened mask was found in the bedside supplies, inside a drawer. RN #164 stated the supplies kept at the bedside were for backup. These supplies contain back up tracheostomies, tubing, ties, masks, and suction kits. The floor nurse will restock. She stated Resident #78 required frequent suctioning, so she liked to stock the supplies, so she knows they were available when she needed them. RN #164 stated Resident #78 was bed bound in a semi-vegetative state, had contractures, and could not move his arms or his head. The resident was non-responsive and may open his eyes now and then. Interview on [DATE] at 3:50 P.M. with LPN #137 revealed Resident #78 was bed bound and could not move his arms or head. Resident #78 could open his eyes but slept most of the time. On the morning of [DATE], she entered the room after RN #164 called for help. Upon entering, she noticed Resident #78's lips were blue, and the [CONDITION(S)] tubing was on the floor with no [CONDITION(S)] mask attached. The compressor and condenser were on and functioning. LPN #137 and RN #164 confirmed there was no pulse, no apical heartbeat, and the resident was cool to the touch. RN #164 confirmed the resident had died . Postmortem care was started, and the room was searched for a [CONDITION(S)] mask including checking the bed linens, under the bed, trash can, behind his dresser, and under the resident. No opened mask was found. There was an unopened [CONDITION(S)] mask in the bedside supplies inside a drawer. Interview on [DATE] at 8:33 A.M., with Medical Director #301 revealed Resident #78 was dependent on continuous oxygen via the [CONDITION(S)] mask. He stated he did not feel the resident had the ability to remove the mask. He could not estimate how long the resident could survive without the mask in place. He stated he last saw Resident #78 on [DATE] and the resident had a [CONDITION(S)] mask on at that time and was unresponsive. Interview on [DATE] at 11:25 A.M. with LPN #105 revealed at around 9:15 P.M., he asked LPN #133 if she would like to watch him change the cannula for the [CONDITION(S)] on Resident #78, since she was newer to the facility. He stated she had completed it on her own before, but thought she might like to see his technique. LPN #105 gathered supplies from the supply room, performed the procedure and returned the [CONDITION(S)] mask to its proper position over the [CONDITION(S)] stoma. He checked the resident's oxygen saturation which was 98%. Interview on [DATE] at 3:05 P.M. with the DON revealed all areas on the checklist are reviewed on hire, with [CONDITION(S)] competency covered under the oxygen supplies and care section. Interview on [DATE] at 8:09 A.M. with STNA #122 revealed that when she arrived at the room, LPN #133 was already in the room providing care. Resident #78 was a two-person assist, so both helped with cleaning up the resident after a bowel movement, changing his linens, and changing a dressing on his back. STNA #122 then left the room taking the dirty linens and trash with her. STNA #122 stated when she left the room, Resident #78's [CONDITION(S)] mask was in place. STNA #122 also stated Resident #78 does not move his body but will open and close his eyes. She revealed LPN #133 remained in the room to complete her work after the STNA left. Review of the facility's policy titled Respiratory: [CONDITION(S)] Care, last revised date ,d+[DATE], revealed [CONDITION(S)] care should be performed, ideally, once per day or as often as required to maintain patency of the airway and minimize the risk of infection. The last step in the procedure stated to replace appropriate oxygen source. This deficiency substantiates Complaint Control Number OH 805.

Based on medical record review, review of a Self-Reported Incident (SRI), review of the facility's investigation, review of policy, staff interviews and interview with the local police detective, the facility failed to immediately report potential neglect that resulted in an unwitnessed death of Resident #78. This affected one (#78) resident out of two (#78 and #24) residents identified by the facility to have tracheotomies and dependent on oxygen. The facility census was 77. Finding include: Review of the closed medical record for Resident #78 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had severely impaired cognition and was assessed as requiring oxygen therapy, suctioning, and [CONDITION(S)] care. Resident #78 was assessed as total dependence on staff for bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. Review of the plan of care, dated [DATE], revealed the resident was oxygen dependent due to a [CONDITION(S)]. Interventions included administering oxygen as ordered, monitoring lung sounds, and oxygen saturations. Review of the physician orders, dated [DATE], revealed orders for oxygen administration to be via [CONDITION(S)] mask at six to ten liters per minute. [CONDITION(S)] suctioning was to be conducted every two to four hours. Review of the nursing progress notes, dated [DATE] at 7:50 A.M., revealed Registered Nurse (RN) #164 entered Resident #78's room and found Resident #78 in bed, cyanotic, and unresponsive with no palpable pulse. The Director of Nursing (DON) was notified. RN #164 checked with another nurse for a sign of life. Review of the facility's Self-Reported Incident (SRI) control number 6, created on [DATE] at 3:50 P.M. revealed Resident #78 died after being found in his room with no oxygen supplied to his [CONDITION(S)] at approximately 7:45 A.M. The event was reported eight hours after it occurred. Interview on [DATE] at 12:27 P.M., with the DON stated she entered Resident #78's room around 8:05 A.M. on [DATE] and noticed the [CONDITION(S)] tubing was on the floor with no mask attached. The [CONDITION(S)] mask was not in the room. The DON notified the Administrator of the findings. LPN #133 and STNA #122 were interviewed. LPN #133 was suspended and terminated on [DATE] and the Ohio Board of Nursing was notified. Resident #78 passed away on [DATE], when he was found by RN #164. Resident #78's [CONDITION(S)] tubing was found on the ground with no mask attached. Interview with Detective #900 on [DATE] at 9:28 A.M. revealed he was notified of this incident on [DATE] and has been assigned this case. This was seven days after the event. He said he was investigating it and considering this a felony three charge for reckless homicide. Interview on [DATE] at 2:05 P.M. with Administrator verified the SRI was reported on [DATE] at 3:50 P.M. Review of the policy titled Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated [DATE], revealed in response to allegations of abuse, neglect, exploitation, and mistreatment a facility must: ensure that all alleged violations of abuse, neglect, exploitation, and mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, no longer than two hours after the allegation is made, if the events that caused the allegation involve abuse or caused serious bodily injury; or no later than 24 hours, if the events that caused the allegation do not involve abuse or do not cause caused serious bodily injury, to the Administrator or facility designee, and to other officials, including the state survey agency, in accordance to state laws.

Based on medical record review, hospital record review, staff and family interviews, review of the medication error report, employee education, and review of facility guidelines, the facility failed to ensure residents were free from significant medication errors when one Resident (#07) had not received the appropriate dose of [MEDICATION(S)] (an anticonvulsant medication) upon admission. This resulted in actual harm for Resident #07 when the resident had not received the correct dose of the [CONDITION(S)] medication and had six seizures requiring hospitalization for four days. This affected one Resident (#07) of three reviewed for [CONDITION(S)] medications. The facility census was 75. Findings include: Medical record review revealed Resident #07 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #07 was discharged to the hospital on 01/24/21 for seizures. Review of the hospital records dated 01/14/21 from an encounter date of 01/12/21 revealed this was for an ambulatory referral to a skilled nursing facility. Current medications as of 01/14/21 were [MEDICATION(S)] ([MEDICATION(S)]) 1000 milligram (mg) tablet take two tablets (2000 mg total) by mouth two times a day. [MEDICATION(S)] (blood pressure medication) 5 mg take one tablet by mouth daily. Ensure liquid one can by mouth two times a day. [MEDICATION(S)] (an antihistamine) 50 mg tablet take one tablet by mouth nightly as needed for sleep. [MEDICATION(S)] (anticonvulsant medication) 100 mg tablet take two and a half tablets (250 mg) by mouth two times a day. [MEDICATION(S)] (anticonvulsant medication) 50 mg capsule take by mouth historical medication. Review of the facility admission physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the January 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress note dated 01/24/21 at 5:00 P.M. revealed State tested Nurse Aide (STNA) noted Resident #07 on floor in his room with visible [CONDITION(S)] activity, staff rolled resident to his side and placed pillow under his head, emergency services 911 called, [CONDITION(S)] activity was as follows: The first lasted four minutes, with a five minute rest, the second lasted four and a half minutes, with a one and a half minute rest, the third lasted one minute, with a 30 second rest, the fourth lasted four minutes, with a one and a half minute rest, the fifth lasted two minutes, with a one minute 20 second rest, the sixth lasted four minutes, the emergency services squad arrived, administered medication, and transported the resident to the local emergency room . Review of the local hospital history and physical dated 01/24/21 at 11:39 P.M. revealed the resident presented with chief complaint of break through seizures and today he apparently had five breakthrough seizures and was sent to emergency department for evaluation. The emergency personnel were able to stop the seizures with Versed (a sedative medication). Upon arrival to the Emergency Department he was also given a one-gram loading dose of [MEDICATION(S)]. After reviewing his Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital identified the main one which was the [MEDICATION(S)] was supposed to be 2000 mg twice a day and he had only received 1000 mg twice a day. Review of the hospital progress notes dated 01/27/21 revealed a [AGE] year old male with a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the report the patient was not getting the right dose of [MEDICATION(S)]. Review of the facility medication incident report dated 02/02/21 for an incident on 01/22/21 revealed Resident #07 was given the wrong dose of [MEDICATION(S)]. Nurse #104 placed orders into the online medical record from home medication list, she stated she was unsure of how the medication error occurred. Review of the employee education training document dated 02/02/21 revealed Nurse #104 had been provided education that all admissions should be checked by a second nurse for accuracy and they will be brought to morning meeting to verify medications for all new admissions and readmissions. Interview with the Director of Nursing (DON) on 02/22/21 at 2:32 P.M., revealed when Resident #07 was admitted to the facility on [DATE], Nurse #104 put in the [MEDICATION(S)] medication as 1000 mg one tab twice a day for a daily total of 2000 mg. The order should have been [MEDICATION(S)] 1000 mg two tabs twice a day for a daily total of 4000 mg. The facility policy was to have a second nurse verify the orders are correct and that was not done. Interview with Nurse #104 on 02/23/21 at 10:32 A.M., revealed she copied the medications from Resident #07's medical records and she must have transcribed them wrong. Nurse #104 stated another nurse should have rechecked the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with Resident #07's Family Member on 2/25/21 at 3:35 P.M., revealed it had been nine or ten months since Resident #07 had a [CONDITION(S)] prior to the 01/24/21 seizures. The Family Member stated she went to the facility and checked the medications before he was readmitted back to the facility after hospital admission for seizures on 01/24/21. The Family Member stated the facility gave him the wrong dose of [MEDICATION(S)] and it should have been 2000 mg twice a day however they were only giving him 1000 mg twice a day. The Family Member stated they brought in the bottles and they were correct and current all they had to do was copy the information correctly. Review of facility guideline titled Nursing Admission Check List dated 01/25/19 revealed to transcribe physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficiency substantiates complaint number OH 759.

Based on observation, record review, staff interview, and policy review, the facility failed to ensure the medication error rate was less than five percent. There were 41 opportunities for error with three observed errors which was a calculated medication error rate of 7.3 percent. This affected two Residents (#13 and #30) of eight observed for medication administration. The facility census was 75. Findings include: 1. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order dated 07/30/20 revealed [MEDICATION(S)] extended release ([MEDICATION(S)] ER) 125 mg, prescribed for depression, 125 mg orally (by mouth) two times a day, in the morning and at bedtime. Observation on 02/22/21 at 10:21 A.M., Registered Nurse (RN) #116 was observed administering medications to Resident #13. RN #116 pulled the Artificial Tears (eye drops) out of the cart with the oral medications for administration. RN #116 then crushed all the oral medications including [MEDICATION(S)] extended release ([MEDICATION(S)] ER) 125 milligrams (mg) prescribed for depression and administered them with vanilla pudding per the residents request. Interview with RN #116 on 02/22/21 at 11:06 A.M., verified the [MEDICATION(S)] administered, was extended release, was crushed by RN #116, and was administered via oral route to Resident #13. RN #116 verified extended released medication should not have been crushed. Review of the Facility policy titled, General Guidelines for Medication Administration, dated 06/21/2017 states For tablets that appear on the Do Not Crush List, check with the pharmacist regarding a suitable alternative, and obtain a new order from prescriber, if appropriate, prior to crushing and Refer to Do Not Crush List prior to crushing any medication for assurance that it can be pulverized. 2. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order dated 10/28/20 revealed [MEDICATION(S)] Suspension ([MEDICATION(S)]), a nasal spray corticosteroid used for allergies, 50 micrograms spray in both nostrils one time a day in the morning. Physician order dated 08/12/20 revealed [MEDICATION(S)] Sulfate (Iron Supplement), 325 mg orally one time a day with breakfast. Observation on 02/23/21 at 9:05 A.M., Licensed Practical Nurse (LPN) #117 was observed administering medications to Resident #30. LPN #117 took out all medications for administration. Before entering the resident's room, LPN #117 verified that she was administering all the morning medications. She had not prepared or administered the residents [MEDICATION(S)] or Iron supplement. Interview with LPN #117 on 02/23/21 at 9:15 A.M. verified that she had not administered the [MEDICATION(S)] nasal spray or iron supplement to Resident #30. This deficiency substantiates Complaint Number OH 759.