Every finding on record at Carecore at Mentor

Based on interview and record review, the facility failed to ensure that facility heating units were maintained in good repair. This affected 20 residents (#8, #23, #30, #37, #39, #41, #42, #43, #49, #55, #58, #60, #65, #70, #72, #75, #81, #85, #86, and #93) of 93 residents residing in the facility. The facility census was 93. Findings include: Record review of the Mentor Fire Department Incident Report #26872, dated 01/31/26 at 4:48 P.M., revealed an incident at the facility involving a blower motor belt smoking and causing excessive heat from the conference room heating unit.On 02/04/26 at 9:41 A.M., an interview with the Administrator revealed on 01/31/26, the facility experienced an issue with the heating unit located in the conference room. The Administrator stated that the motor froze on the heating unit which caused the belt to smoke resulting in excessive heat and the activation of the fire alarm system.A review of a facility document titled Monitoring of Heaters, dated 02/04/26, revealed 18 thermostats were not functioning correctly in the following resident rooms (Rooms 102, 105, 110, 114, 115, 120, 121, 201, 204, 207, 220, 307, 309, 319, 320, 321, 409, and 417) affecting 20 residents living in the rooms (#8, #23, #30, #37, #39, #41, #42, #43, #49, #55, #58, #60, #65, #70, #72, #75, #81, #85, #86, and #93) . A review of Service Quote #0002303, dated 02/05/26, confirmed that 21 thermostats required replacement.On 02/05/26 at 10:10 A.M., an interview with the Administrator revealed the day following the incident on 01/31/26, a heating company inspected all heating units in the facility. The Administrator stated the company identified 21 thermostats in need of replacement, including two thermostats located in non-resident areas (medical records and conference room).On 02/05/26 at 11:00 A.M., an interview with the Administrator confirmed that the rooms listed on the Monitoring of Heaters document were resident rooms identified during the heating unit inspection conducted on 02/01/26. A review of the policy titled Quality of Life- Homelike Environment dated 05/2017 revealed residents are provided a safe, clean, comfortable and homelike environment. The policy further revealed the facility staff and management shall maximize to the extent possible the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary, and orderly environment including comfortable and safe temperatures. The deficiency represents noncompliance identified during investigation of Complaint Number 2733141.

Based on closed medical review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to promote healing and to prevent a decline and infection in pressure ulcers. This affected one resident (#87) of three residents reviewed for pressure ulcers. The facility census was 80.Actual harm occurred beginning on 04/30/25 when Resident #87, who was admitted to the facility with two Stage IV (a severe open sore that has penetrated through all layers of the skin and underlying tissue exposing muscle, tendon or bone) pressure wounds was noted to have a deterioration in wound status (green drainage indicative of infection and increase in size). Wound cultures were not obtained until 05/15/25. On 06/06/25 Resident #87 requested to go to the hospital due to complaints of not feeling well (the resident's family had identified the resident had experienced new onset confusion and lethargy during the week prior). The resident was admitted to the hospital for treatment of osteomyelitis. Findings include:Review of the closed medical record for Resident #87 revealed an admission date of 12/17/24 with diagnoses including unspecified injury at C7 level of the cervical spinal cord, injury at C5 level of the cervical spinal cord, chronic obstructive pulmonary disease, quadriplegia, protein-calorie malnutrition, emphysema, neuromuscular dysfunction of the bladder, osteomyelitis (06/04/25), fusion of the spine, contracture of the muscle, and neurogenic bowel. The resident was transferred to the hospital on [DATE] and did not return to the facility. Review of the admission nursing assessment dated [DATE] identified Resident #87 was admitted with a wound with depth on the right buttock and an open wound with depth on the left buttock.Review of the plan of care dated 12/18/24 revealed Resident #87 was at risk for impaired skin integrity/pressure ulcers related to altered sensations, fragile skin, and quadriplegia. Interventions included to apply barrier cream/ointment after each incontinent episode as needed, to elevate heels off the mattress, encourage fluids, encourage to be out of the wheelchair at least two hours daily as tolerated, the nurse to ensure the resident goes to bed timely just before or after dinner, to inspect the skin during routine daily care, peri care after each incontinent episode, pressure reduction devices as ordered, and treatments per order.Review of the plan of care dated 12/19/24 revealed Resident #87 had an actual pressure ulcer, Stage IV right ischium and Stage IV left ischium. Interventions included administering medications per physician orders, explaining all procedures prior to care, monitoring for signs and symptoms of infection, notifying the physician of wound deterioration, providing wound care per physician orders, and referring to the wound physician as needed.Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #87 had two Stage IV pressure ulcers/wounds which were present on admission. Review of the plan of care dated 01/27/25 revealed Resident #87 was non-compliant related to wound care and supplements for wound healing, non-compliant with a preventative pressure reduction mattress, and non-compliant with off-loading the buttocks from the wheelchair throughout the day. Interventions included to document educational attempts made with resident in relation to compliance, and educate the resident, family or responsible party on negative outcomes related to non-compliance. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #87 dated 03/26/25 revealed the resident was cognitively intact. The resident used a wheelchair and was assessed to have limited range of motion (ROM) on both sides. The assessment revealed the resident required substantial (staff) assistance with oral hygiene, dressing, personal hygiene, rolling left and right, and sitting to lying. The resident was dependent on staff for toileting, bathing, sitting to standing, chair to bed transfers, and toilet transfers. The assessment indicated the resident had two Stage IV pressure ulcers present on admission. Review of Resident #87's physician orders from admission through March 2025 revealed to encourage floating heels off the mattress when in bed, a pressure reducing mattress to bed, encouraging oral fluids, heel protection boots while in bed or as needed, encouraging to be out of the wheelchair at least two hours daily as tolerated, and the nurse to ensure resident goes to bed timely just before or just after dinner. Review of Resident #87's treatment orders revealed on 04/09/25 the right and left ischium were dressed with collagen silver calcium alginate (used for managing moderate to heavy draining wounds with antimicrobial protection) followed by a bordered foam dressing daily and as needed (PRN). Review of Nurse Practitioner (NP) #307's wound note dated 04/14/25 revealed the status of both Resident #87's wounds, the right and left ischium, were stable with both measuring 1.0 centimeters (cm) length (L) by 2.0 cm width (W) by 1.0 cm depth (D) for a calculated area of 2.0 square (sq) cm. Review of the NP #307's wound note dated 04/23/25 revealed the status of both Resident #87's wounds, the right and left ischium, stalled with the right ischium having increased in size to 4.5 cm L by 3.0 cm W by 0.8 cm D for a calculated area of 13.5 sq cm, and the left ischium size unchanged. Surgical wound debridement was completed on the right ischium wound.Review of the NP #307's wound note dated 04/30/25 revealed Resident #87's right ischium wound status remained stalled with the wound further increased in size to 5.0 cm L by 4.0 cm W by 0.8 cm D for a calculated area of 20.0 sq cm. There was a moderate amount of green exudate, so the NP recommended a wound culture of the right ischium due to evidence of infection, wound deterioration, increased size, increased drainage, tissue degradation, and stalled healing. A wound culture was taken at the time of the assessment.Review of Resident #87's physician orders for 04/30/25 revealed an order for wound culture for wound care. The wound treatment orders were changed to dress the right and left ischium with silver calcium alginate (used for managing moderate to heavy draining wounds, controlling infection and promoting healing) followed by a bordered foam dressing daily and PRN.Review of the nurse's note dated 05/02/25 at 6:49 P.M. revealed Resident #87's wound culture needed recollected due to integrity. The physician was aware of a new order placed to recollect on the next scheduled lab day (05/05/25). Review of Resident #87's physician orders for 05/06/25 revealed an order for wound culture for wound care.Review of the NP #307's wound note dated 05/07/25 revealed Resident #87's right ischium wound status remained stalled. The wound measured 4.5 cm L by 4.0 cm W by 0.8 cm D for a calculated area of 18.0 sq cm. A moderate amount of green exudate remained present. The left ischium wound status was also stalled with no change in measurements and a moderate amount of serosanguineous (a thin discharge which contains blood and serious fluid). The note indicated the wound culture taken on the last visit by NP #307 per the facility's wound nurse was not completed and sent to the lab. Another order for another culture was pending.Review of Resident #87's physician orders for 05/13/25 revealed an order for wound culture for wound care for two days. The right ischium wound treatment was changed to day shift in lieu of night shift and the left ischium wound treatment was changed to dress with collagen with silver followed by a bordered foam dressing daily and PRN on day shift in lieu of night shift.Review of the NP #307's wound note dated 05/15/25 revealed Resident #87's right ischium wound status continued to be stalled. The wound measured 5.6 cm L by 4.0 cm W by 0.8 cm D for a calculated area of 22.4 sq cm. The wound now had a moderate amount of purulent (pus containing dead white blood cells, bacteria and tissue debris signaling an active infection that needs prompt medical attention) exudate. The left ischium wound status also remained stalled measuring 2.0 cm L by 3.0 cm W by 3.5 cm D for a calculated area of 6.0 sq cm. The wound continued to have serosanguineous exudate. A wound culture was collected. The previous wound cultures (since 05/07/25) were not completed and/or picked up for the lab so no results were available per the facility nursing staff. Imaging was recommended to rule out osteomyelitis as the right ischium bone was exposed and the left ischium bone was covered with fascia (a web of connective tissue).Review of Resident #87's physician orders revealed an order dated 05/16/25 for wound culture for wound care. The NP recommended imaging from 05/15/25; however, this was not ordered until 05/18/25 for Magnetic Resonance Imaging (MRI) to rule out osteomyelitis due to bone being exposed in the right ischium wound and the left ischium bone covered with fascia in the wound. It was not until 05/22/25 when the MRI appointment was ordered for 06/06/25 at 10:30 A.M. via scheduled transport.Review of the nurse's note dated 05/16/25 at 5:28 P.M. revealed Resident #87's wound culture was still pending as of this date.Review of the wound culture results dated 05/19/25 for the specimen collected 05/16/25 revealed it was positive for heavy growth of multiple bacteria.Review of the lab note dated 05/19/25 at 7:49 P.M. revealed Resident #87's labs were reported to the physician and new orders were given.Review of Resident #87's physician orders for 05/19/25 revealed an order for the antibiotic Doxycycline 100 milligrams (mg) orally twice daily for wound infection for 14 days and to make an appointment with infectious disease specialist for the wounds.Review of the medication administration note dated 05/19/25 at 11:49 P.M. revealed Resident #87 received the initial dose of the ordered antibiotic Doxycycline.Additional review of Resident #87's physician orders revealed on 05/20/25 an infectious disease specialist appointment was scheduled for 06/04/25 with a one-time only wound culture and facility staff were to accompany the resident. Review of NP #307's wound note dated 05/22/25 revealed Resident #87 started on contact isolation as of 05/20/25 secondary to the right ischium wound culture results of heavy growth of the bacteria klebsiella pneumoniae and moderate growth of pseudomonas aeruginosa which was a CRPA (Carbapenem resistant Pseudomonas), heavy growth of streptococcus agalactiae group B, heavy growth of probable non-hemolytic streptococcus with no sensitivity done, and moderate growth of diphtheroid bacillus. Doxycycline 100 mg was started on 05/19/25 with an end date of 06/02/25 to be given orally twice daily for the wound infection for 14 days. Imaging to be completed to rule out osteomyelitis. The MRI appointment was scheduled for 06/06/25. The status of both wounds continue to be stalled. The right ischium measured 2.2 cm L by 5.2 cm W by 3.5 cm D for a calculated area of 11.44 sq cm and had moderate amounts of serosanguineous exudate. The left ischium measured 2.5 cm L by 2.0 cm W by 2.1 cm D for a calculated area of 5.0 sq cm and had moderate amounts of serosanguineous exudate. New recommendations for Resident #87's right ischium were from cultures resulted an antibiotic was started, an MRI was scheduled and pending completion, and no debridement until all imaging resulted. New recommendations for the resident's left ischium was debridement which the resident agreed upon. Review of Resident #87's physician orders for 05/23/25 revealed the right ischium wound treatment was changed to cleanse with 0.125 percent Dakin's solution (an antiseptic liquid) then apply Dakin's moistened gauze followed by a bordered foam dressing daily and PRN. The left ischium treatment was changed to cleanse with 0.125 percent Dakin's solution then apply medical grade honey, followed by calcium alginate and a bordered foam dressing daily and PRN.Review of the nurse's note dated 05/23/25 at 8:23 P.M. revealed Resident #87 continued antibiotic therapy with isolation precautions maintained. The resident complained of discomfort and non-pharmacological interventions were ineffective, so PRN medication was administered.Review of NP #307's wound note dated 05/30/25 revealed Resident #87's wounds continued to be stalled and increased in size. The right ischium measured 4.0 cm L by 6.5 cm W by 3.5 cm D for a calculated area of 26.0 sq cm. The left ischium measured 2.6 cm L by 3.4 cm W by 2.1 cm D for a calculated area of 8.84 sq cm. Surgical wound debridement was done on both wounds.Additional review of Resident #87's plan of care revealed it was not revised until 06/05/25 to include an actual infection of Methicillin-resistant Staphylococcus aureus (MRSA). Interventions included administering antibiotic therapy per physician orders, aerosols per physician orders, assessing and monitoring vital signs, notifying physician of changes, encouraging fluids, and providing isolation per protocol.There was no documented information included in the medical record regarding Resident #87's appointment with the infection specialist on 06/04/25. However, a diagnosis of osteomyelitis was added and the physician orders for 06/04/25 revealed a change of antibiotic to Piperacillin, 4.5 grams to be infused intravenously every six hours for MRSA infection of stage 4 wound for six weeks until finished, and a PICC (peripherally inserted central catheter) to be placed for infusion. Review of the run reports for transportation dated 06/06/25 revealed Resident #87 attended the scheduled MRI appointment on 06/06/25. The facility was awaiting results.Review of the physician's orders for 06/06/25 revealed the right ischium wound treatment was changed to cleanse with 0.125 percent Dakin's solution then apply Dakin's moistened gauze with calcium alginate over the peri wound area followed by a bordered foam dressing daily and PRN. The left ischium treatment was changed to cleanse with 0.125 percent Dakin's solution, then apply medical grade honey and calcium alginate with silver followed by a bordered foam dressing daily and PRN.Review of the nurse's note dated 06/06/25 at 6:25 P.M. revealed Resident #87 requested to go to the hospital for overall not feeling well. The resident had periods of confusion and lethargy throughout the day. The resident's family also requested Resident #87 be transported to the hospital due to the resident being confused a few times throughout the week, which was not reflected in the medical record.Review of the nurse's note dated 06/06/25 at 7:24 P.M. revealed Resident #87 left by ambulance to the hospital.Review of the nurse's note dated 06/07/25 at 2:42 A.M. revealed Resident #87 was admitted to the hospital. Attempts to obtain hospital records to review as part of investigation were unsuccessful. Interviews on 09/23/25 at 12:33 P.M. with Licensed Practical Nurse (LPN) #241, at 1:12 P.M. with LPN #255, and at 4:37 P.M. with LPN #242 revealed floor nurses completed all wound care, and the wound care nurse came to the facility once weekly to do wound measurements and follow up with wounds.Interview on 09/23/25 at 1:40 P.M. with Assistant Director of Nursing (ADON) #269 revealed Resident #87 had a wound culture ordered on 04/30/25. On 05/02/25, the lab results stated there was a problem with sample integrity. The facility policy was to have a nurse redo the culture. The repeat culture was not completed until 05/16/25. Interview on 09/29/25 at 1:00 P.M. with Senior Director of Nursing (SDON) #300 revealed Resident #87 was admitted on [DATE] with right and left Stage IV pressure ulcers/wounds. SDON #300 revealed a culture was collected on 05/02/25 and a repeat culture was not completed until 05/16/25 because the resident refused it on 05/15/25 (this was not reflected in the medical record). On 05/20/25 the antibiotic, Doxycycline was ordered and was changed to a different antibiotic on 06/04/25, given IV through a PICC. Interview on 09/30/25 at 8:02 A.M. with LPN #255 revealed Resident #87 had bad wounds but was not compliant by staying up in her wheelchair for too long. However, the LPN stated the resident was compliant with wound dressing changes. Interview on 09/30/25 at 8:46 A.M. with Certified Nursing Assistant (CNA) #239 revealed Resident #87 was very particular. She was alert and oriented, and needed her wound dressings changed every time she had a bowel movement. The resident used a motorized wheelchair and was up before lunch and laid down before dinner. The resident had an air mattress, a wedge pillow at her feet and floated her heels but the CNA stated the resident was non-compliant at times about repositioning. Interview on 09/30/25 at 11:31 A.M. with the wound company's Clinical Lead Nurse, Nurse #308 revealed Resident #87 was admitted with pressure ulcers and had a history of osteomyelitis. The right ischium wound was debrided on 04/07/25. An air mattress was used, and it was recommended for the resident to not be up for more than two hours at a time. Both wounds were stable on 04/21/25. By 04/30/25 there was some mild moisture associated skin damage (MASD) and the right ischium wound had stalled with healing, so the treatment was changed. A culture was ordered but it was not processed. By 05/07/25 both wounds were stalled and per the nurse, the culture was pending as the resident would not allow testing (this was not reflected in the medical record). On 05/15/25 the treatment was changed and the culture was collected. Imaging was recommended on 05/22/25. The culture came back (reflective of infection) and an antibiotic started for 14 days. The resident had an appointment for an MRI on 06/06/25. On 05/30/25 the wounds remained stalled and were debrided. The nurse revealed staff were to assist the resident with side-to-side turns as tolerated. On 06/04/25 the antibiotic was changed for MRSA. During the interview, Nurse #308 verified the wound culture was not completed timely (resulting in a delay in treatment for infection). Nurse #308 revealed the facility should have called the physician for further advice. Nurse #308 identified the pressures ulcers began to decline on 05/15/25. Interview on 09/30/325 at 12:49 P.M. with Resident #87's attending physician, Medical Doctor (MD) #304 revealed the physician was unaware the resident failed to receive a wound culture for two weeks. Interview on 09/30/25 at 4:12 P.M. with Regional Director of Nursing (RDON) #299 verified Resident #87 had a wound culture completed on 05/02/25 that came back with a sample integrity issue and no further wound cultures were completed until 05/16/25. Interview on 12/09/25 at 2:44 P.M. with Administrator revealed the facility had no policy on wound cultures.This deficiency represents non-compliance investigated under Complaint Numbers 2621314 and 1313686 (OH00167120).

Based on closed record review and interview, the facility failed to adequately monitor Resident #85's condition including bowel and bladder elimination to timely identify and treat infection and constipation. This affected one resident (#85) of three residents reviewed for change in condition. The facility census was 80. Actual harm occurred on 06/25/25 after Resident #85 who had cystitis (inflammation of the bladder), reflux, diabetes, impaired cognition and mobility, a high risk for constipation and infection, and a history of sepsis (a life-threatening response to an infection) failed to receive sufficient monitoring to timely treat constipation and infection. The resident developed progressive symptoms throughout the day including an upset stomach, diaphoresis (heavy sweating), vomiting fecal matter, a firm and distended abdomen, hypoxemia (low blood oxygen), a change in mental status, a high heart rate and pallor before being transferred to the hospital and admitted with aspiration pneumonia and a possible small bowel obstruction. Findings include:Review of the closed medical record for Resident #85 revealed an admission date of 04/21/21. The resident was discharged to the hospital on [DATE]. Resident #85 had diagnoses including diabetes, hemiplegia, reflux, epilepsy, aphasia, cystitis, and schizophrenia.Review of the plan of care dated 04/29/21 revealed Resident #85 was at risk for constipation related to decreased mobility. Interventions included to administer medications as ordered, consult dietary for assistance in meeting dietary needs, encourage exercise as tolerated, and encourage fluids if diet and medical diagnosis permit. The care plan identified the resident's risk of infection which was initiated on 06/05/23 for a history of urinary tract infection, but it did not include the risk of infection from diagnoses of reflux, cystitis or a history of sepsis. Interventions included assessments for signs and symptoms of infection including foul smelling or cloudy urine, urine sediment, and decreased urine output, and report findings to the physician, educating on techniques to prevent infection, encouraging fluids, and obtaining labs as ordered.Additional review of the medical record revealed on 02/04/25, Resident #85 completed a kidney ultrasound prior to a urology appointment on 03/11/25. Thereafter on 04/18/25, the resident received a cystoscopy with visual internal urethrotomy (a procedure to open a stricture or scar tissue in the urethra). After the procedure, Resident #85 had an indwelling urinary catheter for three weeks and received a course of oral antibiotics. The catheter was to be removed in the urologist's office at a follow-up appointment scheduled on 05/13/25.Review of a nurse's note dated 05/13/25 at 5:27 A.M. revealed Resident #85 was sent to the hospital for evaluation due to a high heart rate and elevated temperature. The resident complained of feeling chills and was very shaky.Review of a nurse's note dated 05/13/25 at 8:33 A.M. revealed Resident #85 was admitted to the hospital for sepsis and tachycardia (an elevated heart rate).Additional review of the medical record revealed Resident #85 returned to the facility on [DATE] at 8:11 P.M. There was no evidence of comprehensive assessments for infection monitoring as identified in the resident's plan of care after returning from the hospital on [DATE].Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/21/25, revealed Resident #85 had impaired cognition, and was dependent on staff for toileting and transfers. The assessment revealed the resident used a wheelchair for mobility and was occasionally incontinent of bowel and bladder.Review of the Medication Administration Record (MAR) from April to May 2025 revealed Resident #85 had active as needed (PRN) orders related to a risk of constipation which included oral Milk of Magnesia if no bowel movement (BM) after three days (step one), a Dulcolax suppository if no results from Milk of Magnesia (step two) and an enema (step three) if still no results. The records indicate no history of recurrent constipation as evidenced by the unused PRN suppository and enema. Record review revealed the oral laxative, milk of magnesia was administered once on 04/05/25.Review of Resident #85's physician orders effective June 2025 revealed an order to straight catheterize the resident for possible urine retention, and if no bowel movement (BM) after following steps one, two and three to notify the physician. Review of Resident #85's MAR and bowel tracking record for June 2025 revealed Resident #85 had no BM on 06/21/25, 06/22/25, 06/23/25 or 06/24/25. There were no PRN interventions administered for either step one, two or three. On 06/25/25, the resident received a step two suppository, and thereafter had a medium sized loose BM. Per staff stated protocol (interview with Assistant Director of Nursing [ADON] #269 on 09/30/25) and physician orders, step one was not administered on day three of no BM (on 06/23/25), followed by step two if no result and additionally step three if still no result. Review of a nurse's note dated 06/24/25 at 11:01 P.M. revealed Resident #85 was medicated with the analgesic acetaminophen PRN for pain. Review of a nurse's note dated 06/25/25 at 6:33 A.M. revealed Resident #85 complained of stomach upset. Ginger ale was offered and the resident expressed some relief after drinking it. Resident #85's stomach was visibly distended, and the resident could not recall the last time he had a BM, so the nurse administered a PRN laxative to encourage a BM. Review of the nurse's note dated 06/25/25 at 8:34 A.M. revealed Resident #85 was diaphoretic while in the dining room, so Licensed Practical Nurse (LPN) #305 and other unnamed aides assisted him to bed as the resident requested. The nurse documented vitals were completed with an abnormal heart rate elevated at 111, and a firm abdomen with a denial of pain. Bowel protocol was given as ordered, and all morning medications were taken without difficulty. There was no physician notification at this time. Review of the nurse's note dated 06/25/25 at 10:01 A.M. revealed staff documented Resident #85 had a BM (medium sized and loose). Review of the nurse's note dated 06/25/25 at 11:20 A.M. revealed an unnamed nurse and unit manager observed Resident #85 as diaphoretic while resting on the bed. The resident denied pain or discomfort, but the abdomen was firm and distended. Resident #85 had an emesis (vomited). Vitals signs were within normal limits except for an elevated heart rate of 127 and elevated glucose reading of 194. The physician ordered stat (urgent) tests for a KUB (kidney, ureter, and bladder) x-ray, a CBC (complete blood count) and CMP (complete metabolic panel) lab work, and to straight catheterize for urine. Additional review of Resident #85's physician orders for 06/25/25 revealed orders were entered at 11:30 A.M. for stat lab work of a CBC and CMP due to a change in mental status which was not reflected in the nurse's note dated 06/25/25 at 11:20 A.M., and a stat x-ray KUB due to a firm and distended abdomen.Review of the nurse's note dated 06/25/25 at 12:30 P.M. revealed an unnamed nurse and unit manager attempted multiple times to straight catheterize the resident with no urine return. The resident's abdomen remained distended and firm. He continued to have emesis and was pale in color. Vital signs were completed which revealed abnormal oxygenation of 66 percent, so oxygen was administered via nasal cannula. The physician was notified at this time and ordered to send the resident to the hospital immediately. Resident #85 was alert to name and situation. Emergency medical services (EMS) were called and arrived within minutes. The resident had advanced directives for a DNRCC (Do Not Resuscitate Comfort Care) which was provided to EMS upon transport to the hospital. Review of the nurse's note dated 06/25/25 at 5:31 P.M. revealed Resident #85's mother informed the facility of the resident being transferred to another hospital's intensive care unit (ICU). He was placed on a ventilator and had unstable low blood pressure. Review of the physician's note dated 06/25/25 at 9:20 P.M. revealed upon being contacted regarding Resident #85's change in condition, the facility was advised to obtain a KUB, lab work, and start intravenous fluid (this was not reflected in the physician orders), but within the hour the resident's condition worsened. Resident #85 was vomiting what appeared to be fecal material, so the resident was transferred to the hospital emergency room. The physician came to the facility as soon as possible, but the resident was already on his way to the hospital. Interviews on 09/23/25 from 12:33 P.M. until 1:12 P.M. with LPN #241 and LPN #255 revealed bowel movements were tracked on all residents. The aides recorded bowel movements in the electronic plan of care. The nurses then checked the dashboard for a warning which popped up if a resident had no BM after three days. Although the aides were supposed to chart all bowel movements, the LPNs were now also going around and asking the residents. Interviews on 09/23/25 from 1:52 P.M. to 2:19 P.M. with Certified Nursing Assistants (CNAs) #210, #213, #218 and #239 revealed the CNAs recorded resident BMs in the electronic medical record. If residents were independent they asked the residents. Interview on 09/23/25 at 2:19 P.M. with CNA #213 revealed caring for Resident #85 on 06/25/25. On that morning, the resident was pale and it was reported to an agency nurse. The resident complained that his stomach hurt but did not talk well which may be why he did not express as much. Interview on 09/30/25 at 2:57 P.M. with ADON #269 revealed Resident #85 was alert and oriented and he did not usually have any bowel concerns. The ADON revealed if residents did not have BMs it triggered on the dashboard to start the bowel protocol. The bowel protocol was if a resident did not have a BM on the third day then Milk of Magnesia was given. If no results then it was followed by a Dulcolax suppository, and if still no results then an enema was given. If all intervention did not work, the nurse called the physician to get an order for a KUB and did a bowel assessment. ADON #269 stated she called the physician to get a KUB. When they put Resident #85 back to bed his stomach got bigger and then he was sent out. Interview on 12/04/25 at 1:58 P.M. with Attending Physician #306 revealed Resident #85 was well known to the physician. The physician revealed the resident had improved significantly overall during his stay at the facility. He had past urinary issues had had been admitted to the hospital previously with urosepsis. The resident was being followed for his bladder issues. On 06/25/25, the resident was admitted with hospital diagnoses of aspiration pneumonia and a possible small bowel obstruction. The resident subsequently passed away with the cause of death listed as sepsis. However, during the interview Attending Physician #306 did not feel the constipation was the cause of the possible small bowel obstruction or death. This deficiency represents non-compliance investigated under Complaint Number 2595860 and 2568156.

Based on record review and interviews, the facility failed to timely notify Resident #84's family of the resident's hospitalization. This affected one resident (#84) of three residents reviewed for change in condition. The facility census was 80.Findings include:Review of the medical record for Resident #84 revealed an admission date of 06/19/25. Diagnoses included chronic obstructive pulmonary disease (COPD), displaced fracture neck of the left femur, open wound to the left hip, diabetes, presence of left artificial hip, peripheral vascular disease. The resident was discharged to another facility on 07/16/25.Review of the Five-Day Minimum Data Set (MDS) assessment, dated 06/23/25, revealed Resident #84 had intact cognition. Review of the nurses note on 06/21/25 at 7:00 A.M. revealed at around 4:00 A.M. Emergency Medical Services (EMS) arrived at the facility stating they got a call from a female resident that did not know where she was and was afraid. Upon entering room, Resident #84 was on the phone with 911. The resident's call light was not on. The resident had no complaints of pain, no signs or symptoms of respiratory distress, just stated she was scared. EMS asked the resident if she wanted them to take her to the hospital for evaluation and resident stated yes. Resident #84 was taken to the hospital for evaluation.Review of the nurses note on 06/21/25 at 7:10 A.M. revealed Resident #84's spouse was notified of the transfer and he voiced understanding.Review of Resident #84's medical record revealed emergency contact number one was the granddaughter/the Power of Attorney (POA), emergency contact number two was the daughter, the spouse was emergency contact number three. There was no documented evidence to Resident #84's POA/granddaughter was notified she was taken to the hospital.Review of Resident #84's medical record revealed no change of condition form was completed.Interview on 09/29/25 at 12:53 P.M. the Director of Nursing (DON) verified no change of condition form was completed and timely notification to the resident's POA was not made.This deficiency represents non-compliance investigated under Complaint Number 2572360.

Based on record review and interview, the facility failed to timely collect a urine sample and start an antibiotic for a urinary tract infection (UTI). This affected one (Resident #84) of three residents reviewed for timely lab work. The facility census was 80.Findings include:Review of the medical record for Resident #84 revealed an admission date of 06/19/25. Diagnoses included chronic obstructive pulmonary disease (COPD), displaced fracture neck of the left femur, open wound to the left hip, diabetes, presence of left artificial hip, peripheral vascular disease. The resident was discharged to another facility on 07/16/25.Review of the Five-Day Minimum Data Set (MDS) assessment, dated 06/23/25, revealed Resident #84 had intact cognition. The resident required partial/moderate assistance for toileting hygiene, upper body dressing, to roll left and right, and sit to laying. The resident required substantial/maximal assistance for lower body dressing, sit to stand, chair to bed to chair transfer, and toilet transfer.Review of the nurse's note dated 07/07/25 at 7:10 A.M. revealed the previous shift nurse notified this nurse that resident's daughter requested a urinalysis for culture and sensitivity (UA C&S) due to increased confusion. Later in shift, this nurse went to answer the resident's call light, and Resident #84 stated she doesn't know what she is doing, and she thought she had lost her mind. The nurse attempted to collect urine at that time, but the resident stated she had just gone to the restroom. The oncoming nurse was made aware to the need to attempt to collect urine.Review of the social service's note dated 07/07/25 at 1:17 P.M. revealed Resident #84 had a UA C&S ordered due to the resident's increased confusion and daughter's concern.Review of the nurse's note dated 07/11/25 at 7:00 A.M. revealed Resident #84 had positive UA results with the C&S pending.Review of the nurse's note dated 07/14/25 at 1:25 P.M. revealed Resident #84's granddaughter called for updates on UA C&S and labs. The nurse made the granddaughter aware the physician had not given any orders at this time but told the granddaughter she would reach out to the physician and call her with an update.Review of the nurse's note dated 07/14/25 at 3:51 P.M. revealed Resident #84's granddaughter was updated regarding new orders for Macrobid (antibiotic) and iron.Review of physician orders identified orders for Macrobid oral capsule 100 milligrams (mg). Give one capsule by mouth two times a day for UTI for seven days. The order was dated 07/15/25 at 7:00 A.M. (It took eight days for treatment to begin after Resident #84's daughter originally requested a UA C&S).Interview on 09/26/25 at 8:52 A.M. with the Director of Nursing (DON) confirmed the urine sample was not obtained timely, and the antibiotic was not ordered timely. This deficiency represents non-compliance investigated under Complaint Number 2572360.

Based on observation, interview, and review of facility policy, the facility failed to ensure the ice machine filter was clean and sanitary and that staff properly secured and covered their hair while working in the kitchen. This had the potential to affect all residents (except Residents #45 and #85 who were identified by the facility as having orders for nothing by mouth) who received food from the kitchen. The facility census was 84. Findings include: On 07/08/24 from 8:08 A.M. through 8:20 A.M., the initial tour of the kitchen revealed the ice machine filter was not clean and had a layer of dust. Interview at the time of observation with Dietary [NAME] #814 verified the ice machine filter was dirty and it was supposed to be cleaned monthly. On 07/10/24 at 12:26 P.M., an observation of the kitchen revealed Dietary [NAME] #815 was wearing a hairnet on top of her head with long braids hanging down her back which were not covered by the hairnet. Dietary [NAME] #815 began preparing food without securing or covering her long braids. On 07/10/24 at 1:03 P.M., an interview with Dietary Manager #812 verified Dietary [NAME] #815's braids were unsecured and uncovered. She stated that her expectation was for dietary staff to wear hairnets and keep their hair covered. Review of a facility list of resident diets revealed Resident's #45 and #85 received no food by mouth. Review of the facility policy titled Kitchen Sanitation - Cleaning Policies and Procedures, dated 2010, indicated the ice machine should be cleaned on a regular basis to maintain clean and sanitary conditions.

Based on observation, interview, review of email communication between the facility and the repair company, and review of the quote for repairs, the facility failed to maintain the walk-in freezer in a proper working condition and address a malfunction of the freezer door in a timely manner. This had the potential to affect all residents (except Residents #45 and #85 who were identified by the facility as having orders for nothing by mouth) who received food from the kitchen. The facility census was 84. Findings include: Review of the repair quote, dated 05/13/24, revealed Royal Heating and Air Conditioning Service determined the freezer door sweep needed repaired and quoted the facility $288.00 for the repair with an estimated completion date of 07/10/24 through 08/07/24. Review of an email, dated 07/01/24, sent from Royal Heating and Air Conditioning Service to the Administrator revealed the repair company needed confirmation that the repair quote had been accepted and the part needed to be ordered from the vendor. Review of a facility list of resident diets revealed Residents #45 and #85 received no food by mouth. On 07/08/24 from 8:08 A.M. through 8:20 A.M., the initial tour of the kitchen revealed the walk-in freezer had ice buildup at the top and down the side on the inside of the door, there was ice with snow-like consistency covering the floor on the right side of the freezer, ice on 12 boxes of food items on the bottom shelf along the right side of the freezer, and ice on one box of Italian ice cups on the shelf on the left side of the freezer. Interview at the time of observation with Dietary [NAME] #814 verified the ice buildup inside the walk-in freezer and stated the door did not seal properly which caused the ice buildup. Dietary [NAME] #814 said maintenance was aware of the issue and had not repaired it yet. On 07/08/24 at 8:33 A.M., an interview with Dietary Manager #812 confirmed the freezer door was not working properly and maintenance had known about the issue since at least May 2024. On 07/10/24 at 9:10 A.M., an observation of the walk-in freezer revealed there was still ice with a snow-like consistency on the floor along the right side of the freezer. Interview at the time of observation with Dietary Manager #812 verified the presence of ice buildup inside the freezer. She stated Maintenance Director #608 had cleaned up all the ice inside the freezer but more ice had accumulated. On 07/10/24 at 4:08 P.M., an interview with the Administrator verified the repair company sent her an email on 07/01/24 and she confirmed the email did not indicate the needed part had been ordered yet. The Administrator stated the facility had not yet paid for any repairs. On 07/11/24 at 8:57 A.M., an interview with the Administrator confirmed the quote for repair of the freezer was provided to the facility on [DATE]. On 07/11/24 at 9:04 A.M., an interview with Heating and Air Conditioning Service Consultant #843 confirmed the facility was provided a quote for repair of the freezer door on 05/13/24 and he stated the facility did not approve the quote until 07/10/24. On 07/11/24 at 9:15 A.M., an interview with the Administrator and Maintenance Director #608 said the freezer was maintaining an appropriate temperature. Maintenance Director #608 stated there was no need for immediate action when they got the quote for repairs. The Administrator then stated there was a delay in approving the quote because she had been out of the office for the last three weeks and it was not addressed prior to that leave because there was no immediate need for the repair. Maintenance Director #608 stated the facility was deciding between replacing the broken part of the door or replacing the whole door. The Administrator confirmed the repair quote for the freezer was not approved by the facility until 07/10/24.

Based on observation, interview and record review, the facility failed to change nasal cannula oxygen tubing in a timely manner. This affected four residents (#22, #32, #64 and #69) of 18 residents identified as utilizing oxygen. The facility census was 84. Findings include: 1. Review of Resident #32's medical record revealed an initial admitted [DATE]. Resident #32's significant diagnoses included chronic obstructive pulmonary disease. Review of Resident #32's admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident's cognition was intact and used oxygen continuously over the previous seven-day lookback. Review of care plan dated 04/25/24 revealed Resident #32 had an alteration in respiratory function related to chronic obstructive pulmonary disease. Interventions included to provide oxygen as ordered at three liters per minute via nasal cannula. Resident #32's physician orders included to administer oxygen at three liters per minute via nasal cannula to maintain a pulse oximeter reading of 92 percent (%). A review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) dated June of 2024 and July of 2024 revealed no documentation the nasal cannula for Resident #32 was changed. On 07/08/24 at 9:57 A.M. an observation of Resident #32 revealed the resident in bed with oxygen on via nasal cannula. There was no date on the nasal cannula to indicate when it had been changed. An interview with Resident #32 at the time of the observation revealed they were not sure the last time the nasal cannula had been changed. On 07/08/24 at 10:00 A.M. an interview with Registered Nurse (RN) #790 verified there was no date on the nasal cannula for Resident #32. 2. Review of Resident #64's medical record revealed an admitted [DATE]. Significant diagnoses included chronic respiratory failure. Review of Resident #64's quarterly MDS dated [DATE] revealed the resident's cognition was intact and was on continuous oxygen over the previous seven-day lookback period. Review of Resident #64's care plan dated 06/28/24 revealed Resident #64 had an alteration in respiratory function. Interventions included administer oxygen as ordered. Review of Resident #64's physician orders included to titrate oxygen as needed to maintain an oxygen level above 90% via nasal cannula. A review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) dated June of 2024 and July of 2024 revealed no documentation the nasal cannula for Resident #64 was changed. On 07/08/24 at 9:48 A.M. an observation of Resident #64 revealed the resident in bed with oxygen being administered via nasal cannula. The nasal cannula was dated 05/23/24. An interview with Resident #64 at the time of the observation revealed they did not recall nasal cannula being changed. On 07/08/24 at 9:50 A.M. an interview with RN #790 verified the date on Resident #64 nasal cannula as 05/23/24. 3. Review of Resident #69's medical record revealed an admitted [DATE] with significant diagnoses included atherosclerotic heart disease. Review of Resident #69's quarterly MDS dated [DATE] revealed he resident's cognition was impaired. Review of Resident #69's care plan dated 05/31/24 revealed Resident #69 had altered respiratory function. Interventions included to administer oxygen as ordered. Review of Resident #69's physician orders included to administer oxygen at one to four liters per minute via nasal cannula as needed. A review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) dated June of 2024 and July of 2024 revealed no documentation the nasal cannula for Resident #69 was changed. On 07/08/24 at 10:17 A.M. an observation of Resident #69 revealed them sitting up in a bedside chair with oxygen being delivered via nasal cannula. There was not a date on the nasal cannula to indicate when it had been changed. Interview with State tested Nurse Assistant #811 verified there was no date on the nasal cannula at the time of the observation. 4. Review of Resident #22's medical record revealed an admitted [DATE] with significant diagnoses included chronic obstructive pulmonary disease. Review of Resident #22's quarterly MDS revealed the resident had mild cognitive impairment. Review of Resident #22's care plan dated 05/27/24 revealed Resident #22 had an alteration in respiratory function and required oxygen administration. Interventions included to administer oxygen at two liters per minute via nasal cannula. Review of Resident #22's physician orders included to administer oxygen at two liters per minute via nasal cannula to maintain an oxygen level of greater than 92%. A review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) dated June of 2024 and July of 2024 revealed no documentation the nasal cannula for Resident #22 was changed. On 07/08/24 at 10:24 A.M. an observation of Resident #22 revealed them sitting up in a wheelchair with oxygen being delivered via nasal cannula. There was not a date on the nasal cannula to indicate when it had been changed. RN #790 verified there was no date on the nasal cannula at the time of the observation. On 07/10/24 at 9:47 A.M. an interview with Respiratory Therapist (RT) #840 revealed oxygen tubing and nasal cannulas are to be changed weekly. RT #840 also stated tubing is to be dated and initialed when it is changed. A review of the policy titled, Oxygen Administration revealed oxygen tubing and mask/cannula is to be changed weekly and as needed if it becomes soiled or contaminated.

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5 percent (%). A total of 27 medications were observed with two errors identified for a medication error rate of 14.8 %. This affected one (Resident #3) of five residents reviewed for medication administration. The total census was 84. Findings include: Record review of Resident #3 revealed she was admitted [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD), diabetes, visual hallucinations, major depressive disorder, and bipolar disorder. There was no order allowing her to keep medications at the bedside except for her nasal spray. The record review revealed no evidence of a medication self-administration assessment. Resident #3's physician orders dated 01/27/24 revealed orders for Desvenlafaxine 100 milligram (mg) to be given daily in the morning for depression, an order dated 01/24/24 for artificial tears to be given twice daily for dry eyes, an order dated 01/27/24 for FiberCon 625 mg two pills to be given once daily for constipation, and an order dated 01/27/24 for one inhalation of a Fluticasone inhaler to be given daily for COPD. Observation of a medication administration pass for Resident #3 by Licensed Practical Nurse (LPN) #845 on 07/09/24 at 8:14 A.M. revealed the resident was self-administering a Fluticasone inhaler upon entry into the room. The resident had multiple pill containers at the bedside including two bottles labeled Desvenlafaxine (an antidepressant). LPN #845 administered all medications scheduled for that time except artificial tears and FiberCon (a laxative), which she said could not be found. The administered medications included one 100 mg pill of Desvenlafaxine. Interview with Resident #3 at the time of the above observation revealed she frequently ordered her own medications because the facility often did not have the correct medications to give her. She also took a Desvenlafaxine 25 mg pill before the nurse gave her medications, saying she needed a 125 mg total dose of Desvenlafaxine to prevent panic attacks. Interview with LPN #845 at 9:16 A.M. on 07/09/24 confirmed the above findings. Interview with LPN #845 at 11:57 A.M. on 07/09/24 confirmed that Resident #3 had no orders to self-administer medications and that the FiberCon and artificial tears still were not found or administered. The above findings resulted in four medication errors out of 27 observed potentials for error, creating an error rate of 14.8%. Record review of the medication administration policy dated 2001 revealed medications were to be given in accordance with prescriber orders. Residents were only to self-administer medications if the attending physician and interdisciplinary care team had determined they have the capacity to do so safely.

Based on record review, staff interview, admitting facility documents and hospital paperwork, the facility failed to adequately capture Resident #47 health status at the time of the Minimum Data Set Assessments (MDS). This affected one (#47) of one reviewed for dialysis. The facility census was 84. Findings include: Review of the medical record for Resident #47 revealed an admitted [DATE] with diagnoses that included intraductal carcinoma of left breast, end stage renal disease, and dependence on renal dialysis. Review of the physician orders dated 09/05/23 revealed an order for dialysis every Monday, Wednesday, and Friday starting at 5:10 A.M. and ending at 8:25 A.M. at Fresenius Mentor. Review of the care plan dated 03/04/24 revealed Resident #47 had an alteration in health maintenance related to end stage renal disease and received dialysis on Mondays, Wednesdays, and Fridays with interventions that included attend dialysis as ordered, receive treatments as ordered, and monitor, document, and report to physician. Review of the admitting hospital paperwork dated 08/28/23, prior to Resident #47 admittance to the facility, revealed she had end stage renal disease and was on hemodialysis on Mondays, Wednesdays, and Fridays. Review of the facility's document titled New Admission Information Form dated 08/31/23 revealed Resident #47 admitted to the facility with acuities of dialysis listed. Review of the admission and 5-Day MDS assessments dated 09/09/23, the quarterly and modification of quarterly MDS assessment dated [DATE], revealed no dialysis was selected under section O for special treatments, procedures, and programs. Review of the modification of quarterly MDS assessment dated [DATE], revealed the assessment was modified on 07/08/24, approximately 27 days after the MDS assessment was completed and during the annual survey process. Interview on 07/09/24 at 1:50 P.M. with the Director of Nursing (DON) revealed Resident #47 was admitted to the facility as an established dialysis patient in the community and the MDS assessments should have accurately captured dialysis as a treatment. The DON confirmed and verified the findings at the time of the interview. Review of the facility document titled Comprehensive Assessments revised October 2023, revealed the facility had a policy in place that MDS assessments were conducted to assist in developing person-centered care plans that included direct observations and communication with residents, licensed and non-licensed direct care staff on each shift. Review of the policy revealed the facility failed to communicate to accurately complete the MDS assessments.

Based on record review, interview, and review of facility policy, the facility failed to develop and implement a plan of care for use of psychotropic medications for Resident #72. This affected one (#72) of five residents reviewed for unnecessary medications. The facility census was 84. Findings include: Review of the medical record for Resident #72 revealed and admitted [DATE] with diagnoses including schizophrenia, insomnia, and anxiety. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 04/18/24, revealed Resident #72 received an antipsychotic and antidepressant during the seven day lookback period. Review of the comprehensive care plan, last reviewed 04/19/24, revealed there was no care plan for use of psychotropic medications. Review of the physician's orders for July 2024 identified orders for Invega Sustenna (an antipsychotic) intramuscular prefilled syringe 156 milligrams (mg) per milliliter (ml) inject one ml intramuscularly on the first of every month (ordered 04/01/24) and Trazodone Hydrochloride (HCl) (an antidepressant) 25 mg by mouth once daily at bedtime (ordered 05/16/24). On 07/11/24 at 10:07 A.M., an interview with the Director of Nursing (DON) verified Resident #72 had physician's orders for psychotropic medications and there was no care plan in place for the use of psychotropic medications. Review of the facility policy titled Care Plans, Comprehensive Person-Centered and Advance Care Plans, not dated, indicated a comprehensive person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs would be developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to securely administer medications according to Resident #3's needs. This affected one resident (Resident #3) of five residents reviewed for medications. The total census was 84. Findings include: Record review of Resident #3 revealed she was admitted [DATE] and had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), diabetes, visual hallucinations, major depressive disorder, and bipolar disorder. Review of Resident #3's physician orders revealed no order allowing her to keep medications at the bedside except for her nasal spray. She had an active order dated 01/27/24 for Desvenlafaxine 100 mg to be given daily in the morning for depression. She had an order for as-needed acetaminophen and for scheduled Alrex and Fluticasone doses, but no active order for Turmeric. The record review revealed no evidence of a medication self-administration assessment. Observation of Resident #3 on 07/09/24 at 8:14 A.M. revealed she was self-administering a Fluticasone inhaler when the surveyor entered the room. She had medication bottles at her bedside including one bottle of acetaminophen, one bottle of Turmeric (a dietary supplement), one bottle of Alrex (anti-allergy eye drops), and two bottles of Desvenlafaxine (an antidepressant), as well as the Fluticasone. Interview with Resident #3 on 07/09/24 at 8:41 A.M. revealed the facility often did not have her own medications in stock so she ordered her own. She also noted she self-medicated with her own Desvenlafaxine (one 25 milligram pill per day) in addition to the facility-administered dosage (one 100 milligram pill per day) to equal what she felt was the correct dose. Interview with Licensed Practical Nurse #845 on 07/09/24 at 11:57 A.M. confirmed the above findings.

Based on record review, review of hospital records, facility policy review and interview the facility failed to ensure Resident #91 was free from a significant medication error when the facility administered Resident #91's diuretic (medication to increase the production of urine) when it should have been on hold. Actual Harm occurred on 03/29/24 when the facility failed to hold Resident #91's diuretic medication resulting in a significant change in the resident's condition resulting in an unplanned hospitalization . On 03/29/24 Primary Care Physician (PCP) #615 ordered to hold Resident #91's Torsemide (diuretic medication) due to abnormal lab work including an increase in the resident's creatinine level (a test that measured how well the kidneys filter waste from the blood) to 3.3 mg/ deciliter (dl) indicating worsening of her kidney function, repeat the lab work on 04/01/24 and to notify Nephrologist #614 of the results. On 04/01/24 Resident #91's creatinine increased to 5.4 mg/dl; however, the facility restarted the Torsemide medication on this date without a physician order. The facility was unable to contact Nephrologist #614 regarding the increase in creatinine level until 04/03/24 without PCP #615 knowledge. The facility continued to administer Resident #91's Torsemide until 04/03/23 at 4:25 P.M. when the resident was sent to the hospital. Hospital Internal Medicine Physician #900 noted per his history and physical Resident #91 looked remarkedly dry and he suspected uremia (like threatening condition caused by kidney failure and waste build up in the blood). The note also revealed her labs were consistent with over diuresis (excessive production of urine usually caused by diuretics) and if no improvement the resident would require dialysis. This affected one resident (#91) of three residents reviewed for medication administration. The facility census was 87. Findings included: Review of closed medical record for Resident #91 revealed an admitted [DATE]. The resident was transferred to the hospital on 04/03/24 and she did not return to the facility. Resident #91 had diagnoses including partial amputation of her right foot, diabetes, chronic kidney disease, lymphedema, osteomyelitis, and hypertension. Review of March 2024 physician orders revealed Resident #91 had an order dated 03/20/24 for the diuretic medication, Torsemide 20 milligram (mg) one tablet by mouth two times a day for edema. She also had an order to have weekly lab work, a Completed Blood Count (CBC), Basic Metabolic Panel (BMP) and Renal Function Panel (RFP) with the order indicating to fax the results to Nephrologist #614. Resident #91 was on a 1500 milliliter (ml) fluid restriction per day. Review of an After Visit Summary dated 03/09/24 revealed hospital discharge instructions included start diuretics when approved by nephrology. The summary revealed the resident had chronic kidney disease with chronic edema to her bilateral legs. Her Lasix (diuretic) was discontinued in the hospital due to worsening of renal function. There was nothing in the medical record the nephrologist was aware Resident #91 started the diuretic on 03/20/24. Review of lab work dated 03/15/24 for Resident #91 revealed a BMP that indicated the resident's potassium was 3.6 milliequivalent (mEq)/ liter (l), sodium 146 mEq/l, chloride 100 mEq/l , and creatinine 1.1 mg/dl which were all within normal limits. Review of a care plan dated 03/15/24 revealed Resident #91 was at nutritional risk related to diabetes, chronic kidney disease, hypertension, and lymphedema. The resident was on a fluid restriction. Interventions included administering medications as ordered, encourage compliance with fluid restriction as tolerated, and monitor lab values as available. Review of lab work dated 03/20/24 for Resident #91 revealed a BMP that indicated the resident's potassium was 3.6 mEq/l, sodium was 144 mEq/l, and chloride 101 mEq/l which were all within normal limits. The resident's creatinine was slightly elevated at 1.9 mg/dl (Normal was .6 to 1.2). Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #91 had impaired cognition. The assessment revealed the resident required set up help with eating. Review of lab work dated 03/22/24 for Resident #91 revealed a BMP that indicated a sodium level was high at 147 mEq/l (normal was 136 to 145), potassium was low at 3.3 mEq/l (normal was 3.5 to 5.3), and her creatinine increased to 2 mg/dl. The resident's chloride level continued to be 100 mEq/l within normal limits. Review of lab work dated 03/29/24 for Resident #91 revealed a BMP that indicated the resident's sodium had increased to 149 mEq/l, potassium had now decreased to 2.5 mEq/l, chloride decreased to 95 mEq/l, and her creatine now as at 3.3 mg/dl. The lab results showed signs of dehydration and renal failure. Review of a physician progress note dated 03/29/24 at 4:06 P.M. completed by Primary Care Physician (PCP) #615 revealed Resident #91's creatinine had jumped to three and her lab work was getting faxed to nephrology. He revealed under his assessment and plan a diagnosis of acute kidney injury, to hold diuretics, and check lab work on 04/01/24. Review of a nursing note dated 03/29/24 at 5:50 P.M. completed by Licensed Practical Nurse (LPN) #616 revealed PCP #615 was in to see Resident #91 and placed Torsemide on hold until Monday, 04/01/24 after BMP and encourage oral fluids. Review of April 2024 Medication Administration Record (MAR) revealed Resident #91 received the Torsemide 20 mg tablet by mouth after it was supposed to remain on hold on 04/01/24 4:00 P.M. to 6:00 P.M. dose, 04/02/24 both the early morning dose and the 4:00 P.M. to 6:00 P.M. dose, and on 04/03/24 the early morning dose until she was sent to the hospital. Review of lab work dated 04/01/24 for Resident #91 revealed a BMP that indicated the resident's sodium continued to be elevated at 146 mEq/l, potassium was still low at 3.4 mEq/l and her creatinine was now at 5.4 mg/dl. Review of nursing note dated 04/02/24 at 2:31 A.M. and completed by LPN #617 revealed Resident #91's lab work was sent to PCP #615, and he was also sent a message. Review of a nursing note dated 04/02/24 at 8:16 A.M. and completed by Registered Nurse (RN) #618 revealed the resident's lab work was faxed to Nephrologist #614. Review of a nursing note dated 04/02/24 at 10:58 A.M. and completed by RN/ Assistant director of Nursing (ADON) #620 revealed she received a phone call from Nephrologist #614's office stating Resident #91's husband had called the office regarding Resident #91's lab work. The lab work was re-faxed to the office at 10:55 A.M. and no new orders were received as of this nursing entry. Review of a nursing note dated 04/03/24 at 11:30 A.M. completed by RN/ ADON #620 revealed she spoke with Resident #91's husband in the morning as he had questions regarding the resident's current medications and if Nephrologist #614 had called back with any order changes. She informed Resident #91's husband that the lab work was faxed to the Nephrologist #614's office and that she would follow up with the office. Review of a nursing note dated 04/03/24 at 4:25 P.M. completed by RN #601 revealed Resident #91 was sent to the hospital by a rescue squad. There was no other documentation regarding the resident assessment, the condition of the resident, who had ordered her to go to the hospital and the reason why she was sent. Review of the hospital History and Physical dated 04/03/24 and completed per Hospital Internal Medicine Physician #900 revealed Resident #91 looked remarkedly dry and that he suspected uremia (life threatening condition caused by kidney failure and waste build up in the blood). The note revealed her labs show alkalosis consistent with over diuresis (excessive production of urine usually caused by diuretics). Internal Medicine Physician #900 discussed in detail her status with Nephrologist #614 and if no improvement she would require dialysis. Review of Clinical Note from the hospital dated 04/04/24 and completed by Nephrologist #614 revealed he had sent Resident #91 to the emergency room as he was sent lab work which he just became aware of for the first time yesterday afternoon, 04/03/24. The note revealed Resident #91's husband was concerned as his wife was displaying change in mental status including eyes rolling back in her head. The note revealed notably another provider had checked her lab work and stopped her Torsemide (the note does not reference how the facility had restarted the Torsemide on 04/01/24). The note revealed her creatine was 6.7 mg/dl, high sodium level at 149 and she was encephalopathic (disorder that affect the brain including confusion, memory loss and mental changes). The note revealed the resident appeared very dry and showed signs of significant dehydration. He recommended to continue to hold all diuretics. He diagnosed Resident #91 with acute kidney injury, and hypernatremia (low sodium) secondary to significant dehydration. He recommended if by the next morning, 04/05/24 her renal function had not improved, he would have her start dialysis. Interview on 05/06/24 at 4:42 P.M. with RN #601 revealed she was the nurse on duty on 04/03/24 caring for Resident #91. She revealed she could not remember why Resident #91 went to the hospital, who had ordered her to go to the hospital, and/ or her status at the time she was sent to the hospital. She revealed after reviewing the medical record, I cannot believe I did not write anything about it including documenting an assessment. Interview on 05/07/24 at 11:08 A.M. with PCP #615 revealed he thought Resident #91's husband had requested her to start on the Torsemide 20 mg twice a day on 03/19/24 but was unsure. He revealed he then ordered it as he knew she was getting weekly lab work that was being reviewed by Nephrologist #614. He revealed he was at the facility on 03/29/24 and was notified of Resident #91's lab work indicating her creatinine had increased to above three. He revealed he was told Nephrologist #614 was not in the office and since it was a Friday he handled the abnormal lab work. He revealed he placed her Torsemide on hold as residents displaying renal failure signs and dehydration should not continue a diuretic. He revealed he assumed then that the facility would have Nephrologist #614 address her lab work on 04/01/24 and continue to hold the Torsemide until then. He verified that he never gave the order to restart the Torsemide as this needed continued to be held especially since her creatinine on 04/01/24 increased to 5.4 as this medication would affect her kidney function. He revealed he was not informed she had received the Torsemide on 04/1/24 through 04/3/24 (date she was sent to the hospital). He stated, no she should not have. He revealed he was not aware the facility was not able to get a hold of Nephrologist #614 until 04/03/24 and that her lab work had not been addressed. Interview on 05/07/24 at 11:30 A.M. with Resident #91's husband revealed Resident #91 should have never been receiving a diuretic as this was what caused her renal failure to deteriorate. He revealed on 03/29/24 he had expressed concern that his wife was severely dehydrated as her lips/ mouth were severely dry and she was confused with mental status changes. He revealed he was told that they placed Torsemide on hold on 03/29/24 as her creatine level had increased. He revealed he found out that the level continued to rise as the facility kept giving her the Torsemide instead of holding it as it should have been. He revealed he continued to question the facility as she continued to not look well but they seemed to ignore her symptoms especially that she was severely dehydrated, and in renal failure. He revealed on 04/03/24 that since the facility was not doing anything he contacted Nephrologist #614's secretary who had called the facility to have her sent out by 911- emergency rescue services. He revealed at the hospital the resident's creatinine had increased further and that she required emergency dialysis to get her kidneys functioning again. He revealed she now was doing a lot better and no longer required dialysis. Interview on 05/07/24 at 1:41 P.M. with the Director of Nursing verified she had nothing in the medical record to support Nephrologist #614 was aware Resident #91 had started on a diuretic. She also verified Resident #91 had received the following doses of Torsemide when it should have continued to be on hold: on 04/01/24 4:00 P.M. to 6:00 P.M. dose, 04/02/24 both the early morning dose and the 4:00 P.M. to 6:00 P.M. dose, and on 04/03/24. She revealed PCP #615 had contacted her after the interview with this surveyor and had stated the Torsemide should never had been restarted especially because of how high the resident's creatinine level was and that he was not aware that they were having difficulty contacting Nephrologist #614 and that they should have contacted him. Review of facility policy labeled, Administering Medications dated April 2019 revealed medications were to be administered in a safe and timely manner as prescribed. This deficiency represents non-compliance investigated under Complaint Number OH00152934 and Complaint Number OH00152981.

Based on medical record review, facility policy review and interview the facility failed to ensure Resident #91's medical record was complete and accurate. This affected one resident (#91) of nine residents reviewed for accuracy of medical records. The facility census was 87. Findings included: Review of the closed medical record for Resident #91 revealed an admitted [DATE]. The resident was transferred to the hospital on 04/03/24 and did not return to the facility. Resident #91 had diagnoses including partial amputation of her right foot, diabetes, chronic kidney disease, lymphedema, and osteomyelitis. Review of a nursing note dated 04/02/24 at 2:31 A.M. and completed by Licensed Practical Nurse (LPN) #617 revealed Resident #91's lab work was sent to PCP #615, and he was also sent a message. Review of a nursing note dated 04/02/24 at 8:16 A.M. and completed by Registered Nurse (RN) #618 revealed the lab work was faxed to Nephrologist #614. Review of a nursing note dated 04/02/24 at 10:58 A.M. and completed by RN/ Assistant director of Nursing (ADON) #620 revealed she received a phone call from Nephrologist #614 office stating Resident #91's husband had called the office regarding Resident #91's lab work. The lab work was refaxed to the office at 10:55 A.M. and no new orders were received as of this nursing entry. Review of a nursing note dated 04/03/24 at 11:30 A.M. completed by RN/ ADON #620 revealed she spoke with Resident #91's husband in the morning as he had questions regarding her current medications and if the Nephrologist #614 had called back with any order changes. She informed Resident #91's husband that the lab work was faxed to the Nephrologist #614's office and that she would follow up with the office. Review of a nursing note dated 04/03/24 at 4:25 P.M. completed by RN #601 revealed Resident #91 was sent to the hospital by a rescue squad. There was no other documentation regarding the resident assessment, the condition of the resident, who had ordered her to go to the hospital and the reason why she was sent. Interview on 05/06/24 at 4:42 P.M. with RN #601 revealed she was the nurse on duty on 04/03/24 caring for Resident #91. She revealed she could not remember why Resident #91 went to the hospital, who had ordered her to go to the hospital, and/ or her status at the time she was sent to the hospital. She revealed after review of the medical record, I can not believe I did not write anything about it. Interview on 05/07/24 at 1:41 P.M. with the Director of Nursing verified Resident #91's medical record was not complete as RN #601 should have documented a resident assessment, condition of the resident, who had ordered her to go to the hospital and reason why she was sent to the hospital. She verified she had questioned RN #601 as well after the surveyor had brought it to her attention who could not remember why Resident #91 was sent to the hospital and/ or any details which were concerning especially since it was not documented. Review of facility policy labeled, Charting and Documentation dated July 2017 revealed all services provided to the resident, progress toward the care plan goals, or any changes in resident's medical, physical, functional, psychosocial condition shall be documented in the resident's medical record. This deficiency represents non-compliance investigated under Complaint Number OH00152934.

Based on record review, facility policy review and interview, the facility failed to provide comprehensive, individualized and sufficient wound care for Resident #28 and Resident #95. This affected two residents (#28 and #95) of three residents reviewed for non-pressure related wound care. The facility census was 90. Actual harm occurred on 03/21/24 when Resident #28, who was incontinent and admitted for wound care, was directly admitted to the hospital with a foul smelling, pus draining, painful wound and diagnosed with cellulitis/infection due to a lack of monitoring and adequate wound care following the resident's admission on 03/12/24. Findings include: 1. Review of the medical record for Resident #28 revealed an admitted [DATE]. Diagnoses included polyneuropathy, diabetes mellitus type II, congestive heart failure, hidradenitis suppurativa (chronic skin condition which involve lesions from inflammation and infection of sweat glands), pain in hip, dorsalgia (back pain), cervicalgia (neck pain), acute kidney failure, and sciatica (pain down leg from back). Resident #28 was discharged to the hospital on 03/21/24 and returned to the facility on [DATE]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #28 had no cognitive impairment, was occasionally incontinent of urine and frequently incontinent of bowel. Review of the hospital discharge information dated 03/11/24 revealed Resident #28 was treated for a hidradenitis suppurativa (HS) flare of the buttocks with left hip and buttock pain and received antibiotic treatment and zinc oxide paste (medicated paste that treats or prevents skin irritation like cuts, burns, or diaper rash) to the area. The wound care consultant recommended zinc oxide 20 percent ointment applied three times daily. Review of Resident #28's admission assessment dated [DATE] revealed a wound to the left buttock with no description or treatment documented. A weekly skin review dated 03/12/24 also reflected the left buttock wound with no documented description or treatment. In addition, the baseline care plan indicated open areas to the left buttocks. Review of the nursing progress notes dated 03/12/24 revealed Resident #28 was admitted to the facility for wound care. A message was left with the physician to review the admission, but there was no documented evidence the physician verified the admission orders. Review of the wound nurse practitioner progress note dated 03/14/24 revealed Resident #28's left buttocks HS measured 10.0 centimeters (cm) length by 12.0 cm width and 0.1 cm depth. Treatment was indicated to cleanse with normal saline, apply silver alginate (dressing to facilitate wound healing) to the base of the wound and secure with bordered foam twice daily. The nurse practitioner requested this order on 03/14/24 after examination, but the order was not initiated. Review of the skilled nursing note dated 03/14/24 indicated Resident #28 had two areas covered by bandages without a location or further information related to the areas. Review of the nursing progress note dated 03/16/24 revealed Resident #28 called emergency services and indicated not feeling well, wanting narcotics and to be taken to the hospital. Emergency services provided transfer but there was no additional documentation related to Resident #28's complaint. Review of the hospital visit summary dated 03/16/24 revealed Resident #28 was treated at the emergency room for a musculoskeletal problem and returned to the facility. Diagnoses included rib pain and muscle strain of chest wall, initial encounter. Orders were given for Robaxin (muscle spasms and pain) 750 milligrams (mg) every six hours as needed up to three days, and Lidocaine four percent patch (relieves minor pain including nerve pain) daily for five days and remove after 12 hours. Review of Resident #28's physician orders dated 03/17/24 revealed a left buttocks treatment to cleanse with normal saline, dry, apply silver alginate and cover with a foam border dressing twice daily and as needed. There were no treatment orders initiated to the left buttocks prior to 03/17/24. Review of Resident #28's physician orders and medication administration record (MAR) for March 2024 revealed the hospital ordered Robaxin and Lidocaine patches were not ordered or made available to Resident #28 until 03/18/24. These orders should have started on 03/16/24 following the residents return from the emergency room . Review of the wound nurse practitioner progress note dated 03/21/24 revealed Resident #28's left buttocks HS had worsened, measuring 4.0 cm length by 24.0 cm width and 0.1 cm depth, and had a malodourous (foul smelling) odor after cleansing was completed. The wound had a heavy amount of seropurulent exudate (yellow to tan colored secretions). There was a high concern for infection and escalation of care to the hospital was recommended. Arrangements were made for hospital transfer. Review of the nursing progress note dated 03/21/24 revealed Resident #28 was direct admitted to the hospital using emergency services. Resident #28 complained of pain and was medicated with Oxycodone, an opioid pain medication. The progress note was void of the location of the pain. Review of the hospital discharge information dated 03/25/24 revealed Resident #28 was admitted for diagnosis of left hip cellulitis. Resident #28 was presented to the hospital with a left hip infection and had a history of HS of the buttock and received treatment for it at the facility. (The buttock and hip were used interchangeably because the area was large and encompassed both the buttock and hip). Resident #28 reported to the hospital staff the dressing was supposed to be changed twice daily but the facility staff were not doing it, indicating four dressing changes in ten days. Resident #28 developed pain in the left buttock which gradually got worse which required an emergency room visit due to difficulty sitting and standing due to the pain. Intravenous (IV) antibiotic treatment was administered, and wound orders were to wash daily with soap and water, cover with Xeroform (non-adherent dressing) and apply Mepilex (absorbent foam dressing). Review of Resident #28's physician orders dated 03/25/24 revealed the left buttocks treatment order was changed to wash daily with soap and water, cover with Xeroform and cover with Mepilex daily at bedtime. Review of the wound nurse practitioner progress note dated 03/28/24 at 12:59 P.M. indicated the left buttocks HS was a full thickness wound with a mild odor and ordered a new treatment plan to cleanse with normal saline, apply silver alginate to the base of the wound, and secure with an abdominal dressing pad daily. Review of Resident #28's treatment administration records from March 2024 to April 2024 revealed there was no evidence of wound care provided to the left buttock from admission on 03/12/24 until initiated on 03/17/24. The left buttocks wound treatment ordered on 03/17/24 was not signed as completed on 03/19/24 but was signed as completed on 03/22/24 day shift when Resident #28 was no longer in the facility. Additional treatments effective March 2024 including vital signs every shift and laboratory testing were signed as completed on 03/22/24 day shift when Resident #28 was not in the facility. The left buttock wound treatment dated 03/25/24 was administered from 03/25/24 through 04/03/24 and was not changed on 03/28/24 as requested by the wound nurse practitioner. On 04/02/24 at 11:47 A.M. interview with Resident #28 revealed complaints of left hip dressing changes not being completed by facility staff and indicated the dressing was changed four times in the last 11 days which caused an infection. Resident #28 reported trying to talk to the nurses, and no one did anything about it. Pain in the wound area increased so he called emergency services to get help. Then the wound became infected, and Resident #28 was admitted to the hospital. Attempts to observe wound care three times throughout the survey were unsuccessful because Resident #28 refused to allow the surveyor to observe the area. Interview on 04/04/24 at 1:17 P.M. with Director of Nursing (DON) verified the above findings. The DON stated Resident #28's wound was not treated after admission until 03/17/24 but remembered placing a dressing on it on 03/14/24 when Resident #28 complained about treatments not being completed. Despite the complaint, wound treatment orders were not initiated until 03/17/24 when the DON audited the wound notes. The DON notified the physician but did not document it. The DON confirmed Resident #28 contacted emergency services for increased pain and upon return on 03/16/24 was not offered treatment intervention until 03/18/24. The DON indicated a phone call was received at some time by the hospital case manager regarding Resident #28's complaint of no wound care and verified Resident #28 was ultimately admitted with a wound infection. Review of the facility policy, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised April 2018, revealed the staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions, and the physician will order pertinent wound treatments. Review of the facility policy, Pain - Clinical Protocol, revised October 2022, revealed the physician and staff will identify pain, and provide non-pharmacologic and medication interventions to address the pain. 37097 2. Review of the medical record for Resident #95 revealed an admitted [DATE]. Diagnoses included diabetes, neuropathy, cellulitis of the right lower limb, and localized edema. Review of the admission MDS assessment dated [DATE] revealed Resident #95 had intact cognition. Review of physician orders for April 2024 identified orders to cleanse the left shin with normal saline solution, pad dry, cover with form dressing daily and as needed dated 03/01/24. Review of the Treatment Administration Record (TAR) for March and April 2024 revealed ordered wound care was not completed as ordered on 03/12/24, 03/13/24, 03/19/24, and 03/22/24. Interview on 04/04/24 at 3:56 P.M. the DON verified Resident #95 did not receive wound care on the dates noted. This deficiency represents non-compliance investigated under Complaint Number OH00152133 and Complaint Number OH00152075.

Based on interview and record review, the facility failed to provide sufficient tracheostomy care for Residents #19 and #29. This affected two residents (#19 and #29) of three residents reviewed for tracheostomy care. The facility census was 90. Actual harm occurred on [DATE] and on [DATE] when Resident #19, who was cognitively impaired and was dependent on staff for tracheostomy care, was admitted to the hospital with acute on chronic respiratory failure with hypoxia, recurrent infection, and need for mechanical ventilation. On [DATE] there was concern for mucus plugging prior to the hospital stay which contributed to the respiratory failure. From admission on [DATE] through [DATE], there was no evidence Resident #19 received routine ordered tracheostomy care including administering oxygen, continuous monitoring of oxygenation levels, suctioning, changing the cannula, and cleaning the tracheostomy site outside of when the respiratory therapist was in the facility. Findings include: 1. Review of the medical record for Resident #19 revealed an admitted [DATE]. Diagnoses included diabetes mellitus type II, acute respiratory failure with hypoxia, hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side, tracheostomy status, encephalopathy, and chronic kidney disease stage four, severe. Resident #19 was discharged to the hospital on [DATE], re-entered the facility on [DATE], was discharged to the hospital on [DATE], re-entered the facility on [DATE], and was discharged to the hospital on [DATE]. Review of the admission Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #19 was rarely or never understood. The plan of care dated [DATE] indicated a need for tracheostomy care. Interventions included oxygen as ordered, monitor oxygenation levels as ordered, and suction tracheostomy as ordered. Review of Resident #19's physician orders for tracheostomy care revealed effective from [DATE] to [DATE] to change trach circuit every week and as needed; continuous pulse oximeter monitoring; maintain oxygenation greater or equal to 92 percent; suction as needed to clear secretions; oxygen via humidified trach collar on FIO2 (fraction of inspired oxygen) 28 percent two liters per minute (LPM) continuous; speaking valve as tolerated and maintain oxygenation of 92 percent or greater; and trach tube #6 Shiley every 30 to 45 days per respiratory therapy (RT). Effective from [DATE] to [DATE] were orders to suction via trach as needed and may use saline if needed every two hours, and trach care every shift and as needed. Review of Resident #19's medication administration records (MARs) and treatment administration records (TARs) for [DATE] to [DATE] revealed tracheostomy care every shift and as needed was completed. There was no documented evidence the additional effective tracheostomy care orders were completed. Review of the progress notes from [DATE] to [DATE] revealed Resident #19 received varied tracheostomy care less than daily from a respiratory therapist during a scheduled shift in the facility. The care included tracheostomy care, changing of the cannula, suctioning, monitoring of oxygenation levels and respiratory assessment. The documented dates of completed tracheostomy type care were [DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE], [DATE], [DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE], [DATE] to [DATE], and [DATE] to [DATE]. There was no documented evidence nursing provided routine ordered tracheostomy care on dates when a respiratory therapist was not working in the facility. On [DATE] at 8:55 P.M. the primary care physician (PCP) examined Resident #19 and indicated coarse lung sounds were present with upper airway secretions observed. On [DATE] at 3:22 P.M. the PCP examined Resident #19 and indicated rhonchi was present with a copious (abundant) amounts of secretions observed. On [DATE] Resident #19 had bloody sputum and was transferred to the hospital for evaluation and treatment. On [DATE], Resident #19 was sent to the hospital after pulse oxygenation decreased to 78 percent and heart rate was decreasing. Suctioning was performed until all secretions were cleared, but the heart rate still decreased. CPR (cardio-pulmonary resuscitation) was started until emergency services arrived. Resident #19's spouse reported to facility staff of Resident #19 being back on a ventilator. Resident #19 returned to the facility on [DATE]. On [DATE], the PCP examined Resident #19 and indicated rhonchi was present. Resident #19 was taken to the hospital for cardiac arrest, but it appeared it was respiratory failure and infection. On [DATE], Resident #19 had low oxygen saturation. Suctioning was performed and the inner cannula was changed but saturation kept decreasing. Staff bagged for ventilation until emergency services arrived. Review of hospital information from [DATE] to [DATE] revealed Resident #19 was previously admitted on [DATE] for tracheal bleeding and pneumonia with tracheal aspirate positive for multiple organisms which required antibiotic treatment. On [DATE], Resident #19 presented to the hospital post cardiac arrest with acute on chronic hypoxic respiratory failure. CPR was started at the facility and upon emergency services arrival had a heart rate in the 20s. Resident #19 was bagged and upon arrival to the hospital had a heart rate in the 80s and was placed on a ventilator. Resident #19 had decreased breath sounds, wheezing and rhonchi (coarse and loud sound in the larger airways). There was concern for mucus plugging prior to hospital arrival that caused the episode, and concern for pneumonia with sputum culture growing mixed bacteria. Antibiotic treatment was provided. Review of Resident #19's MAR and TAR for [DATE] revealed tracheostomy care every shift and as needed was completed. The suction via trach as needed and may use saline if needed every two hours effective from [DATE] to [DATE] was signed as completed on [DATE] at 10:29 A.M. and 3:00 P.M. There was no documented evidence the additional effective tracheostomy care orders were completed. Review of hospital information dated [DATE] revealed Resident #19 presented to the hospital with hypoxia and respiratory distress. After emergency services suctioned and bagged for ventilation, Resident #19 returned to normal oxygen saturation levels. Resident #19 was unable to respond to questions due to aphasia (difficulty with communication). Diagnoses was acute one chronic respiratory failure with hypoxia due to recurrent aspiration pneumonia, and sepsis. During an interview on [DATE] at 1:52 P.M. with Resident #19's family, the family voiced concerns Resident #19 did not receive adequate tracheostomy care which caused hospital stays and reported the hospital staff indicated Resident #19's trach was filthy. Interview on [DATE] at 9:31 A.M. with the Director of Nursing (DON) indicated Resident #19 was admitted to the hospital on [DATE] due to low pulse oxygenation and possible pneumonia. Interview on [DATE] at 12:22 P.M. with Respiratory Therapist (RT) #281 revealed a lack of routine or adequate suctioning could contribute to infection but was more likely to cause shortness of breath, difficulty breathing or desaturation (decreased oxygenation levels). Interview on [DATE] at 1:42 P.M. with the DON verified the above findings and indicated the respiratory care orders were in place but not visible to the nursing staff so there was no evidence the required care was provided as ordered or outside of when respiratory therapy was present in the facility. 2. Review of the medical record for Resident #29 revealed an admitted [DATE] and re-entry date of [DATE]. Diagnoses included acute respiratory failure with hypoxia, metabolic encephalopathy, tracheostomy status, and dependence on respiratory ventilator status. Review of the quarterly MDS assessment dated [DATE] revealed Resident #29 had no cognitive impairment. The plan of care dated [DATE] indicated a need for tracheostomy care. Interventions included oxygen as ordered, monitor oxygenation levels as ordered, and suction tracheostomy as ordered. Review of the hospital information for facility re-entry on [DATE] indicated Resident #29 had a tracheostomy and collar without mechanical ventilation. Orders included continuous pulse oximetry, oxygen at ten liters per minute and suctioning. Review of Resident #29's active physician orders for tracheostomy care from [DATE] through [DATE] revealed to change trach circuit every week and as needed; change tracheostomy tube every 30 to 45 days and as needed; maintain oxygenation levels greater than 92 percent and respiratory rate less than 30 by continuous pulse oxygenation monitoring every shift; oxygen via humidified trach collar at FIO2 40 percent during daytime hours when respiratory therapy present; suction as needed; and trach care every shift. Review of Resident #29's MARs and TARs for [DATE] to [DATE] revealed no evidence of tracheostomy care orders completed after re-entry to facility on [DATE]. Review of the progress notes from [DATE] to [DATE] revealed Resident #29 received varied tracheostomy care less than daily from a respiratory therapist during a scheduled shift in the facility. The care included tracheostomy care, changing of the cannula, suctioning, monitoring of oxygenation levels and respiratory assessment. The documented dates of completed tracheostomy type care were [DATE] to [DATE], and [DATE] to [DATE]. There was no documented evidence nursing provided routine ordered tracheostomy care on dates when a respiratory therapist was not working in the facility. Interview on [DATE] at 2:03 P.M. with Resident #29 revealed the resident believed tracheostomy care was provided but was not sure if it was completed or how it was supposed to be. Resident #29 indicated calling staff if help with the tracheostomy was needed. Interview on [DATE] at 2:46 P.M. with RT #281 and Licensed Practical Nurse (LPN) #238 while reviewing the electronic medical records verified there were no visible tracheostomy care orders for Resident #29. LPN #238 stated a reliance on RT #281 to perform tracheostomy related care when in the facility, but there was not anything visible for the nurses to follow or sign as completed when RT #281 was not in the facility. RT #281 stated the tracheostomy care orders must not have been put back in place when Resident #29 re-entered the facility on [DATE]. Interview on [DATE] at 3:30 P.M. with the DON verified the above findings. This deficiency represents non-compliance investigated under Complaint Number OH00152226.

Based on observation, interview, record review, and policy review, the facility failed to ensure Resident #62 received nutritional supplements as ordered, failed to develop and implement a comprehensive and effective nutrition program, and failed to obtain re-weights and/or weekly weights when a severe weight loss was noted. This affected one resident (#62) of three residents reviewed for nutrition. The facility census was 90. Actual harm occurred when Resident #62, who weighed 11.0 pounds on 01/04/24, experienced a severe 6.2% weight loss from 01/04/24 to 02/01/24, continued to lose an additional 8.4% from 02/01/24 to 03/01/24, and the weight loss was not addressed until 02/28/24. Resident #62 did not receive nutritional supplements as ordered. Resident #62's weight of 95.4 pounds on 03/01/24 reflected a severe weight loss of 14.5% over 56 days. Findings include: Review of the medical record for Resident #62 revealed an admitted [DATE]. Diagnoses included rheumatoid arthritis (RA), diabetes, lupus, emphysema, Bell's palsy, hypertension (HTN), diabetes mellitus (DM), hyperlipidemia (HLD), schizophrenia, hypothyroidism, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 had intact cognition. The assessment indicated the resident was 63 inches tall and weighed 111 pounds. Weight loss was marked as no or unknown. Review of the physician's orders for diet and nutritional supplements revealed: Consistent Carbohydrate Diet, Mechanical Soft texture, thin consistency Diet was ordered on 07/13/23. Super Cereal (high calorie, nutritious, and fortified cereal) in the morning with breakfast was ordered on 07/28/23. Boost Glucose Control (supplement) every morning and at bedtime eight (8) ounces (oz) between meals from nursing was ordered 09/27/23 and discontinued on 02/28/24. House Supplement with meals four (4) oz No Sugar Added Health Shake (supplement) three times a day with meals. Document percent consumed was ordered on 02/28/24. Regular diet, Mechanical Soft texture, thin consistency was ordered 02/29/24. Weekly weights for four weeks in the morning every Monday until 04/15/24 was ordered on 03/25/24. Review of weights revealed Resident #62 weighed 104.1 pounds on 02/05/24 (a 6% weight loss in one month). Review of the Medication Administration Record (MAR) for February 2024 for the Boost Glucose Control every morning and evening 8 oz between meals from nursing revealed morning intake was 0% (per staff, the 0% was when the resident did not receive the supplement) on 02/05/24, 02/06/24,02/ 07/24, 02/08/24, 02/09/24, 02/10/24, 02/11/24, 02/15/24, 02/16/24, 02/19/24, 02/20/24, 02/21/24, 02/22/24, 02/23/24, 02/24/24, 02/24/24, 02/25/24, and 02/26/24. Evening intake was 0% on 01/03/23, 02/04/24, 02/0524, 02/06/24, 02/07/24, 02/08/24, 02/09/24, 02/14/24, 02/15/24, 02/16/24, 02/18/24, 02/19/24, 02/20/24, 02/22/24, 02/24/24, and 02/25/24. Review of the nutrition note dated 02/28/24 at 1:40 P.M. authored by Registered Dietitian (RD) #282 revealed Resident #62 received a regular diet and liquids, mechanical soft meats, and protein. The resident had a pork intolerance. Meal intakes 50-100% consumption which is adequate, accepts fluids well. No skin issues or edema noted at this time per skin assessments. Recommended DC Boost Glucose Control due to corporate formulary update, recommending a four ounce No Sugar Added Health Shake three times daily with meals for 600 calories and 24 grams of protein daily; document percent consumed on the medication administration record (MAR). Continue Super Cereal as ordered. Will monitor upcoming March weight. The physician was notified of the significant weight loss. Review of weights revealed Resident #62 weighed 95.4 pounds on 03/01/24 (an additional 8% weight loss). Review of the medical record revealed no documented evidence a re-weight was obtained. Review of the medical record revealed no re-weight or weekly weight was documented after 03/01/24. Review of the nutritional care plan (initiated 07/13/23), last revised 03/21/24, revealed the resident was at risk for altered nutrition and dehydration related to multiple medical conditions including HTN, RA, lupus, emphysema, DM, HLD, schizophrenia, hypothyroidism, anxiety. The care plan reflected the resident had a pork intolerance and use of a mechanically altered diet. Therapeutic diet (supplement with meals). The resident's March (2024) weight indicated serious weight loss trend and underweight status. The resident was at risk for malnutrition related to serious weight loss and underweight status as evidenced by a body mass index (BMI) less than 18.5 and chronic disease. The interventions included supplements with meals three times a day, super cereal, and weekly weights. Review of the nutrition note dated 03/21/24 authored by RD #282 revealed Resident #62 received No Added Sugar Health Shakes three times daily with meals. Meal intake average 75-100% most meals per intake records. Dietary caters to food preferences and offers Super Cereal in the morning with breakfast. No chewing or swallowing difficulty reported. Weight history reviewed, noted September 2023 to January 2024 weights between 111 - 115 pounds. February weight was 104.1 pounds. Resident #62 remains at risk for altered nutrition and dehydration related to multiple medical conditions including hypertension, rheumatoid arthritis, lupus, emphysema, diabetes mellitus, hyperlipidemia, schizophrenia, hypothyroidism, anxiety, pork intolerance, mechanically altered diet, therapeutic diet (supplement with meals), significant weight loss and underweight status. Resident #62 is at risk for malnutrition related to significant weight loss as evidenced by body mass index less than 18.5, and chronic disease. Requests re-weight to confirm current body weight. Requests weekly weights times four weeks to monitor for trends. On 03/21/24 a request for diagnosis of at risk for malnutrition form was completed for Resident #62 based on the following criteria: Involuntary loss of 10% or more of usual body weight within six months, or involuntary loss of greater than or 5% or more of usual body weight in one month. BMI less than 18.5 (weight in kilograms divided by the square of height in meters (kg/m2) or greater than 25 kg/m2 and chronic disease. It was signed by the dietitian on 03/21/24 and approved by the physician on 03/21/24. Review of the medical record revealed no physician notes regarding nutrition or weight status in the medical record. Review of the MAR for March 2024 for the No Sugar Added House supplement revealed Resident #62 drank 100% or 0%. The 0% was when the resident did not receive the supplement. Breakfast was 0% on 03/03/24, 03/14/24, 03/15/24, 03/16/24, 03/20/24, 03/24/24, 03/27/24, 03/28/24, and 03/31/24. Lunch was 0% on 03/04/24, 03/14/24, 03/15/24, 03/17/24, 03/20/24, 03/24/24, 03/28/24, 03/29/24, and 03/31/24. Dinner was 0% on 03/02/24, 03/09/24, 03/11/24, 03/13/24, 03/14/24, 03/15/24, 03/20/24, 03/24/24, 03/27/24, 03/28/24, 03/29/24, and 03/31/24. Interview on 04/03/24 at 12:46 P.M. with Resident #62 revealed the resident stated she often didn't receive her sugar free supplement. She thought maybe the facility had been out of the sugar free ones. Observation on 04/03/24 at 12:12 P.M. and 12:46 P.M. of the lunch meal revealed Resident #62 did not have a supplement on her lunch tray. Interview on 04/03/24 at 1:16 P.M. with Dietary Manager, #285 revealed the facility had ginger ale per request. For supplements the facility carried Mighty Shakes, Sugar Free Mighty Shakes, boost pudding for medication administration, and Gelato magic cups. The Sugar Free Mighty Shakes had just come in and might have still been frozen. The Dietary Manager revealed the facility did not have a problem getting supplements. The dietary aide was responsible to place the supplements on the resident meal trays. Interview 04/03/24 at 1:40 PM. RD #282 revealed the RDs run a monthly report on weight loss. When they see weight loss, they try to figure out the cause. If the weight loss was unplanned, the RDs see if the resident was eating. The kitchen could offer extra portions, health shake mighty. The facility carried a protein supplement and a high protein pudding. Interview on 04/04/24 at 3:56 P.M. the Director of Nursing (DON) verified the above dates/meals a nutritional supplement was not received by Resident #62. Review of the MAR for April 2024 for the No Sugar Added House supplement revealed Resident #62 drank 100% or 0%. The 0% was when the resident did not receive the supplement. Breakfast was 0% on 04/15/24. Lunch was 0% on 04/17/24 and dinner was 0% on 04/13/17/24, 04/17/24, and 04/18/24. Interview on 04/19/24/ at 9:27 A.M. with the DON revealed weight loss was followed up on at the weekly risk management meetings. RD #282 sent an email at least weekly regarding resident's nutritional concerns. Interview on 04/19/24/ a 9:43 A.M. with Licensed Practical Nurse (LPN) /Unit Manager #247 revealed nursing did not notify the RD of weight loss. The RD reviewed weights and contacted the facility. The RD notified the physician of nutritional concerns. The unit manager and the nurses were responsible for making sure weekly weights were completed as ordered. LPN /Unit Manager #247 verified no weights were documented in the medical record for Resident #62 after 03/01/24. Interview on 04/19/24 at 10:58 A.M. with the DON verified no weights were documented in the medical record for Resident #62 after 03/01/24, and there had been no new orders due to the resident's weight loss. Interview on 04/19/24 at 11:12 A.M. with RD #282 revealed nursing did not notify the RD of residents with weight loss, the RD tracked it. The RD verified there was no nutrition note documented until 02/28/24 after the resident's weight loss documented 02/05/24, 23 days earlier. Weight loss residents were normally monitored weekly. The RD stated they might not write a note if there was no new information. RD #282 revealed Resident #62 was originally offered Boost, due to formulary changes made 02/28/24, the only option was to provide the house supplement. RD #282 did not usually recommend an appetite stimulant because she avoided adding additional medication. The physician or nurse practitioner sometimes ordered an appetite stimulant. RD #282 notified the physician of all resident nutritional concerns weekly on one form. Review of the Weight Assessment and Intervention policy, dated 03/2022, revealed residents were weighed upon admission and at intervals established by the interdisciplinary team. Weights were recorded in each unit's weight record chart and in the individual's medical record. Any weight change of 5% or more since the last weight assessment was retaken the next day for confirmation. If the weight was verified, nursing would immediately notify the dietitian in writing. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months- 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. This deficiency represents non-compliance investigated under Complaint Number OH00152036.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff used appropriate infection control practices by not implementing required enhanced barrier precautions for Residents #19 and #61, appropriately handling soiled linen and paper hand towels for Resident #61, and not performing hand hygiene and using a clean barrier during wound care for Resident #22. This affected three residents (#19, #22 and #61) and had the potential to affect all 90 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #19 revealed an admitted [DATE]. Diagnoses included respiratory failure, tracheostomy status, and gastrostomy status. Hospital documentation dated 03/17/24 indicated a positive MRSA (Methicillin-resistant Staphylococcus aureus) which was a recognized MDRO (multidrug-resistant organism). Review of the medical record for Resident #61 revealed an admitted [DATE]. Diagnoses included respiratory failure, gastrostomy status and tracheostomy status. Observation on 04/02/24 at 9:45 A.M. revealed Resident #61 was in bed and had a tracheostomy and gastrostomy tube. There were no enhanced barrier precautions (EBP) posted and no PPE (personal protective equipment) available at the room entrance. Observation on 04/02/24 at 9:47 A.M. revealed Resident #19 was in bed and had a tracheostomy. There were no posted EBPs and no PPE available at the room entrance. Observation on 04/02/24 at 12:07 P.M. revealed Licensed Practical Nurse (LPN) #238 at Resident #19's bedside and had completed a dressing change to Resident #19's tracheostomy. There were no posted EBPs and no PPE available at the room entrance. LPN #238 wore gloves and no gown. Observation on 04/03/24 at 10:46 A.M. revealed State tested Nursing Assistant (STNA) #211 performed incontinence care for Resident #19. There were no posted EBPs and no PPE available at the room entrance. STNA #211 wore gloves and no gown. Observation on 04/03/24 at 10:59 A.M. revealed Respiratory Therapist (RT) #281 performed tracheostomy suctioning, cannula cleaning, and dressing change for Resident #61. There were no posted EBP's and no PPE available at the room entrance. RT #281 wore gloves and no gown. Interview on 04/03/24 at 12:26 P.M. with LPN #247 and Director of Nursing (DON) verified Residents #19 and #61 did not have posted EBPs or PPE available at the room entrances. The DON indicated only just receiving the training regarding EBP on 04/01/24 and although knowing the requirement was effective had not yet trained the facility staff. Review of the facility policy, Enhanced Barrier Precautions, dated August 2022, revealed EBPs are used as an infection prevention and control intervention to reduce the spread of MDROs to residents, and are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Review of the memorandum, QSO-24-08-NH, entitled Enhanced Barrier Precautions in Nursing Homes, dated 03/20/24, by the Centers for Medicare & Medicaid Services, Department of Health & Human Services revealed enhanced barrier precautions are indicated for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. The effective date for implementation of enhanced barrier precautions under the guidelines was 04/01/24. 2. Review of the medical record for Resident #61 revealed an admitted [DATE]. Diagnoses included respiratory failure, gastrostomy status and tracheostomy status. Observation on 04/03/24 at 10:59 A.M. with RT #281 of tracheostomy care for Resident #61 revealed RT #281 entered the bathroom and performed hand washing. There was a small, soiled towel balled up and placed on the left sink area next to where RT #281 performed hand washing. The towel appeared wet and had a large amount of brown and yellow substance throughout with moist stringy brown mucus visible. Upon completion of hand washing, RT #281 noted there were no towels to dry hands then left the room with the soiled towel still in place on Resident #61's sink. RT #281 returned with a large roll of continuous paper towel used for the dispenser located on the bathroom wall. RT #281 placed the roll of paper towels on the back of the toilet on top of the toilet tank then proceeded to perform hand washing again with the same visibly soiled towel still on the left sink area and used the soiled roll of paper towels for hand drying. Interview at the time of the observation with RT #281 verified the soiled linen was not appropriately handled and needed to be removed. RT #281 removed the soiled linen, returned to Resident #61's bathroom, performed hand washing, and used the soiled roll of paper towel for hand drying. RT #281 proceeded to perform tracheostomy care including suctioning, cleaning of tracheostomy, and changing of the dressing. Multiple glove changes were performed with hand washing as required; however, RT #281 continued to use the soiled roll of paper towel for hand drying during the procedure. An additional interview at the time of the observation with RT #281 verified the roll of paper towel was soiled and used for hand drying during tracheostomy care for Resident #61. Review of the facility policy, Departmental (Environmental Services) - Laundry and Linen, revised January 2014, revealed all soiled linen must be placed directly into a covered laundry hamper which can contain the moisture and place any linen saturated with blood or body fluids into a leak-resistant bag before placing it into the hamper. 3. Review of the medical record for Resident #22 revealed an admitted [DATE]. Diagnoses included gastrostomy status, tracheostomy status, colostomy status, chronic respiratory failure, hemiplegia, and hemiparesis following cerebral infarction affecting right dominant side, and post procedural complications and disorders of digestive system. The physician orders effective March 2024 indicate an abdominal wound treatment to cleanse with wound cleanser, apply skin preparation, place alginate (wound dressing to promote healing) to the wound base, and cover with a foam dressing daily. Observation on 04/04/24 at 11:28 A.M. with LPN #238 of wound care for Resident #22 revealed posted EBP at the room entrance door with PPE. Resident #22 had a tracheostomy and gastrostomy tube in place. LPN #238 donned a gown and gloves after performing hand washing. LPN #238 placed one of Resident #22's bed pillows on top of the lower extremities then prepared the wound supplies by opening a small abdominal dressing pad and spreading it out on top of the bed pillow. LPN #238 opened and placed the following wound supplies on top of the abdominal dressing pad: two cotton tip applicators, several gauze pads, a skin preparation pad, a calcium alginate dressing, and a foam dressing. Due to the number of supplies, it entirely covered the abdominal dressing pad and portions of the calcium alginate dressing and foam dressing exceeded the size of the pad used as a barrier and rested upon Resident #22's pillow. LPN #238 removed the old dressing with a gloved hand, discarded it then performed hand washing. LPN #238 donned a clean pair of gloves and cleansed the wound with wound cleanser from a spray bottle then used the gauze pads with cotton tip applicators to ensure adequate cleansing. LPN #238 removed the soiled gloves and without performing hand washing or hand hygiene, donned another pair of gloves. Using the unwashed gloved hands, LPN #238 with then applied skin preparation followed by the calcium alginate dressing and foam dressing which were contaminated by Resident #22's pillow. Interview at the time of the observation with LPN #238 verified hand washing or hand hygiene was not performed between gloves changes as required, and the confirmed the clean dressing supplies were not placed on top of an adequate barrier upon a disinfected surface. Review of facility policy, Handwashing/Hand hygiene, revised August 2019, revealed to perform handwashing or hand hygiene after removing gloves. This deficiency represents non-compliance investigated under Complaint Number OH00152036 and Complaint Number OH00152394.

Based on observation and interview the facility failed to maintain a clean and homelike environment within resident hallways and a shower room. This affected eight residents (#17, #24, #33, #35, #38, #46, #55 and #73) and had the potential to affect all 90 residents residing in the facility. Findings include: 1. Observation on 04/02/24 at 9:05 A.M. revealed two unused incontinence briefs stuffed into the handrail outside the room entrance for Residents #33 and #46; a yellow soiled sock on the floor near the room entrance for Resident #24; and a large Starbucks beverage and Starbucks food package placed within the handrail alongside the soiled linen and trash containers placed next to the room entrance for Resident #55. Observation on 04/02/24 at 12:01 P.M. revealed a consumed and dirty breakfast tray placed on top of a heating unit underneath the handrail next to the room entrance for Residents #17 and #38; two unused incontinence briefs stuffed into the handrail outside the room entrance for Residents #33 and #46; a yellow soiled sock previously on the floor now stuffed into the handrail between the room entrances for Residents #24 and #73; a consumed and dirty breakfast tray placed upon the seat of a wheelchair parked near the room entrance for Resident #35; a consumed and dirty breakfast tray placed on top of the soiled linen and garbage container located next to the room entrance for Resident #55. The large Starbucks beverage and Starbucks food package remained located within the handrail alongside the soiled linen and trash container. Interview on 04/02/24 at 12:07 P.M. with State tested Nursing Assistant (STNA) #284 verified the above observations. STNA #284 indicated the dirty meal trays were from residents who received a late breakfast tray and although it needed to go back to the kitchen, was uncertain of the procedure and had not yet been returned. STNA #284 confirmed the Starbucks beverage and food container were items purchased for her breakfast and being from agency did not know where to keep them, so she kept it near her in the resident care area. 2. Observation on 04/03/24 at 12:41 P.M. revealed the 300-hall shower room had no bag in the trash can, and the trash can was overfilled with trash items spilled over onto the floor which included paper towels, wadded up toilet paper, and a candy wrapper. Interview on 04/03/24 at 12:43 P.M. with Licensed Practical Nurse (LPN) #238 verified the above findings in the 300-hall shower room. This deficiency represents non-compliance investigated under Complaint Number OH00152036 and Complaint Number OH00152394.

Based on interview and record review the facility failed to ensure thorough and accurate fall investigations were completed for Residents #5, #94, and #97. This affected three residents (#5, #94, and #97) of four residents reviewed for accidents. The facility census was 90. Findings include: 1. Review of the medical record for Resident #97 revealed a readmitted [DATE]. The resident was discharged to the hospital on 03/12/24. Diagnoses included acute kidney failure, gout, urinary tract infection (UTI), anxiety disorder, diabetes, cirrhosis of liver, fall from chair-subsequent disorder, and ascites. Review of the admission 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #97 had moderately impaired cognition. Review of the nurse's note dated 03/13/24 at 12:56 A.M. revealed the nurse went to Resident #97's room to take her vital signs for blood pressure medication administration. Resident #97 was found on the floor with her back leaning against her bed. Vital signs included temperature 97.7 degrees Fahrenheit (F), blood pressure 79/36, pulse 85, respirations 20, oxygen saturation 97% on room air, 0/10 pain. No injuries were noted. The resident was assisted back into bed. The resident was to be sent to the emergency room (ER) for further evaluation. The family was notified of the fall and the transfer to the hospital. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) #248 were notified as well. Review of the nurses note dated 03/21/24 at 9:09 P.M. revealed Resident #97's risk factors were reviewed by the interdisciplinary team (IDT) related to the fall that occurred on 03/12/024. The root cause of the fall appeared to be impaired cognition/altered mental status/balance deficit. All care plan interventions were in place at the time of the incident, and the resident did not sustain major injury. All previous/current interventions remain appropriate currently to assist in minimizing resident opportunity for fall and injury. Intervention immediately implemented: assessed for injury/pain, assisted to place of safety. The resident was sent to the hospital for altered mental status. Intervention was reviewed and appeared appropriate. All responsible parties were notified of the incident and agreed with the current intervention and plan of care. Fall Investigation into Resident #97's fall on 03/12/24 at 9:30 P.M. revealed the nurse's description of the incident, which was the same as the nursing progress note. No injuries were noted at this time. Physiological factors included the resident was confused and hypotensive. Situational factors were ambulating without assistance, and the resident did not use the call light. The investigation included the IDT note, nurses progress note, a pain assessment, a therapy referral, and a new fall risk evaluation. There were no witness statements. Interview on 04/02/24 at 10:56 A.M. with the family of Resident #97 revealed they had only left the facility about 30 minutes earlier when they got the word the resident had fallen. The nurse found her up against the wall. It was very unclear to them how she could have fallen. She was not talking, not able to transfer, and not able to stand, yet she was found lying up against the wall. The facility called to let us know she had fallen, we said we were on our way. While getting ready, the facility called back and said the resident's blood pressure was low, and she was being sent out in an ambulance. Interview on 04/02/24 at 2:01 P.M. with State tested Nurse Aide (STNA) #211 revealed Resident #97 did not fall. STNA #211 and another STNA were changing her, and the resident was too close to the edge. The resident was placed in a sitting position up against the bed and then one of the STNAs got the nurse. Interview on 04/02/24 at 2:39 P.M. with the DON revealed Resident #97 had a fall and went to the hospital, we were trying to rule out an UTI because her behavior was different. The fall the DON saw documented was during night shift, and the facility had a problem with getting fall witness statements. Interview on 04/04/24 at 9:01 A.M. with the DON revealed there were no witness statements for the fall. The DON stated STNA #211 had an excellent memory and did not doubt his accuracy. Interview on 04/09/24 at 3:33 P.M. verified fall concerns with DON. The DON verified the fall investigation was not thorough and was inaccurate considering STNA #211's interview. The resident had not gotten out of bed and fallen. She was not ambulating without assistance and had not failed to use the call light. 2. Review of the medical record for Resident #5 revealed a readmitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), conduct disorder, cellulitis, and congestive heart failure. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #5 had impaired cognition. Review of the nurse's note date 01/13/24 at 7:11P.M. revealed Resident #5 was noted on the floor lying on the left side close to his bed. The resident denied pain. Resident was assessed. No injuries or skin tears were noted. Neurological checks were initiated, and the resident's vital signs were within normal limits. Review of the Fall Investigation completed 01/13/24 revealed there were no witness statements. The intervention was a perimeter mattress. Observation on 04/04/24 at 12:23 P.M. of Resident #5 revealed there was not a perimeter mattress on the bed. There was no documentation regarding why the intervention of a perimeter mattress was not completed. Interview on 04/04/24 at 9:01 A.M. with the DON revealed there were no witness statements for the falls. Resident #5 refused to get out of bed for us to put the perimeter mattress on. The facility had a perimeter mattress. The DON verified there was no documentation of the refusal. 3. Review of the medical record for Resident #94 revealed a readmitted [DATE]. Diagnoses included fracture of the left femur, diabetes, falls, dementia with agitation, and bipolar disorder. Review of the Annual MDS assessment dated [DATE] revealed Resident #94 had intact cognition. There were no nursing notes regarding Resident #94's fall on 02/12/24. The Fall Investigation for 02/12/24 revealed the fall description did not have enough detail. The nursing description was that the nurse heard a loud noise, and Resident #94 fell . The resident description was that she was trying to pull her pants down and fell . No neurological checks were implemented with an unwitnessed fall. The predisposing factors were listed as poor lighting and incontinence, but these were not addressed in the intervention. There were no witness statements. Interview on 04/09/24 at 3:28 P.M. all fall concerns were verified with the DON. This deficiency represents non-compliance investigated under Complaint Number OH00152036.

Based on observation, record review and interview the facility failed to ensure fall prevention devices were in place as planned, failed to complete thorough fall investigations and failed to implement new fall prevention interventions as needed for Resident #120. This affected one of three residents reviewed for accidents and supervision (Resident #120). The facility census was 98. Harm occurred to Resident #120 when she fell and sustained a laceration to her head requiring an emergency room visit and one staple to close her head laceration and there was no evidence that her fall prevention devices were in place and functioning properly. Findings include: Record review revealed Resident #120 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Review of the Minimum Data Set 3.0 (MDS) assessments dated 02/06/15 and 05/04/15 revealed the cognitive interview was not completed as Resident #120 was rarely or never understood. These assessments indicated the resident had short and long term memory deficits and was severely cognitively impaired for decision making. These assessments indicated Resident #120 required extensive assistance with one to two staff for all activities of daily living (ADL), including transfers and walking. The most recent assessment dated [DATE] revealed a cognitive score of three, with scores of zero to seven indicating severe cognitive impairment. Resident #120 still required extensive assistance with one to two staff for all ADL's. All three of these assessments indicated Resident #120 had sustained falls. Record review revealed a care plan for Resident #120's risk for falls and potential injury related to a history of falls, cognitive impairment and weakness was initiated on 12/26/14. Interventions included low bed, mats to floor along her bedside, personal alarm to her chair and bed (ordered 03/30/15), low wheelchair, frequent visualization of resident and having non-skid material on top of the wheelchair cushion. Review of the physician orders [REDACTED]. Resident #120's fall investigations for the last six months were requested. The facility provided documentation for 14 falls sustained by Resident #120 in this time frame. These falls were reviewed with the director of nursing (DON) on 09/24/15 at 2:36 P.M. and the following concerns were identified: 1. On 03/26/15 at 2:05 P.M. Resident #120 sustained a fall. The facility investigation indicated the nurse heard Resident #120's alarm sounding and entered her room to find her on the floor next to her bed with her head towards the foot of the bed, lying on her left side facing the window. She sustained skin tears to her left elbow and left wrist. No measurements or treatments were recorded. The new intervention was to put mats to floor along each side of her bed. 2. On 03/28/15 at 10:48 A.M., the nurse's note provided indicated the nurse was alerted by the STNA that Resident #120 was on the floor. The nurse documented she found her on the floor in front of her wheelchair with her neck against the side of the seat and with her right leg bent at the knee and over the right leg rest and her left leg on the floor. Resident #120 said she didn't know what happened; she just got up and fell down. Reddened areas were noted to the back of Resident #120's right knee and to her back. The nurse indicated the personal alarm was in place but did not sound. The nurse documented the string for the alarm was shortened to disengage sooner and sound if she attempted to stand or ambulate without assistance. The nurse also indicated non-skid material was added to her wheelchair seat on top of the cushion to aid in preventing further occurrences. There was no evidence the facility completed an investigation for this fall to determine the root cause of the fall or if any other inventions may be appropriate to attempt to prevent further falls. 3. A nurse's note on 04/02/15 indicated the nurse was called at 5:00 A.M. to the 400 hall to find Resident #120 being re-seated into her wheelchair. The two STNA's told the nurse they observed Resident #120 slide from her wheelchair onto her stomach onto the floor. The nurse's note indicated Resident #120 sustained a skin tear measuring 1.5 centimeters (cm) long by 0.5 cm wide on her right elbow. There was no documentation that the non-skid material was in her wheelchair as planned since her last fall on 03/28/15. The facility fall investigation listed their new interventions as protective sleeves to her arms, medication review and to place non-skid material to her wheelchair. The facility did not ensure the non-skid material was in her wheelchair as planned after her last fall on 03/28/15 which may have prevented Resident #120 from sliding from her wheelchair. The DON verified this concern. 4. A nurse's note on 04/12/15 at 1:59 P.M. revealed Resident #120 was observed reaching for a wrapper that fell on the floor and she slid out of her wheelchair. There was no documentation in the nurse's note or in the facility fall investigation that Resident #120's personal alarm was in place and sounding or that the non-skid material was in her wheelchair as ordered. This concern was verified with the DON. The new intervention was to put a pouch on side of her wheelchair to put things in so she does not have to hold them. 5. A nurse's note on 04/13/15 at 7:55 P.M. indicated Resident #120 was in her wheelchair in the hall at 7:45 P.M. and then the nurse went into her room at 7:55 P.M. and Resident #120 was on the floor in front of the bathroom door. Resident #120 was bleeding from the right side of her head. The resident received blood thinning medications. She was sent to the emergency room . Review of the skin assessment dated [DATE] revealed the laceration was on the right top of Resident #120's head and was 0.3 cm long by 0.2 cm wide and 0.1 cm deep. This assessment indicated there was one staple to the laceration. The nurse's note on 04/14/15 at 10:55 A.M. indicated Resident #120 had one staple to the small laceration to the top of her scalp on the right side and orders to cleanse the area were obtained. The facility investigation and nurse's notes did not indicate the alarm was in place and sounding on Resident #120's wheelchair or that the non-skid material was in place as ordered. The investigation indicated the STNA was educated on alarms. These concerns were verified with the DON. An additional facility intervention was to lower her wheelchair so her feet could flatly touch the floor. 6. On 05/01/15 at 5:46 P.M., the nurse's notes indicated the nurse heard Resident #120 calling for help and upon entering her room found her lying on the right side of her bed on the floor on her right side. This note indicated Resident #120 had on non-skid socks. There was documentation that her alarm was functioning as the nurse documented she was drawn to the room by the president ' s call for help and not for a sounding alarm. There was no evidence the bilateral floor mats were in place since Resident #120 was documented as lying on the floor. The facility did not complete and provide a fall investigation for this fall to determine the root cause of the fall and for any additional interventions to prevent further falls. The DON provided documentation that an intervention was added for Resident #120 to be up in her wheelchair for all meals. This meant the fall was from her bed. These concerns were verified with the DON. 7. On 05/25/15 at 1:22 P.M., the nurse's note indicated Resident #120 was in her wheelchair at the nurse's station when the alarm sounded and before the nurse could get to her, she slid down from the wheelchair and onto the foot pedals. The facility fall investigation revealed Resident #120 said she did not know what happened and that she must have a slippery butt. The nurse completing the investigation indicating dycem, a non-skid material, was ordered for Resident #120's wheelchair. The facility investigation revealed the non-skid material had been removed from Resident #120's wheelchair. This concern was verified with the DON. 8. On 06/27/15 at 9:00 P.M., the nurse's notes indicated the nurse had just assisted Resident #120 out into the hall from another resident room and she said she was hungry. As the nurse went to get her a snack, she heard the alarm and saw Resident #120 stand and then her knees buckled and she fell on her buttocks with legs out and rolled onto her back. Resident #120 was yelling and rubbing her right hip and she said her back hurt and that she heard a crack in her back when she fell . This note indicated she was wearing non-skid socks and had the non-skid material in her wheelchair. Resident #120 was sent to the hospital and diagnosed with [REDACTED]. The DON indicated a therapy screen was completed. There was no evidence therapy provided any services and no evidence that any other fall prevention interventions were implemented. This concern was verified with the DON. 9. The nurse's note on 07/05/15 at 11:58 P.M. indicated they heard a noise and found Resident #120 on the floor on her left side. This note said there were no injuries and they assisted her up and into her wheelchair with the personal alarm in place. There was no documentation the bed and wheelchair alarms were in place and sounding and no information if Resident #120 fell out of her wheelchair or from her bed. There was no documentation to indicate the mats were on the floor by her bed. The new intervention listed was for frequent visualizations of the resident when she was restless. These concerns were verified with the DON. 10. The facility investigation dated 07/10/15 indicated Resident #120 said she was having a bowel movement and was done. The statement from STNA #29 indicated she put Resident #120 on the toilet and she left her to give her privacy. This STNA said she was keeping an ear out for her but Resident #120 got off the toilet so quick and was already on the floor when she walked into the bathroom. Resident #120 had cognitive impairment, bed and wheelchair alarms and a history of getting up on her own and falling. The STNA left her unattended in the bathroom resulting in a fall. The only intervention listed on the facility investigation was to do a three day bowel and bladder tracking. There was no documentation that this STNA was re-educated or counseled and no other immediate interventions to prevent further falls. These concerns were verified with the DON. 11. The facility provided two witness statements for a fall Resident #120 sustained on or about 07/16/15 but there were no nurse's notes or a fall investigation provided. The statement from STNA #11 indicated she left Resident #120 alone on the toilet to go to the resident's dresser to get a new brief and Resident #120 got up off toilet and fell . She was found between the toilet and the sink on the floor and the nurse was notified. The statement from LPN #30 indicated she was called to the room and Resident #120 said she slipped. She was assessed and no injuries identified. She was assisted back to her wheelchair. There was no documentation that she was wearing non-skid socks and there were no new interventions found documented including re-education or counseling of the STNA who left the resident unattended in the bathroom. These concerns were verified with the DON. 12. On 07/18/15, Resident #120 was documented as rolling out of her bed to the mat with the alarm sounding. There were no injuries or concerns with this fall. It illustrated her continued attempts of getting up unassisted. 13. The facility fall investigation revealed Resident #120 sustained a fall on 08/05/15 while the STNA was getting a brief. This report indicated Resident #120 was nonadherent to waiting for assistance. The section for the cause of the fall indicated the STNA was in the room getting a brief and Resident #120 was supposed to have one on one supervision/assist when she was being assisted with toileting. There was no documentation that the STNA was re-educated or counseled or that any other fall prevention interventions were implemented. 14. The facility fall investigation dated 09/08/15 indicated Resident #120 slid against the wall, was not completely on the floor and was unable to say what she was doing. The third page provided for this fall did not match with the information on the first page about not knowing what the resident was doing. It indicated Resident #120 was being transferred without a gait belt and lost her balance. The first page was dated 09/08/15 and the last page was dated 09/11/15. The DON verified these concerns and indicated the only other documentation she could find in the computer was an entry on the Kardex on 09/10/15 for staff to use a gait belt for transfers. There were no nurse's notes documenting this fall. 15. The facility fall investigation dated 09/19/15 indicated Resident #120 was trying to get up to walk and fell . It indicated she was attempting to toilet herself. There was no information as to whether Resident #120 was in her bed or wheelchair, but assumed she was in her wheelchair since the intervention was to lay her down after dinner. There was no corresponding nurse's note for this fall to indicate an assessment was completed after the fall. There was no documentation that any of the other fall prevention interventions were in place and functioning as planned including alarms, non-skid material in her wheelchair and her wearing non-skid socks. These concerns were verified with the DON. The DON indicated since the resident was attempting to toilet herself the intervention by the nurse to lay her down after meals was not appropriate and she implemented hipsters on 09/22/15 for the resident's protection. On 09/23/15 at 10:25 A.M., Resident #120 was observed up in her wheelchair in the activity room with her chair alarm in place. At 12:35 P.M., Resident #120 was up in her wheelchair in hallway by the nurse's station with her chair alarm in place. On 09/23/15 at 12:35 P.M., an interview was conducted with her nurse, Licensed Practical Nurse (LPN) #10. The nurse indicated Resident #120 has attempted to get up from the toilet and her wheelchair and has fallen. She indicated the fall safety and prevention devices in use included bed and wheelchair alarms, floor mats to both sides of her bed and non-skid material to her wheelchair seat. At 12:40 P.M., LPN #10 assisted Resident #120 to stand and there was no non-skid material in her wheelchair. The nurse went to her room and checked the closet, the night stand, the dresser and in the bathroom and no non-skid material for the wheelchair was found. An interview with State tested Nursing Assistant (STNA) #11 revealed the nursing assistants all worked together and weren't assigned to one particular resident. STNA #11 indicated Resident #120 was gotten up to her wheelchair by nightshift staff. She verified they had toileted Resident #120 during the day but they had not realized the non-skid material was not in the wheelchair. STNA #11 indicated fall interventions were listed on the resident's Kardex. Review of Resident #120's Kardex revealed non-skid material was supposed to be placed in the wheelchair. This deficiency substantiates Complaint Number OH 832.

Based on observation, interview and medical record review, the facility failed to provide supervision to prevent falls for one resident (Resident #44). This resulted in actual harm for Resident #44 when she left the building unsupervised and fell in her wheelchair outside the front door, sustaining bruising and abrasions to her face. This affected one of three residents reviewed for falls. The facility census was 114. Findings include: Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 dated 05/22/14 revealed Resident #44 had severe cognitive impairment. Resident #44 wandered in the facility every day. She was dependent on the assistance of at least one other person for locomotion off the unit. A plan of care to address Resident #44's wandering behavior was initiated on 11/15/13 and revealed Resident #44 propelled herself in her wheelchair. She was alert to herself only and had poor safety awareness. The plan of care indicated Resident #44 was to be distracted from wandering by offering pleasant diversions and structured activities. A plan of care to address Resident #44's risk for falling was initiated on 11/15/13 and indicated Resident #44 was to be provided with a safe environment that included even floors free from spills and clutter. Review of a nursing progress note dated 07/28/14 timed 1:30 P.M. revealed a state tested nursing assistant (STNA) reported to the nurse that a staff member observed Resident #44 on the ground outside after she had tipped over in her wheelchair. Resident #44 sustained a hematoma to her left eye and abrasions to the left side of her face. She was transferred to the emergency room for an evaluation and returned to the facility at 3:00 P.M. with a new [DIAGNOSES REDACTED]. Review of the facility fall investigation revealed Resident #44 exited the facility unsupervised by staff after she had propelled her wheelchair through the main entrance doors when a visitor walked through the doors to leave the building. The investigation revealed the facility admissions coordinator, Licensed Practical Nurse (LPN) #150 happened to look out her office window and noticed Resident #44 was outside. LPN #150 immediately got up to go outside to assist the resident back into the facility but by the time LPN #150 reached the main entrance doors, she saw that Resident #44's wheelchair had tipped over and the resident was lying on her left side on the pavement. An interview with LPN #150 on 08/04/14 at 11:55 A.M. confirmed the above information. LPN #150 stated the visitors who had allowed Resident #44 to leave the building were preoccupied with getting into their car and did not seem to notice Resident #44's fall. She stated no other facility staff were with Resident #44 while she was outside. An interview with the corporate administrator on 08/04/14 at 4:00 P.M. revealed there was a lot of activity with new admissions and visiting families in the main lobby on 07/28/14 when Resident #44 left the building. The corporate administrator indicated the increased commotion made it easier to Resident #44 to exit the building without staff supervision. On 08/04/14 at 8:50 A.M., Resident #44 was observed in her wheelchair. The left side of her face, from her hairline to her chin, was covered in yellow and purple bruises. She had an abrasion on her left temple. Resident #44 stated she had fallen at home when she stepped off the front steps. She stated that her face hurt, then shrugged her shoulders and stated, "But what can I do?" The above deficiency substantiates Complaint Number OH 798.

Based on resident interview, staff interview and record review, the facility failed to accurately assess, revise and implement a toileting program. This resulted in Actual Harm to Resident #19 after a decline from occasionally incontinent to frequently incontinent of urine. This affected one resident, Resident #19, of one resident reviewed for urinary continence. Findings include: Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. The assessment revealed the resident required extensive assistance for transfers and limited assistance for toilet use and hygiene. Resident #19 was assessed as occasionally incontinent of urine, indicating less than seven episodes of urinary incontinence in seven days, and was on a toileting program. A bladder evaluation form dated 08/23/13 revealed the resident was incontinent of bladder related to urgency and unable to suppress, duration 2-5 years, cause noted as impaired mobility/ambulation, contributing [DIAGNOSES REDACTED]. The treatment program was prompted void. The bladder evaluation was updated on 11/24/13, 1/20/14, and 4/22/14 and revealed no changes. The plan of care dated 08/23/13 revealed Resident #19 was incontinent of bladder related to impaired mobility. The goal was Resident #19 would improve in the number of continent episodes through the next review date of 07/23/14. Interventions included to encourage the resident to use the call system or verbalize when assist is needed, establish her normal voiding pattern, provide assistance to use the toilet or bedpan per the normal voiding pattern and as needed, record and monitor urinary voiding in the Activities of Daily Living (ADL) flow record, praise the resident for continent attempts, and psychotherapy and psychiatry consults as needed. Resident #19's record contained a three day bowel and bladder tracker dated 08/29/13 to 08/31/13. An ADL flow record dated 04/16/14 to 04/22/14, the reference period for the MDS assessment dated [DATE], revealed Resident #19 had multiple episodes of urinary incontinence daily on afternoon and night shifts. The quarterly MDS 3.0 assessment dated [DATE] revealed the resident was cognitively intact. The assessment revealed that the resident required extensive assistance for transfers and limited assistance for toilet use and hygiene. Resident #19 was assessed as occasionally incontinent of urine, indicating less than seven episodes of urinary incontinence in seven days, and was on a toileting program. A nurse practitioner progress note dated 05/28/14 stated Resident #19's incontinence [MEDICAL CONDITION] improved, encourage frequent toileting, and reeducated patient on benefits of routine toileting. An interview with State tested Nurse Aide (STNA) #23 on 06/18/14 at 2:30 P.M. revealed Resident #19 had episodes of urinary incontinence at times on day shift. When asked if Resident #19 was on a toileting program, STNA #23 stated, "Every two hours like everybody else in the building." An interview on 06/19/14 at 10:50 A.M. with Licensed Practical Nurse (LPN) #19, the facility's restorative nurse, revealed she coded the urinary continence section of the MDS assessment based on the ADL flow records and the nurse's notes. LPN #19 also indicated the toileting program and plan of care was determined by a three day bowel and bladder tracking record. LPN #19 verified the three day bowel and bladder tracker was dated 08/29/13 to 08/31/13, after the plan of care and toileting program had been updated on 08/23/13. LPN #19 also verified that the ADL flow records dated 04/16/14 to 04/22/14 indicated Resident #19 was frequently incontinent of urine, which showed a decline in urinary continence, with no change in the plan of care or the toileting program. An interview with Resident #19 on 06/19/14 at 1:18 P.M. revealed she has had an increase in urinary incontinence because staff did not take her to the bathroom when they were supposed to. She stated they were to take her to the bathroom, but, "Once in a blue moon somebody comes in." The resident stated she would have less episodes of uninary incontinence if the staff assisted her to the bathroom like they were supposed to. The resident stated that this was upsetting to her.

Based on interview, medical record review and review of a medication discrepancy investigation, the facility failed to ensure Resident #105 was not deprived of a narcotic pain medication that was ordered by her physician, which resulted in the resident suffering twelve hours of unrelieved pain. This affected one resident (Resident #105) of three residents reviewed for pain management. The facility census was 125. Findings include: Resident #105 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #105 was on a scheduled pain regimen. She reported frequent pain that limited her activities. She rated her pain as a seven on a zero to ten scale. A plan of care was initiated on 07/15/13 for Resident #105's chronic pain related to arthritis and diabetic [MEDICAL CONDITION]. Interventions included, but were not limited to, the following: administer pain medications as ordered, anticipate her need for pain relief and respond immediately to any complaint of pain. The August 2013 physician order [REDACTED]. Review of a facility investigation dated 08/19/13 revealed that on 08/16/13, during the 11:00 P.M. to 7:00 A.M. shift, it was brought to the attention of registered nurse (RN) #44 that five pills were discovered hidden under the portable blood glucose monitor machine on the 400 Hall medication cart. One of the pills was found to be [MEDICATION NAME] 5 mg. The facility investigation revealed licensed practical nurse (LPN) #34 signed the [MEDICATION NAME] out on the controlled substance record to indicate it was to be administered to Resident #105 on 08/16/13 at 5:00 P.M. However, Resident #105's August 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the investigation revealed Resident #105, who was assessed to be alert and oriented, was interviewed by RN #44 on 08/17/13. Resident #105 stated that she complained of pain at 5:00 P.M. on 08/16/13. She rated her pain as eight to nine on a zero to ten scale, with ten being the highest level of pain. Resident #105 stated the nurse gave her two pills, which she identified as Extra Strength [MEDICATION NAME] tablets. She indicated the pills she was given were not effective and that she remained in pain. She stated that her pain continued at the level of nine to ten on a zero to ten scale. She indicated she had managed to fall asleep, but had to ask the night shift nurse for a pain pill. Review of the August 2013 MAR indicated [REDACTED].M. on 08/17/13. Resident #105 stated her pain then decreased to a level two on a zero to ten scale within an hour after she received the narcotic pain medication. The above findings were confirmed with RN #44 and the DON on 09/04/13 at 1:00 P.M. This deficiency substantiates Complaint Number OH 480. This deficiency also demonstrates continued non-compliance from Complaint Number OH 084 completed on 07/25/13.