Every finding on record at Carecore at Minster

Based on observation, staff interview, review of manufacturer instructions, and policy review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner. This had the potential to affect all residents who receive food from the kitchen. The facility identified one (#10) resident that did not receive food from the kitchen. The facility census was 56.Findings include:1. Observation of the kitchen on 09/15/25 at 7:49 A.M. revealed one of the two hand washing sinks did not have paper towels to dry hands, the two storage shelves under the preparation tables were covered in a greasy debris. Additional observation revealed greasy debris in the cabinet shelf above the preparation table. The findings were confirmed by Dietary [NAME] (DC) #310 at the time of the observation.2. Observation on 09/15/25 at 7:55 A.M. of the of the four flavor cold beverage juice dispenser revealed a sticky dried on substance on all four nozzles. Further observation revealed a sticky dried substance on top of and under the shelf that holds the bottles of concentrate in the refrigerated section.Interview on 09/15/25 at 7:55 A.M. with Dietary Aide (DA) #355 revealed the four flavor cold beverage juice dispenser was cleaned once a week. Further interview revealed the machine was cleaned about one week ago and was not listed on the daily or weekly cleaning list. DA #355 confirmed the appearance of the juice dispenser at that time. Review of the undated manufacture instructions for the four flavor cold beverage juice dispenser revealed daily cleaning and parts washing instructions included to remove and wash the dispense nozzles, drip tray, and drip tray cover in a mild detergent solution and rinse thoroughly. Further review revealed additional cleaning included wiping the splash panel, areas around dispense nozzle, and refrigerated compartment with a clean, damp cloth. Users are to use a brush and a mild detergent solution to clean inside dispense area where dispense nozzles are removed and rinse clean.3. Observation of the walk-in refrigerator on 09/15/25 at 8:15 A.M. revealed three bags of wilted brown lettuce with a best by date of 09/08/25, three bags of lettuce with the best by date of 09/07/25, and two bags of lettuce with a best by date of 09/09/25. Additional observation revealed three heads of lettuce on a tray that were wilted and uncovered.Interview on 09/15/25 at 8:31 A.M. with the Dietary Manager (DM) #354 stated all products are checked for expiration by one dietary aide every day they work and stated the dietary aide's last day of work was on 09/12/25. Further interview verified the presence of the expired bags of lettuce and the uncovered and wilted lettuce heads. DM #354 stated the lettuce heads are only used for garnish and the best by date was not the same as the expiration date.Review of policy titled, Food Receiving and Storage, revised November 2022, revealed all foods stored in the refrigerator or freezer are to be covered, labeled, and dated with use by date. Additional review revealed refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded.4. Observation of the preparation area on 09/15/25 at 8:22 A.M. revealed DC #310 using a bucket of sanitizer to clean the preparation table. DA #355 tested the sanitizer and revealed concentration sanitizer between 100 and 200 parts per million (PPM).Interview on 09/15/25 at 8:23 A.M. with DA #355 stated the sanitizer concentration must be a minimum of 200 PPM. Further interview stated the bucket between 100 and 200 PPM should be dumped out and a new one should be filled.5. Observation on 09/15/25 at 10:17 A.M. with DC #310 revealed DC #310 completed preparation of a new puree of meat for lunch. DC #310 removed gloves, took the food processor to the dish washing area, washed the food processor, brought it back to the preparation area, put gloves on, then proceeded to handle the meat portions with their gloved hand. Interview on 09/15/25 at 10:41 A.M. with DC #310 verified she did not wash her hands, and stated the dish area was sanitary, so she did not have to wash hands after removing gloves and cleaning the food processor.Review of policy titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, dated November of 2022, revealed employees must wash their hands after handling soiled equipment or utensils and whenever entering or reentering the kitchen.

Based on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure orders for dressing changes were completed as ordered. This affected one (#44) of two residents sampled for dressing changes. The facility census was 56.Findings include:Review of the medical record revealed Resident #44 was admitted on [DATE] with diagnoses including unspecified atrial fibrillation and diabetes mellitus with neuropathy.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognitive function.Review of the care plan for Resident #44 dated 09/18/25 revealed Resident #44 was at risk for impaired skin integrity due to a left lower extremity contusion and a left posterior ankle blister. Interventions included to provide treatment as ordered.Review of physician orders for Resident #44 revealed an order dated 09/12/25 for a dressing to the left lower leg contusion with directions to cleanse with wound cleanser, pat dry, apply calcium alginate, wrap with kerlix, and wrap with Coban The treatment was to be changed every day. Review of Resident #44's physician orders revealed an order dated 09/11/25 for a dressing to a left posterior ankle blister with directions to cleanse with wound cleanser, pat dry, apply betadine, wrap with kerlix, and wrap with Coban. The treatment was to be changed every day.Observation on 09/15/25 at 12:31 P.M. revealed the dressing to Resident #44's left lower leg was wrapped with kerlix but had no Coban. Further observation revealed the treatment was undated and falling off.Interview on 09/15/25 at 12:31 P.M. with Resident #44 stated the dressing was last changed two days ago.Observation on 09/16/25 at 11:47 A.M. revealed Resident #44 with a dressing to the lower left leg, dated 09/15/25, and wrapped with kerlix but not wrapped with Coban.Interview on 09/17/25 at 9:51 A.M. with Licensed Practical Nurse (LPN) #392 verified the order for the dressing change to the left lower leg included a Coban wrap. Further interview verified Resident #44 dressing was not wrapped with Coban.Review of policy titled, Wound Care, dated 2001, revealed the wound should be washed, dried with gauze and treatment applied as indicated in the order.

Based on review of the medical record, observations, staff interviews, and review of the Long- Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure accurate coding on Minimum Data Set (MDS) assessments. This affected one (#50) of five residents reviewed for accidents. The facility census was 56. Findings include:Review of the medical record for Resident #50 revealed an admission date of 09/01/24 with medical diagnoses including convulsions, diabetes mellitus, morbid obesity, and Down syndrome. Review of the medical diagnoses revealed on 08/04/25 Resident #50 was given a diagnosis of a pathological fracture of the right humerus. Review of the medical record for Resident #50 revealed no documentation to support a diagnosis of osteoporosis prior to 08/03/25. Review of the medical record for Resident #50 revealed a discharge Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 08/16/25, which indicated Resident #50 had moderate cognitive impairment and was independent with bed mobility, transfers, and ambulation up to 10 feet. The MDS assessment indicated Resident #50 required supervision only with ambulation up to 50 and 150 feet and did not use a wheelchair. The MDS assessment also indicated Resident #50 had two or more falls with no injury noted since last assessment on 07/16/25. Review of the annual MDS assessment, with ARD of 08/27/25, indicated Resident #50 had moderately impaired cognition, was independent with bed mobility, transfers, and ambulation up to 10 feet and required supervision with ambulation up to 50 and 150 feet. The MDS assessment indicated Resident #50 did not use a wheelchair. The MDS assessment indicated Resident #50 had two or more falls with no injury since readmission on [DATE]. Review of the medical record for Resident #50 revealed a nurse's note dated 08/03/25 at 3:22 A.M. which revealed Resident #50 was found on the floor in his room. The note revealed Resident #50 complained of right shoulder pain and was only able to move his right arm from the elbow down. The note continued Resident #50 had ice applied to the right shoulder and pain medication was administered. Resident #50 was sent to the hospital for evaluation and treatment of increased right shoulder pain. Review of the medical record for Resident #50 revealed hospital documentation dated 08/03/25 which indicated Resident #50 was seen for a fall with right shoulder pain. The hospital x-ray indicated Resident #50 sustained an impacted right humeral neck fracture and had mild degenerative changes. The x-ray did not have any documentation to support Resident #50 had osteoporosis. Review of the medical record for Resident #50 revealed the activities of daily living (ADLs) documentation from 08/10/25 to 08/16/25 did not have documentation to support Resident #50 was independent with transfers or ambulation but indicated Resident #50 required supervision to substantial/maximum staff assistance. Further review of ADLs documentation from 08/21/25 to 08/27/25 did not have documentation to support Resident #50 was independent with transfers or ambulation but indicated Resident #50 required supervision to partial/moderate staff assistance with ambulation and partial/moderate to substantial/maximum assistance with transfers. Review of the facility ADLs documentation revealed the facility does not document on resident's wheelchair mobility. Review of the medical record for Resident #50 revealed a care plan for ADLs self-care performance deficit related to abnormalities of gait and mobility. The care plan stated fluctuations in ADLs self-performance and support provided are anticipated related to diagnoses and impaired cognition. Review of the interventions revealed staff are to assist with ADLs as needed and Resident #50 was independent with transfers, bed mobility, and required supervision with ambulation. Observations on 09/16/25 at 2:43 P.M. and on 09/17/25 at 9:45 A.M. revealed Resident #50 wheeled himself in a wheelchair around the facility. Resident #50 was observed to have a sling on his right arm with each observation. Interview on 09/17/25 at 9:46 A.M. with Licensed Practical Nurse (LPN) #392 stated she provided care for Resident #50 routinely. LPN #392 stated since Resident #50's fall on 08/03/25 he required staff assistance with ambulation in his room and with transfers. LPN #392 stated Resident #50 no longer walked in the hallways since his fall on 08/03/25, but would propel himself around the facility in a wheelchair independently. Interview on 09/16/25 at 3:11 P.M. with the Director of Nursing (DON) confirmed Resident #50 was given a diagnosis of pathological fracture to the right humerus on 08/03/25 because the Medical Director stated the x-ray did not indicate if the fracture was acute. The DON confirmed Resident #50's medical record did not contain any documentation to support Resident #50 had any bone density disorder or osteoporosis. The DON also confirmed Resident #50's x-ray on 08/03/25 showed an impacted right humeral fracture and mild degenerative changes. Interview on 09/17/25 at 10:46 A.M. with Medical Director #410 confirmed Resident #50's medical record did not have any documentation to support a bone density disorder or osteoporosis which could be the cause of a pathological fracture. Medical Director #410 stated Resident #50's x-ray on 08/03/25 did not indicate the fracture was acute and that was why he diagnosed the right impacted humeral fracture as pathological. Interview on 09/17/25 at 9:50 A.M. with Certified Nurse Aide (CNA) #383 stated Resident #50 was independent with transfers and ambulation prior to his fall on 08/03/25, but since then Resident #50 required staff assistance with transfers and ambulation. CNA #383 also stated Resident #50 used a wheelchair to propel self around facility and no longer ambulated in the fall since fall on 08/03/25. Interview on 09/17/25 at 1:54 P.M. LPN #325 confirmed Resident #50's discharge MDS assessment, with ARD of 08/16/25, and annual MDS assessment, with ARD of 08/27/25, indicated Resident #50 was independent with transfers and ambulation and that Resident #50 did not use a wheelchair for mobility. LPN #325 confirmed both MDS assessments had incorrect coding for Resident #50's ambulation, transfers, and wheelchair mobility. LPN #325 stated the facility utilized the Resident Assessment Instrument (RAI) manual for policies and procedures on accurate completion of MDS assessment. Review of the Long-Term Care Facility RAI 3.0 User's Manual, dated October 2024, on page GG-1 through GG-73 revealed the MDS assessment was to be coded with the usual performance for each activity for the day of the ARD and two previous days. Review of the RAI manual on page J-32 revealed to code a fall with fracture if the resident or family or medical records document a fracture related to a fall in the last six months.

Based on medical record review, review of fall investigation reports, and staff interview, the facility failed to ensure care plans were updated with current fall interventions. This affected one (#50) of five reviewed for accidents. The facility census was 56. Findings include:Review of the medical record for Resident #50 revealed an admission date of 09/01/24 with medical diagnoses including convulsions, diabetes mellitus, morbid obesity, and Down syndrome. Review of the medical record for Resident #50 revealed an annual Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #50 had moderately impaired cognition, was independent with bed mobility, transfers, and ambulation up to 10 feet, and required supervision with ambulation up to 50 and 150 feet. The MDS assessment indicated Resident #50 did not use a wheelchair. The MDS assessment indicated Resident #50 had two or more falls with no injury since readmission on [DATE]. Review of the fall care plan, dated 09/23/24, revealed Resident #50 was at risk for falls related to impulsive, medication side effects, and abnormalities of gait and mobility. The fall inventions included on 07/15/25 to offer activity upon rising, on 07/16/25 to ensure staff to use two staff members during transfers when behaviors are noted, on 07/17/25 to use night light during nighttime hours, and on 08/04/25 for non-skid strips to bedside.Review of the medical record for Resident #50 revealed documentation to support Resident #50 sustained falls on 07/10/25, 07/17/25, 07/18/25, and 08/03/25.Review of the fall investigation reports for Resident #50 revealed the resident had a fall on 07/10/25 with a new intervention to encourage two staff members to assist Resident #50 with ambulation when having behaviors, a fall on 07/17/25 with a new intervention to use a night light, a fall on 07/18/25 with a new intervention for staff to ambulate behind Resident #50 in the doorway, and a fall on 08/03/25 with a new intervention for non-skid strips to bedside. Interview on 09/17/25 at 12:10 P.M. with the Director of Nursing (DON) confirmed Resident #50's fall care plan did not contain documentation to support the 07/18/25 fall intervention to have staff to ambulate behind Resident #50 in the doorway.

Based on medical record review, staff interview, and policy review, the facility failed to develop a plan of care to address resident's with a diagnosis of post-traumatic stress disorder. This affected two (#7 and #43) of two residents review for PTSD. The facility census was 56.Findings include:1. Review of medical record for Resident #7 revealed an admission date of 05/30/25 with diagnoses including but not limited to post-traumatic stress disorder (PTSD), major depressive disorder, anxiety disorder, and dementia.Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had moderate cognitive impairment. Resident #7 was assessed with PTSD.Review of Resident #7's care plan dated 05/30/25 revealed no care plan addressing the resident's PTSD.Review of a psychiatric note dated 08/19/25 revealed Resident #7's PTSD listed as a diagnosis but was not addressed.Interview on 09/17/25 at 11:26 A.M. with Certified Nurse Aide (CNA) #345 revealed the CNA did not know what Resident #7's PTSD was related to. CNA #345 stated she was unaware of what the resident's triggers were or interventions to assist the resident if he had an exacerbation. CNA #345 stated she would ask the Director of Nursing (DON) for assistance. Interview on 09/17/25 at 11:31 A.M. with the DON revealed she did not know what Resident #7's triggers were or what caused the resident's PTSD. The DON stated Social Services completed a trauma screen for the resident in June 2025, and the DON verified Resident #7's care plan did not specify PTSD as a focus regarding what the trauma was or how to address any triggers.2. Review of medical record for Resident #43 revealed an admission date of 09/19/23 with diagnoses including but not limited to bipolar disorder, major depressive disorder, PTSD, suicidal ideations, and anxiety disorder.Review of the MDS assessment dated [DATE] revealed Resident #43 was cognitively intact. Resident #43 had a diagnosis of PTSD.Review of Resident #43's care plan dated 09/12/25 revealed no care plan for PTSD to include trauma and what triggers were present.Review of a Social Service trauma screen document dated 06/17/25 revealed Resident #43 was asked if she experienced anything that was so frightening, horrible, or upsetting that, the past month they have felt they were constantly on guard, watchful, or easily startled. The resident answered, Yes, with a comment by the resident that two of her husbands were violent. One husband was verbally and physically abusive to everyone and one husband was physically abusive to her baby. Resident #43 divorced both men. Resident #43 indicated since being at the facility she had not had any issues, but one resident residing in the facility she was watchful of due to that resident's behavior.Interview on 09/17/25 at 11:29 A.M. with CNA #345 revealed she did not know what Resident #43's trauma was or if she had any triggers.Interview on 09/17/25 at 11:31 A.M. with the DON revealed she did not know what Resident #43's triggers were or why she had PTSD. The DON stated Social Services completed a trauma screen for the resident in June 2025. The DON verified Resident #43's care plan did not specify PTSD as a focus regarding what the trauma was or how to address any triggers.Review of policy titled, Care Planning-Interdisciplinary Team, revised March 2022, revealed comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT).

Based on medical record review, staff interview, and Medical Director interview, the facility failed to ensure a resident was free from unnecessary medications including duplicate drug therapy. This affected one (#45) of three residents reviewed for antibiotic use. The facility census was 56.Findings include: Review of the medical record for Resident #45 revealed an admission date of 06/13/24 with medical diagnoses including anxiety, anemia, chronic kidney disease stage III, and personal history of urinary tract infection (UTI). Review of the medical record for Resident #45 revealed a quarterly Minimum Data Set (MDS) assessment, dated 09/15/25, that revealed Resident #45 had moderate cognitive impairment and required partial/moderate staff assistance with toilet hygiene, and substantial/maximum staff assistance with bathing, bed mobility, and transfers. The MDS assessment indicated Resident #45 received an antibiotic medication. Review of the medical record for Resident #45 revealed a nurse's notes dated 11/20/24 at 1:20 P.M. which documented the doctor assessed Resident #45, reviewed the chart, and a new order was given for an antibiotic, Bactrim double strength (DS), with instructions to take one tablet by mouth every Monday, Wednesday, and Friday for UTI prevention. Further review revealed Resident #45 was aware and verbalized understanding.Review of Resident #45's orders revealed a physician order dated 11/20/24 for Bactrim DS 800-160 milligrams (mg), one tablet by mouth daily on Monday, Wednesday, and Friday for UTI prevention.Review of a nurse's note on 02/24/25 at 7:43 A.M. revealed Resident #45 was noted to have increased agitation and difficulty urinating. The note also revealed Resident #45's urine was dark in color, had a foul odor, and the physician was notified. Review of a nurse's note dated 02/24/25 at 1:56 P.M. revealed a Certified Nurse Practitioner (CNP) assessed Resident #45 and reviewed the resident's chart. The note revealed Resident #45 was having urinary symptoms and received a new order for Keflex (antibiotic) 500 milligram (mg) two times per day for five days. Review of Resident #45's medical record revealed an order dated 02/24/25 for cephalexin (Keflex) 500 mg one tablet two times per day for five days for a UTI.Review of the medical record for Resident #45 revealed the medication administration record (MAR) for February 2025 had documentation to support Resident #45 was administered cephalexin from 02/24/25 to 02/28/25. Further review of the February 2025 MAR revealed documentation to support Bactrim DS 800-160 mg one tablet was administered on 02/24/25, 02/26/25, and 02/28/25. Review of Resident #45's nurse's note dated 06/22/25 at 7:07 P.M. revealed physician was notified of urine culture results and received a new order for Cipro (antibiotic) two times per day for seven days. Review of Resident #45's physician orders revealed an order dated 06/23/25 for Cipro 500 mg one tablet by mouth two times per day until 06/29/25 for a UTI.Review of Resident #45's June 2025 MAR revealed documentation to support the resident was administered Cipro from 06/24/25 to 06/25/25. Review of the June 2025 MAR revealed Resident #45 refused Cipro from 06/26/25 to 06/29/25. Further review of the June 2025 MAR revealed Resident #45 was administered Bactrim DS on 06/25/25 and refused the medication on 06/23/25 and 06/27/25. Review of the medical record for Resident #45 revealed no documentation to support the facility completed a urinalysis in February 2025. Further review revealed on 06/22/25 an urinalysis with culture and sensitivity was completed which showed Escherichia coli (e-coli) greater than 100,000. The culture revealed the bacteria was susceptible to Cipro and resistant to Bactrim. Interview on 09/16/25 at 3:36 P.M. with Assistant Director of Nursing (ADON) #353 confirmed Resident #45 received Bactrim DS prophylactically for history of UTIs. ADON #353 confirmed the facility did not complete a urinalysis for Resident #45 in February 2025, but treated the resident for a suspected UTI due to urinary symptoms. ADON #353 confirmed Resident #45 continued to receive Bactrim DS on Monday, Wednesday, and Friday while she received cephalexin in February 2025 and Cipro in June 2025.Interview on 09/17/25 at 10:49 A.M. with Physician #410 stated he would expect the facility to obtain a urinalysis with culture prior to administering an antibiotic. Physician #410 also stated he would expect the prophylactic antibiotic to be put on hold while the cephalexin and Cipro were administered.

Based on medical record review, staff interview, physician interview, and policy review, the facility failed to ensure the antibiotic stewardship program was followed per policy. This affected one (#45) of three residents reviewed for antibiotic use. The facility census was 56.Findings include:Review of the medical record for Resident #45 revealed an admission date of 06/13/24 with medical diagnoses including anxiety, anemia, chronic kidney disease stage III, and personal history of urinary tract infection (UTI). Review of the medical record for Resident #45 revealed a quarterly Minimum Data Set (MDS) assessment, dated 09/15/25, that revealed Resident #45 had moderate cognitive impairment and required partial/moderate staff assistance with toilet hygiene, and substantial/maximum staff assistance with bathing, bed mobility, and transfers. The MDS assessment indicated Resident #45 received an antibiotic medication.Review of the medical record for Resident #45 revealed a nurse's notes dated 11/20/24 at 1:20 P.M. which documented the doctor assessed Resident #45, reviewed the chart, and a new order was given for an antibiotic, Bactrim double strength (DS), with instructions to take one tablet by mouth every Monday, Wednesday, and Friday for UTI prevention. Further review revealed Resident #45 was aware and verbalized understanding.Review of Resident #45's orders revealed a physician order dated 11/20/24 for Bactrim DS 800-160 milligrams (mg), one tablet by mouth daily on Monday, Wednesday, and Friday for UTI prevention.Review of a nurse's note on 02/24/25 at 7:43 A.M. revealed Resident #45 was noted to have increased agitation and difficulty urinating. The note also revealed Resident #45's urine was dark in color, had a foul odor, and the physician was notified.Review of a nurse's note dated 02/24/25 at 1:56 P.M. revealed a Certified Nurse Practitioner (CNP) assessed Resident #45 and reviewed the resident's chart. The note revealed Resident #45 was having urinary symptoms and received a new order for Keflex (antibiotic) 500 milligram (mg) two times per day for five days. Review of Resident #45's medical record revealed an order dated 02/24/25 for cephalexin (Keflex) 500 mg one tablet two times per day for five days for a UTI.Review of the medical record for Resident #45 revealed the medication administration record (MAR) for February 2025 had documentation to support Resident #45 was administered cephalexin from 02/24/25 to 02/28/25. Further review of the February 2025 MAR revealed documentation to support Bactrim DS 800-160 mg one tablet was administered on 02/24/25, 02/26/25, and 02/28/25.Review of the medical record for Resident #45 revealed no documentation to support the facility completed a urinalysis in February 2025. Interview on 09/16/25 at 3:36 P.M. with Assistant Director of Nursing (ADON) #353 confirmed Resident #45 received Bactrim DS prophylactically for history of UTIs. ADON #353 confirmed the facility did not complete a urinalysis for Resident #45 in February 2025, but treated the resident for a suspected UTI due to urinary symptoms. ADON #353 confirmed Resident #45 continued to receive Bactrim DS on Monday, Wednesday, and Friday while she received cephalexin in February 2025.Interview on 09/17/25 at 10:49 A.M. with Physician #410 stated he would expect the facility to obtain a urinalysis with culture prior to administering an antibiotic. Physician #410 also stated he would expect the prophylactic antibiotic to be put on hold while the cephalexin was administered. Review of the facility policy titled, Antibiotic Stewardship Staff and Clinical Training and Roles, revised December 2016, revealed the facility would educate and train staff and practitioners about the facility antibiotic stewardship program, including appropriate prescribing, monitoring, and surveillance of antibiotic use and outcomes.

Based on observation, staff interview, recipe review, and policy review, the facility failed to ensure pureed food was prepared in a manner that preserved flavor and nutrition. This had the potential to affect three (#12, #22, and #56) of three residents identified by the facility as being on a diet with pureed meat. The facility census was 56.Findings include:Observation on 09/15/25 at 9:41 A.M. revealed Dietary [NAME] (DC) #310 prepared country fried steak with a pureed texture. Continued observation revealed DC #310 placed five portions of the country fried steak into the food processor. DC #310 proceeded to add water to puree the meat. DC #310 placed the pureed steak into a container, covered with foil, and placed it in the oven for service.Review of the undated recipe titled, Country Fried Steak with Cream Gravy, revealed pureed food characteristics included puree being smooth without lumps, held its shape on a plate, was soft pudding like consistency, liquid did not separate from the solid and it did not need to be chewed. Further review revealed the procedure for preparation of pureed food was to count out the number of portions, place in the food processor, and process by adding cream gravy a little at a time to achieve the above characteristics then serve with additional cream gravy to maintain moisture.Interview on 09/15/25 at 9:53 A.M. with Dietary Manager (DM) #354 verified DC #310 added water to puree the country fried steak and not cream gravy. DM #354 further verified the recipe called for cream gravy to be used. Continued interview with DM #354 stated the facility served the food with cream gravy, so they did not need to use it for the puree.Review of a policy titled, Pureed Diet, dated August 2025, revealed food items for puree must be prepared in a food processor. Additionally, at times it may be necessary to add liquid to puree the food and liquids used include gravies, broth, juices or milk. Water was not to be used since it causes flavor loss and results in poor intake.

Based on medical record review, review of a dialysis binder, and staff interview, the facility failed to ensure adequate and appropriate clinical information was provided to and received from a dialysis provider to ensure coordination of care. This affected one (#4) of one residents reviewed for dialysis. The facility census was 56.Findings include:Review of the medical record for Resident #4 revealed an admission date of 07/31/25 with diagnoses including but not limited to end stage renal disease, non-compliance with renal dialysis for other reasons, and dependence on renal dialysis.Review of current physician orders revealed Resident #4 was scheduled for dialysis treatments on Mondays, Wednesdays, and Fridays.Review of a care plan dated 07/31/25 revealed Resident #4 had renal failure related to end stage renal disease and dependence on renal dialysis. Interventions included to auscultate heart and lung sounds, check bruit and thrill (a thrill is a palpable, buzzing sensation or vibration felt on the skin overlying a blood vessel due to turbulent blood flow, while a bruit is the audible whooshing sound that results from the same turbulent flow and is detected by listening with a stethoscope), dietary consultation to regulate protein and potassium intake, fluids as ordered, monitor changes in mental status including lethargy, somnolence, fatigue, tremors, and seizures, and monitor for signs and symptoms of hypovolemia or hypervolemia.Further review of a care plan dated 07/31/25 revealed Resident #4 needed hemodialysis related to end stage renal disease. Interventions included to check and change the dressing daily at access site, monitor for dry skin and apply lotion as needed, monitor laboratory values and report to the doctor as needed, monitor/document for peripheral edema, monitor/document and report to the doctor signs and symptoms of depression, monitor/document/report to doctor any signs and symptoms of infection to access site including redness, swelling, warmth, or drainage as needed, monitor/document/report to the doctor any signs and symptoms of renal insufficiency including changes in level of consciousness, changes in skin turgor, oral mucosa, and changes in heart and lung sounds, and obtain weights and vital signs per protocol and report significant changes in pulse, respirations, and blood pressure immediately.Review of the dialysis communication binder provided by the facility, which was a binder Resident #4 took to dialysis treatments, revealed only the time the resident left the facility for dialysis was documented. Further review revealed no documentation was provided to include vital signs, any medications taken, or any incidents (if applicable) that occurred with the resident.Review of Resident #4's medical record revealed no pre- or post-dialysis vital signs or assessments completed by the facility.Review of Resident #4's weights revealed the resident's weights were obtained monthly and there was no pre- or post-dialysis weights recorded.Interview on 09/17/25 at 2:26 P.M. with the Director of Nursing (DON) revealed the facility did not complete any pre- or post-dialysis assessments. The DON stated Resident #4 was skilled, so they do skilled documentation daily, but no other information besides an order sheet and face sheet was sent with the resident to dialysis treatments. The DON verified the facility did not send weights, vital signs, what medications were taken prior to dialysis, or any blood sugars reading with dialysis residents to coordinate care between the facility and the dialysis provider. The DON verified they do not obtain vital signs or complete assessments on Resident #4 when she returns from dialysis, and the facility did not have documentation from the dialysis center upon return.

Based on observation, resident representative interview, staff interview, medical record review, and policy review, the facility failed to assist residents in attending scheduled activities of their preference and on a consistent basis. This affected two (#10 and #9) of three residents sampled for activities. The facility census was 56.Findings include:1. Review of the medical record revealed Resident #10 was admitted on [DATE] with diagnoses of spastic quadriplegic cerebral palsy and aphasia. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #10 revealed the resident was completely dependent for all care and exhibited no rejection of care or behavioral issues. Review of the care plan dated 09/16/25 for Resident #10 revealed the resident was dependent on staff for all activities with interventions to bring the resident to the activity room to be around other residents during activities and to escort the resident to activities they may be interested in. Review of an order dated 05/30/25 revealed Resident #10 may go out on a leave of absence (LOA) with supervision. The order had no end date. Further review revealed an order dated 06/19/24 that Resident #10 was to be up once a day on the 7:00 A.M. to 3:00 P.M. shift for two hours for therapeutic wheelchair positioning. The order had no end date. Interview on 09/17/25 at 11:40 A.M. with Resident #10's family revealed they participated in the resident's care planning and had an expectation Resident #10 would be brought down to activities such as BINGO. Observation on 09/15/25 at 12:44 P.M. revealed Resident #10 lying in bed with the television (TV) on. Observation on 09/16/25 at 9:24 A.M., 11:44 A.M., 12:03 P.M., 1:28 P.M., 2:18 P.M., and 3:00 P.M. revealed Resident #10 laying in bed with the TV on. Further observation 09/16/25 at 2:18 P.M. revealed BINGO was being played in the activities room. Interview on 09/16/25 at 3:05 P.M. with Licensed Practical Nurse (LPN) #392 verified the order for Resident #10 to be up in wheelchair between 7:00 A.M. and 3:00 P.M., and further verified Resident #10 was not up in the wheelchair before 3:00 P.M. Continued interview with LPN #392 revealed staff get Resident #10 up by 6:00 P.M., but do not take the resident outside or down to activities. Interview on 09/17/25 at 11:30 A.M. with Activities Director (AD) #357 stated Resident #10 was never brought down to activities due to being on continuous tube feeding and needing to be plugged in. Further interview with AD #357 verified the BINGO activity conducted on 09/16/25 and Resident #10 was not brought down. 2. Review of the medical record for Resident #9 revealed an admission date of 04/21/21 with diagnoses including but not limited to displaced fracture of the left humerus, dementia, depression, and restlessness and agitation. Review of the MDS assessment dated [DATE] revealed Resident #9 had severe cognitive impairment with delusions. Review of the MDS assessment dated [DATE] revealed Resident #9 had the the following activity preferences listed as very important including being around animals such as pets, doing things with groups of people, doing favorite activity, and participating in religious services or practices. Review of a care plan dated 07/28/25 revealed Resident #9 engaged in daily independent activities of her choice. Her family was supportive with care and psycho-social well-being. Resident #9 went on outings as permitted with family and enjoyed visits from others. Interventions included Resident #9 enjoyed playing BINGO, trivia, talking, and going outside when it was nice out. Resident #9 attended Rosary and church services. Resident #9 enjoyed sitting in the common area during waking hours and socializing with other ladies. Staff were to assist the resident to and from activities of her desire. Review of Resident #9's activity documentation for August 2025 revealed no documentation for 08/01/25, 08/04/25, and 08/18/25. Further review of one-on-one activity with the codes for conversation (CO), games/cards (GC), music (MU), snacks/hydration (SH), prayers (PR), communication (CM), outside (OU), strolling the unit (SU), nails/hand massage (NH), reading (RE), art/coloring (AC), comfort measures (CM), and activity cart (AC) were charted as not applicable (NA) on 08/06/25, 08/10/25, 08/12/25, 08/14/25, 08/19/25, 08/21/25, 08/22/25, and 08/29/25. Spiritual activity with Catholic communion and/or mass (C), pastoral visit (PV), and any church service (CS) or Bible study was marked as not applicable on 08/06/25, 08/09/25, 08/12/25, 08/16/25, 08/19/25, 08/23/25, and 08/30/25. Review of Resident #9's activity documentation for September 2025 revealed one-on one-activity was marked as not applicable on 09/01/25, 09/02/25, 09/05/25, 09/09/25, 09/10/25, and 09/15/25.; and spiritual activity was marked as not applicable on 09/02/25. Observation on 09/15/25 at 9:26 A.M. of the memory care unit activity calendar revealed activities for the day included at 10:15 A.M., morning stretches in the main lobby, 10:30 A.M., Rosary in the main lobby, 11:00 A.M., daily chronicles, and at 1:30 P.M. watercolors in the main lobby. Further observation revealed the main lobby was located outside of the memory care unit. Observation on 09/15/25 at 10:35 A.M. revealed residents in the main lobby for Rosary. Rosary was observed to be a recording on TV and no residents from the memory care unit are observed in the activity, including Resident #9. Interview on 09/18/25 at 11:19 A.M. with Activity Director (AD #357) revealed the activities staff run the activities in the memory care unit. AD #357 verified the activity staff document the activities. AD #357 stated she will mark an activity as not applicable when it does not pertain to the activity per the key. AD #357 stated there was no option to mark other for an activity. AD #347 verified there was no consistent documentation of staff providing activities for Resident #9 and verified Rosary was held outside the memory care unit. Review of policy titled, Resident Self Determination and Participation, dated August 2025, revealed the administration and staff will include resident preferences on activities in the care planning process. Additional review revealed residents should be provided with assistance as needed to engage in their preferred activities on a routine basis Review of policy titled, Activities, reviewed 09/16/25, revealed the facility provided an ongoing program to support residents in their choices of activities based on their comprehensive assessment, care plan, and preferences. Further review revealed staff will assist residents to and from activities when necessary.

Based on medical record review, staff interview, review of a Facility Reported Incident, review of police report, review of hospital records, and review of policy, the facility failed to ensure a cognitively impaired resident was free from physical abuse by a facility staff member. This resulted in physical harm when Resident #01 was forcefully pushed down on to a bed by Certified Nursing Assistant (CNA) #200 causing physical injuries of bruising, skin impairments and pain. During the incident, Licensed Practical Nurse (LPN) #202 observed and failed to intervene to protect Resident #01 from abuse. This affected one (#01) of three residents reviewed for abuse. The facility census was 55. Findings include:Review of the medical record of Resident #01 revealed an admission date of 11/26/24. Diagnoses include unspecified psychosis, depressive disorder, Alzheimer's disease, and dementia.Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #01 was cognitively impaired and required set-up or clean-up assistance for transfers and personal care. Resident #01 was self-ambulatory.Review of the care plan revealed a focus, initiated 12/09/24, of delirium, or an acute confusion episode related to acute disease process, dementia, and Alzheimer's disease with interventions to include engage resident in simple, structured activities, make eye contact when speaking with him, and if becomes agitated, stop and return. Another focus, initiated 12/09/24, of impaired cognition related to dementia with interventions to keep routine consistent as possible and cue and re-orient as able. A third focus of potential for behavior problems, initiated 12/09/24, with interventions to medicate as ordered, approach and speak in a calm voice, and psych/counseling services as needed. A focus, initiated 04/17/25, revealed Resident #01 resides on the secure unit related to elopement risk and aggressive behavior. Review of the Facility Reported Incident (262612) dated 07/10/25 revealed an alleged incident occurred on 07/10/25 at approximately 2:00 A.M. involving Resident #01 and Certified Nursing Assistant (CNA) #200. The alleged incident was reported to the local police by a neighbor. The police arrived at the facility and conducted an interview with Licensed Practical Nurse (LPN) #202 and CNA #200. Resident #01 was taken to the emergency room for an evaluation. The report revealed the neighbor, who lived approximately 500 feet from the facility, witnessed Resident #01 stumbling and a staff member, with arms extended towards the resident. The report indicated the neighbor was interviewed by the Administrator and the Regional Director of Clinical Operations #900 and stated he had witnessed Resident #01 stumble and one staff member (identified by the facility as CNA #200) extend out their arms. This was taken directly from the FRI. The facility did not substantiate the allegation.Review of the police report #25-005782 revealed the incident occurred on 07/10/25 between 1:30 A.M. and 2:10 A.M. The report revealed a phone call was received at approximately 2:14 A.M., from a male. The male (neighbor) reported witnessing two nurses acting violently towards a resident at the facility. The officer first made contact with the male, a neighbor, who reported seeing nurses throw the patient onto the bed in an aggressive manner. The officer arrived at the facility and informed LPN #202 of the purpose of his visit. LPN #202 reported CNA #200 had been in the room with Resident #01. LPN #202 stated she had entered the room to observe Resident #01 standing behind the bathroom door. CNA #200 forcefully placed both hands onto Resident #01's shoulders and threw him onto the bed. CNA #200 then lifted Resident #01's legs and forcefully positioned them on the bed. The report indicated LPN #202 expressed concern of CNA #200's handling of Resident #01 appeared rough. The officer interviewed CNA #200 who denied any use of force. The officer observed bruises on the right and left pectoral muscles, the left triceps, and a large bruise on the right buttock. The report further indicated Resident #01 exhibited pain when the left rib cage area was touched, without any visible injuries or markings. Resident #01 was sent to the local emergency room for potential internal injuries. At this point in time, no charges have been filed.Review of the hospital record dated 07/10/25 at 5:20 A.M. revealed Resident #01 was evaluated for alleged assault in the emergency room at the local hospital. The report revealed a physical examination documented an induration between the webspace of digits one and two of the right foot, erythema extending upwards from the toe on the dorsal aspect, and the area was warm to the touch. Resident #01 had four small areas of excoriation located on the right anterior shin without active bleeding. The areas almost look like insect bites. Resident #01 had a half centimeter circumferential eschar on the left proximal tibia, anteriorly. Resident #01 had area of ecchymosis in the left lower quadrant, just lateral to the umbilicus, (without description of color) and two areas of ecchymosis one the anterior chest. One of the areas was above the nipple and medial, the other was four to six inches above and medial to the right nipple. An area of ecchymosis was noted to the right buttocks the size of a hand but did not appear to in the shape of a hand. It is in various stages of healing. Resident #01 appeared to be in no distress, resting comfortably and hemodynamically stable. Resident #01 was discharged back to the facility with a new order for an antibiotic for cellulitis in the toe (previously diagnosed and was being treated). Review of the Skin Assessment dated 07/10/25 at 11:40 A.M. revealed Resident #01 exhibited a right pectoral bruise measuring three centimeters (cm.) by two cm., a bruise to the left pectoral bruise measuring 10 cm. by 12 cm., a bruise on the right forearm measuring one cm. by half cm., a bruise to right shoulder/top of arm measuring half cm. round, a bruise on the right antecubital area (inner elbow) measuring two point five cm. by one point five cm., a skin tear on the left wrist measuring two cm. by one cm., a bruise to the left posterior upper arm measuring three point five cm. by four cm., a bruise to the right buttock measuring seven point five cm. by 14 cm., a bruise to the right knee (rear) measuring one cm. by two cm., a skin tear to the front right thigh measuring half cm. round, a skin tear to the front right upper shin measuring zero point two cm. round, and a skin tear to the right lower shin measuring one cm. by zero point seven cm. The report indicated no sign or symptoms of pain during the assessment and medication was available if needed. During a phone interview on 07/14/25 at 1:00 P.M. with CNA #200 revealed, on 07/10/25 at approximately 2:00 A.M. Resident #01's call light was activated. As CNA #200 entered his room, Resident #01 was noted to have the call light in his hand, pulled from the wall, and was urinating on the wall. CNA # 200 allowed him to finish and asked him if he needed the toilet. CNA # 200 opened the bathroom door and Resident #01 slammed it shut and raised a fist. CNA #200 stated, Resident #01's name, please do not hit me. At which time the nurse arrived. Resident #01 sat on the bed and CNA #200 bent down to assist with his legs as they were swollen. Once he was laid down, CNA #200 covered him, turned the lights out and left the room. During a phone interview on 07/16/25 at 2:08 P.M. with LPN #202 revealed she had been at the nurses' station at approximately 2:00 A.M. on 07/10/25 and heard CNA #200 and Resident #01 getting loud. LPN #202 stated she entered Resident #01's room to discover him standing in the room with a puddle of urine around him. CNA #200 was trying to get him into the bathroom, and he was resisting. LPN #202 reported CNA #200 forced Resident #01 onto the bed, with more force than she felt was necessary, and swung his legs up quickly. LPN #202 stated she went to the head of the bed to prevent him from falling. LPN #202 reported having told CNA #200 she had been rough and had man-handled Resident #01. LPN #202 reported the incident to the Administrator upon the police arrival. Review of the undated policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention, revealed the facility will protect residents from abuse by anyone. The facility will develop policies and protocols to prevent and identify abuse of residents by ensuring adequate staffing and oversight/support and conduct background checks on employees.This deficiency represents the noncompliance investigated under Complaint Number 2560552.

Based on employee file review and staff interview, the facility failed to ensure the Activity Director was qualified. This had the potential to affected 28 residents (#1, #2, #3, #4, #5, #7, #12, #14, #16, #18, #20, #25, #26, #28, #29, #31, #33, #34, #35, #36, #37, #39, #41, #46, #47, #48, #52 and #53) who regularly attend activities. The facility census was 53. Findings include: Review of the employee file for Activities Director (AD) #340 revealed a hire date of 07/25/21 to the activity department as a part time activities assistant. Review of application revealed no previous activities experience. No documentation located regarding when AD #340 went full-time or was promoted to Activities Director. Interview on 02/18/25 at 12:59 P.M. with AD #340 revealed she believed she was promoted approximately a year ago to Activities Director and went full-time approximately three months after hire. AD #340 stated she was taking the certification program through a sister facility. AD #340 verified she did not have a certificate for Activities Director. The facility confirmed there were 28 residents (#1, #2, #3, #4, #5, #7, #12, #14, #16, #18, #20, #25, #26, #28, #29, #31, #33, #34, #35, #36, #37, #39, #41, #46, #47, #48, #52 and #53) who regularly attend activities. This deficiency represents noncompliance investigated under Complaint Number OH00162380.

Based on medical record review, review of resident trust accounts, resident interview, staff interview, resident representative interview and review of facility policy, the facility failed to maintain a complete, accurate and accessible accounting of resident trust accounts and further failed to provide quarterly statements to residents for those accounts. This affected three (#1, #2 and #3) of three residents reviewed for personal funds. The facility identified 35 residents who had resident trust accounts. The facility census was 57. Findings include: 1. Review of Resident #1's medical record revealed an admitted [DATE]. Diagnoses included epilepsy, anxiety disorder, post-traumatic stress disorder, major depressive disorder, and dementia. Review of the Minimum Data Set (MDS) assessment, dated 12/31/24, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of nine, indicating the resident was moderately cognitively impaired. Review of the care plan, revised 01/17/25, revealed Resident #1 had supports and interventions for pain, communication problems, limited physical mobility, impaired cognition and a self-care deficit. Review of Resident #1's profile information revealed the resident's daughter was his responsible party and guarantor. Review of Resident #1's Management of Personal Funds consent form, dated 09/26/22, revealed Resident #1 and his representative signed the consent for the facility to manage his resident funds. Review of the last available quarterly statement for Resident #1's resident trust account, dated 09/30/24, revealed accounting was kept from 07/10/24 to 09/30/24. There was no evidence of a quarterly statement, including transactions and account balance, for the quarter from 10/01/24 to 12/30/24. Review of the last accounting of Resident #1's resident trust account, dated 11/30/24, revealed a balance of $995.10, which was transferred to the new facility owner. Review of the facility's Petty Cash Withdrawal Record from 11/30/25 to 01/17/25 revealed Resident #1 withdrew $10.00 on 12/09/24, $20.00 on 12/13/24, $15.00 on 12/27/24, $10.00 on 01/03/25, and $10.00 on 01/16/25. There was no accounting for Resident #1's resident trust balance following each withdrawal. Review of the facility's resident trust fund balances, requested on 01/17/25 and provided on a word document, revealed Resident #1 had $995.10 in his resident trust account. No itemization of deposits and/or withdrawals was provided. Reconciliation of Resident #1's petty cash withdrawals from 11/30/24 through 01/17/25 with the account balance from 11/30/24 and the balance provided on 01/17/25 revealed a balance of $930.10, indicating a discrepancy of $65.00. Interview on 01/17/25 at 11:50 A.M. with Resident #1 revealed the resident was alert and orientated. Resident #1 reported he was able to get out money from his account at the facility but had not been told how much was in his account. Resident #1 reported his daughter was in charge of his money and she would get any statements. Interview on 01/17/25 at 12:20 P.M. with Resident #1's daughter verified she was the resident's responsible party when it came to finances. Resident #1's daughter confirmed she had not received a quarterly statement or any updates of any kind regarding Resident #1's account at the facility and she should be provided that information. Review of Resident #1's current account balance detail, provided by the facility's corporate staff on 01/17/25 at 3:45 P.M., revealed a balance on 01/07/25 of $1,025.19. The Trust Balance log indicated Resident #1 had $995.10 in his account. The accounting was inaccurate and not accessible in a timely manner. 2. Review of Resident #2's medical record revealed an admitted [DATE]. Diagnoses included mild cognitive impairment, anemia, cellulitis, major depressive disorder, anxiety disorder, lymphedema, morbid obesity, and type II diabetes. Review of Resident #2's MDS assessment, dated 12/26/24, revealed a BIMS score of 14, indicating the resident was cognitively intact. Resident #2 displayed no behaviors at the time of the review. Review of Resident #2's care plan, revised 01/16/25, revealed supports and interventions for psychosocial well-being, behavior of picking skin related to anxiety, potential for pain, and self-care deficit. Review of Resident #2's profile information revealed the resident was her own responsible party. Review of Resident #2's Management of Personal Funds consent form, dated 12/11/23, revealed the resident signed the consent for the facility to manage her resident funds. Review of the last available quarterly statement for Resident #2's resident trust account, dated 09/30/24, revealed accounting was kept from 07/10/24 to 09/30/24. There was no evidence of a quarterly statement, including transactions and account balance, for the quarter from 10/01/24 to 12/30/24. Review of the last accounting of Resident #2's resident trust account, dated 11/30/24, revealed a balance of $1592.93, which was transferred to the facility's new owner. Review of the facility's Petty Cash Withdrawal Record from 11/30/24 to 01/17/25 revealed Resident #2 withdrew $50.00 on 12/04/24 and $50.00 on 01/03/25. There was no accounting for Resident #2's personal funds balance found following each withdrawal. Review of the facility's trust fund balances, requested on 01/17/25 and provided on a word document, revealed Resident #2 had $1592.93 in her resident trust account. No itemization of deposits and/or withdrawals was provided. Reconciliation of Resident #2's petty cash withdrawals from 11/30/24 through 01/17/25 against the account balance on 11/30/24 and the balance provided on 01/17/25 revealed a balance of $1492.93, a discrepancy of $100.00. Interview on 01/17/25 at 10:48 A.M. with Resident #2 revealed she was alert and aware. Resident #2 reported the facility managed her money for her and she used to get quarterly statements with her balances, but she had not received one in a while. Resident #2 reported she was not aware of what her account balance was. Review of Resident #2's current account balance detail, provided by the facility's corporate staff on 01/17/25 at 3:45 P.M., revealed a balance on 01/03/25 of $1,592.97. The Trust Balance log indicated Resident #2 had $1,592.93 in her account. The accounting was inaccurate and not accessible in a timely manner. 3. Review of Resident #3's medical record revealed an admitted [DATE]. Diagnoses included paranoid schizophrenia, schizoaffective disorder, chronic pain, major depressive disorder, suicidal ideation, paranoid personality disorder, and anxiety disorder. Review of Resident #3's MDS assessment, dated 11/05/24, revealed a BIMS score of 15, indicating the resident was cognitively intact. Resident #3 had delusions and displayed other behavioral symptoms not directed toward others, rejection of care, and wandering behaviors one to three days during the review period. Review of Resident #3's profile information revealed the resident had a Power of Attorney (POA). Review of Resident #3's Management of Personal Funds consent form dated 10/30/24 revealed the resident's POA signed the consent for the facility to manage her resident funds. Review of Resident #3's accounting record revealed no evidence of a quarterly statement or accounting of her resident trust funds, including deposits, withdrawals or account balance. Review of the last accounting of Resident #3's resident trust account, dated 11/30/24, revealed a balance of $1,850.57, which was transferred to the facility's new owner. Review of the facility's Petty Cash Withdrawal Record from 11/30/24 to 01/17/25 revealed Resident #3 withdrew $10.00 on 12/04/24 and $10.00 on 01/16/25. There was no accounting for Resident #3's personal funds balance found following each withdrawal. Review of the facility's trust fund balances, requested on 01/17/25 and provided on a word document, revealed Resident #3 had $1,820.57 in her resident trust account. No itemization of deposits and/or withdrawals was provided. Reconciliation of Resident #3's petty cash withdrawals and the resident trust fund balance provided on 01/17/25 revealed a discrepancy of $10.00. Interview on 01/17/25 at 1:24 P.M. with Resident #3 revealed she was not aware of what her resident trust balance was. Attempts to contact Resident #3's POA were unsuccessful. Review of Resident #3's current account balance detail, provided by the facility's corporate staff on 01/17/25 at 3:45 P.M., revealed the resident had a resident trust balance on 01/08/25 of $1,835.62. The Trust Balance log indicated Resident #3 had $1,820.57 in her account. The accounting was inaccurate and not accessible in a timely manner. Interview on 01/17/25 at 10:24 A.M. with Business Office Manager (BOM) #256 revealed a new company took over ownership of the facility on 12/01/24. Since that time, BOM #256 reported she was no longer able to access the system to log accounting and was unable to run quarterly statements. BOM #256 verified quarterly statements had not been provided to residents or their representatives for the quarter of 10/01/24 to 12/30/24. BOM #256 showed a written log of petty cash withdrawals and reported residents still had access to their funds, but the clip board with the sign out amounts (petty cash withdrawals) was all the documentation she had. BOM #256 confirmed there were no account balances, record of deposits, or interest tracked. BOM #256 stated her ability to log transactions and balances ended 11/30/24 when the accounts were closed and transferred to the new company for management. Interview on 01/17/25 at 1:26 P.M. with the Administrator verified account statements were not provided to the residents or their representatives when their accounts were closed 11/30/24. The new company took over 12/01/24 and quarterly statements would be provided with a start date of 12/01/24. Review of the corporate provided accounting for all resident trust accounts, viewed with the Administrator on the Administrator's computer, revealed the accounting for all residents that had been done by the new company. The surveyor requested clarification as only the transactions and accounting for Resident #1, Resident #2 and Resident #3 was requested and unable to be determined from the information provided. The Administrator was unable to provide clarifying information related to the accounting of Resident #1, Resident #2 or Resident #3's resident trust accounts. A follow-up interview on 01/17/25 at 3:40 P.M. with the Administrator revealed the current accounting was not yet available for Residents #1, #2, or #3 as the information was not accessible onsite and had to be sent from the corporate office. The information was subsequently provided on 01/17/25 at 3:45 P.M. Review of the facility policy titled, Management of Residents' Personal Funds, revised March 2021 revealed the facility would manage the personal funds of residents who requested the facility to do so. Funds were to be managed in accordance with established policies and federal/state requirements. Copies of all financial transactions were filed in the resident's permanent record. Funds would be placed in an interest-bearing account, separate from the facility's accounts, quarterly accounting statements would be provided, resource limit notices would be provided, personal funds would be returned to appropriate sources within 30 days of discharge, and no charges would be assessed against the personal funds account unless the items were requested by the resident. Review of the facility policy titled, Accounting and Records of Resident Funds, revised April 2021 revealed the facility's business office was to maintain accounting records of all financial transactions involving the resident's personal fund. Individual accounting records were made available through quarterly statements and upon request. Quarterly statements were to include the resident's balance at the beginning and end of the statement period, the total deposits and withdrawals by the resident for the quarter, interest earned on the resident's funds, resident funds available through the petty cash, and the total amount of petty cash on hand. This deficiency represents non-compliance investigated under Complaint Number OH00160687.

Based on record review, staff interview, and policy review, the facility failed to prevent resident to resident abuse. This affected two (Residents #52 and #45) of four reviewed for abuse. The facility census was 63. Findings include: 1. Review of the medical record for Resident #52 revealed an admitted [DATE] with a diagnosis of Alzheimer's disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 had moderate cognitive impairment, required set-up assistance with eating and personal hygiene, required supervision with oral hygiene. Resident was independent with dressing, bed mobility, transfers, and ambulation. Review of the Care Plan dated 04/09/24 revealed Resident #52 required a secured unit. Review of progress notes revealed on 07/11/24 at 8:17 P.M., Resident #52 was walking towards the nurse's station when a male resident turned and put his arm around her head from behind and shoved a pudding cup into her face. 2. Review of the medical record for Resident #45 revealed an admitted [DATE] with diagnoses of unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Admission MDS assessment dated [DATE] revealed Resident #45 had severe cognitive impairment and required supervision assistance with eating, oral hygiene, toileting hygiene, bed mobility, transfers, and ambulation. Review of Resident #45's care plan revealed no goals or interventions in place for Resident #45 having behaviors. Review of the progress note dated 7/11/24 at 8:05 P.M. revealed Resident #45 came to the nurse's station and picked up a pudding. While the nurse went to get a spoon for Resident#45, the resident turned to another resident (Resident #52), wrapped his arm around the other resident's head from behind, and pushed the pudding into the resident's face. Resident #45 was visibly agitated with fist raised. A State tested Nurse Aide (STNA) attempted to calm Resident #45 down, with the resident attempting to strike the STNA. Interview on 07/23/24 at 2:20 P.M. with the Director of Nursing (DON) confirmed Resident #45 had behaviors prior to the incident that occurred on 07/11/24. Interview confirmed that on 07/08/24, Resident #45 had a butter knife and attempted to attack staff and it took two staff members to get the knife away from the resident. Resident #45's care plan was not updated after the butter knife incident for behaviors. Interview also confirmed on 07/11/24, Resident #45 grabbed Resident #52 from behind, wrapped his arms around her head and shoved a pudding cup in her face. Interview confirmed Resident #45's care plan did not include behaviors or interventions for behaviors and did not include his use of psychotropic medications. Resident #45's care plan did not include any interventions for behaviors since his admission on 05/08/24. Interview also confirmed Resident #45's care plan has not been updated with any behaviors and that staff had no way of knowing what interventions were to be used with the resident. Interview on 07/23/24 at 2:36 P.M. with the Administrator revealed an incident occurred between Resident #45 and Resident #52 where, Resident #45 grabbed Resident #52 from behind and shoved a pudding cup into her face. Interview confirmed the incident did occur, but the facility unsubstantiated the incident due to Resident #45 having dementia and that the facility thought if an incident occurs with a resident with dementia, it is not substantiated due to the diagnosis. Interview also confirmed Resident #45's care plan did not have any interventions implemented for behaviors and that the care plan had not been updated with behaviors since admission on 05/08/24. Review of the, Abuse, Neglect, Exploitation & Misappropriation of Residents Property, policy dated 08/10/23 revealed the facility will not tolerate abuse, neglect, exploitation of its residents or the misappropriation of resident property. It is the facility's policy to investigate all alleged violations involving Abuse, Neglect, exploitation, mistreatment of a resident, or misappropriation of resident property, including injuries of unknown source, in accordance with this policy. Review of the policy also revealed facility procedures will include the assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents rooms, residents with self-injurious behaviors, residents with communication disorders, and those that require heavy nursing care and / or totally dependent on staff. This deficiency represents non-compliance investigated under Complaint Number OH00155796.

Based on observations and staff interviews, the facility failed to ensure the laundry room wall was in good repair without missing drywall or black substance on wall and around the window. This had the potential to affect 55 residents who have their laundry washed at the facility, the facility identified three (#20, #21 and #25) residents who do not have their laundry washed by the facility. The facility census was 58. Findings include: Interview on 04/19/24 at 8:50 A.M. with Laundry Aide #123 stated the wall near the folding table in the laundry room had several areas of black substance on the wall below the window, around the window and under the air conditioning (AC) unit which was above the window. Laundry Aide #123 stated the wall had been missing part of the drywall for over one year and there had not been a change in the appearance of the black substance around the window and AC unit. Observation on 04/19/24 at 9:05 A.M. revealed a window and wall near the folding table in the laundry room to be missing part of the drywall under the window, window ledge deteriorated with part of the ledge missing, and black substance noted on several areas of the wall below the window, around the window, and around the air conditioning unit above the window. Interview on 04/19/24 at 9:10 A.M. with Administrator confirmed the wall located in the laundry room near the folding table had drywall missing from below the window and there was black substance noted on several areas on wall below the window, around the window and under the AC unit above the window. Administrator denied any recent concerns with water or roof issues in that area. Interview on 04/19/24 at 9:15 A.M. with Laundry Aide #117 stated she had worked in the laundry room for over one year. Laundry Aide #117 confirmed the wall under the window near the folding table in the laundry room was missing part of the drywall, the window ledge was deteriorated and missing part of the ledge, and the wall under the window, around the window, and under the AC unit above the window had several areas of black substance. Laundry Aide #117 stated the wall had looked like that for over one year and had not changed. Interview on 04/19/24 at 9:25 A.M. with Maintenance Director #121 confirmed the wall located near the folding table in the laundry room was missing part of the drywall, the window ledge was deteriorated and missing part of the ledge, and the wall below the window, around the window, and under the AC unit located above the window had several areas of black substance. Maintenance Director #121 stated he was not aware of any leaks around the window or roof in that area. Maintenance Director #121 stated he has had to replace the AC unit above the window two times because of water leaking down the wall. The facility confirmed there are 55 residents who have their laundry washed in the laundry room, the facility identified three (#20, #21 and #25) residents who do not have their laundry washed by the facility. This deficiency represents non-compliance investigated under Complaint Number OH00151864.

Based on medical record review, review of hospital records, and staff and Physician #850 interviews, the facility failed to ensure a newly admitted resident received appropriate diabetes care when the facility staff failed to clarify a resident's diabetes diagnosis and the need for blood sugar monitoring and insulin administration. This resulted in Actual Harm when staff failed to monitor Resident #04's blood sugars and the resident subsequently had a change in condition resulting in hospitalization and a diagnosis of hyperglycemia requiring intravenous (IV) and subcutaneous (SQ) insulin administration and (IV) fluids. Additionally, the facility failed to have blood glucose monitoring and insulin in place for Resident #38, which placed the resident at risk for more than minimal harm. This affected two (Residents #04 and #38) of three residents reviewed for diabetes management. The facility census was 50. Findings include: 1. Review of the medical record of Resident #04 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus with hyperglycemia (11/02/23), encephalopathy, bipolar disorder, impulse disorder, and transient ischemic attack and cerebral infarction without residual deficits. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 was cognitively impaired and was dependent on staff for all aspects of daily living. The assessment identified a diagnosis of diabetes mellitus. The assessment did not indicate the use of insulin. Review of the paperwork from the sending facility (Long-Term Care Acute Hospital [LTACH]) revealed Resident #04 had a diagnosis of diabetes. The documents revealed discharge medications of acetaminophen 650 milligrams (mg) by mouth every six hours as needed for fever greater than 100.4 degrees Fahrenheit and all levels of pain. Review of the LTACH Patient Care Summary dated 08/06/23 revealed Resident #04 had a history of diabetes with insulin use. Review of the laboratory results revealed on 08/25/23, 08/28/23, 10/06/23, and 11/03/23 Resident #04 refused laboratory (lab) draws. Review of Resident #04's admission orders dated 08/17/23 revealed the only medication ordered was acetaminophen 650 mg orally every six hours as needed for pain. Further review of physician orders from August 2023 to October 2023 revealed no orders for blood sugar monitoring or insulin. Further review of the medical record revealed no documentation the physician was notified of Resident #04 having diabetes and/or clarification regarding the need for blood sugar monitoring or insulin administration. Review of the hospital records dated 10/30/23 revealed Resident #04 presented to the emergency department for lethargy that began that morning. The note indicated Resident #04 was started on an antibiotic on 10/29/23 for symptoms of a Urinary Tract Infection (UTI) and was his usual self until this morning when found lethargic and less responsive. Laboratory tests revealed a blood glucose level of greater than 1,000 milligrams per deciliter (mg/dL). Per staff at the nursing home, Resident #04 had not been receiving treatment for diabetes as they said he had no history of diabetes. The assessment revealed diagnoses of sepsis, acute kidney injury, acute UTI, and hyperglycemia. The note indicated Resident #04 was not in DKA (diabetic ketoacidosis). Resident #04 received IV insulin and SQ insulin in the emergency room and will start a sliding scale insulin and a long-acting insulin. Upon return to the nursing facility will continue with sliding scale and long-acting insulin. Interview on 12/04/23 at 2:52 P.M. with Licensed Practical Nurse (LPN) #100 revealed Resident #04 did not have an order for blood sugar monitoring or insulin from his admission on 08/17/23 until he was hospitalized on [DATE]. LPN #100 stated when a resident admits with a diagnosis of diabetes mellitus with no order for blood sugar monitoring, the doctor should be contacted to obtain an order for blood sugar monitoring, at a minimum. Interview on 12/04/23 at 3:05 P.M. with Clinical Director of Operations (CDO) #800 revealed Resident #04 had been on insulin at the hospital, but the discharge orders lacked documentation for insulin or blood sugar monitoring. The list of diagnoses included diabetes mellitus type II. It would be assumed nurses would clarify if a diagnosis of diabetes was found. CDO #800 confirmed prior to Resident #04's admission to the facility he had a history of being diabetic and required insulin administration. CDO #880 further verified Resident #04 was hospitalized due to being hyperglycemic and required insulin administration on a regular basis when the resident returned from the hospital. Interview on 12/04/23 at 3:27 P.M. with LPN #102 revealed when a diagnosis of diabetes is noted in the medical record with no order for blood sugar monitoring or insulin, the doctor should be notified to clarify. Interview on 12/04/23 at 3:32 P.M. with LPN #103 revealed the doctor or an assistant should be notified when a resident admits with a diagnosis of diabetes without any blood sugar monitoring or insulin. Interview on 12/04/23 at 4:47 P.M. with CDO #800 revealed the facility is to follow the Admission Review checklist upon admissions. The checklist indicated physician orders will be clarified with a doctor or nurse practitioner within one hour and all medications will be clarified, and any concerns clarified. A baseline care plan will then be completed. Interview on 12/04/23 at 4:55 P.M. with Physician #850 confirmed the lack of diabetes care upon Resident #04's admission was a miscommunication issue. Physician #850 stated going forward, all residents with a history of diabetes will receive a minimum of blood glucose checks daily. 2. Review of the medical record of Resident #38 revealed an admitted [DATE]. Diagnoses include vascular dementia, unspecified mood disorder, and diabetes mellitus type II. Review of the admission MDS assessment dated [DATE] revealed Resident #38 was cognitively impaired and required supervision with bed mobility, transfers, and personal hygiene. The assessment further indicated the use of antipsychotic medication but no insulin. Review of physician orders revealed no insulin ordered at the facility. Review of the discharge paperwork from the hospital revealed Resident #38 had been receiving insulin Human Lispro per sliding scale while at the hospital; however, the discharge orders revealed no documentation for insulin, either discontinued, changed, or continued. Review of the medical record revealed blood glucose results dated 10/09/23 at 6:28 A.M. to read 90 mg/dL (low), 10/23/23 at 6:04 A.M. to read as 102 mg/dL (low), and 12/04/23 at 7:03 A.M. revealed a blood glucose of 108 mg/dL (low). Hemoglobin A1C (blood sugar test) drawn on 12/04/23 was 6.2% with normal range of 4.1 to 6.1%. Interview on 12/04/23 at 3:27 P.M. with LPN #102 revealed when a diagnosis of diabetes is noted in the medical record, but no order for blood sugar monitoring or insulin, the doctor should be notified to clarify. LPN #102 verified Resident #38 had blood glucose monitoring and no insulin ordered. Interview on 12/04/23 at 3:35 P.M. with CDO #800 revealed Resident #38's current blood sugar read 288 mg/dL after having recently drank a large glass of cranberry juice. CDO #800 stated the physician would be notified of the lack of blood glucose monitoring and would obtain an order. The facility did not provide a policy related to diabetic care. This deficiency represents non-compliance investigated under Complaint Number OH00148261.

Based on record review, staff interview and review of information from Medscape, the facility failed to ensure the physician was notified regarding a residents low blood glucose reading. This affected one (#14) of three residents reviewed for notification of change. The facility census was 45. Findings include: Review of medical record for Resident #14 revealed admission date of 08/17/23. Diagnoses included acute kidney failure, sepsis, type two diabetes mellitus with hyperglycemia, and bipolar disorder. The quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment and he required moderate assistance with eating, maximum assistance for bed mobility and dependence for transfers. Review of the physician orders for Resident #14 revealed an order for Lantus (long-acting insulin) 20 units subcutaneously two times daily. Hold medication for a blood sugar of less then 80 and contact physician for further instructions. This was scheduled for 8:00 A.M. and 8:00 P.M. with a start date of 12/12/23. Review of Resident #14's Electronic Medication Administration Record (EMAR) note revealed on 12/20/23 at 5:00 A.M. the residents blood glucose was 48, and his Lantus was held. There was no documentation that Resident #14's physician was notified of the low blood sugar reading. Interview on 12/28/23 at 11:44 A.M. with Licensed Practical Nurse (LPN) #102 revealed when he checked the blood glucose of Resident #14 around 6:00 A.M. on 12/20/23 it was 48. LPN #102 confirmed Resident #14 did not have an order for glucose monitoring at 6:00 A.M. and that the residents blood sugar was checked out of habit as the resident previously had an order to check it at 6:00 A.M. but it was changed to 8:00 A.M. LPN #102 stated Resident #14 was alert, oriented and was given apple juice on 12/20/23 at 6:00 A.M. A recheck about ten minutes later revealed a blood glucose of 90. LPN #102 verified he did not contact the physician as ordered. LPN #102 also confirmed the assessment, monitoring and/or intervention provided to Resident #14 for the low blood sugar reading of 48 was not documented. Review of information from Medscape at https://emedicine.medscape.com/article/2087913-overview?form=fpf revealed the normal glucose levels for an adult are between 74-106 milligrams (mg) per(/) deciliter (dl) with possible critical values for an adult male as less than 50 mg/dl. This is a new deficiency based on the post survey revisit for the complaint survey completed on 12/04/23.

Based on record review and staff interviews, the facility failed to ensure a residents admission physician orders were implemented. This affected one (#11) of three residents reviewed. The facility census was 45. Findings include: Review of medical record for Resident #11 revealed admission date of 12/22/23. Medical diagnoses included dementia without behaviors, chronic pain, non-pressure chronic ulcer, and atrial fibrillation. Review of the transfer admission orders for Resident #11 revealed an order for Milk of Magnesia (laxative) 30 milliliters (ml) every 24 hours as needed. Further review of the physician orders and December 2023 Medication Administration Record (MAR) for Resident #11 revealed no order for Milk of Magnesia. Interview on 12/27/23 at 10:54 A.M. with the Director of Nursing (DON) verified an admission order for Milk of Magnesia 30 ml every 24 hours as needed for Resident #11 was not ordered and not placed on the MAR upon the residents admission. This is a new deficiency based on the post survey revisit for the complaint survey completed on 12/04/23.

Based on record review and staff interviews, the facility failed to ensure a residents admission physician orders were implemented. This affected one (#11) of three residents reviewed. The facility census was 45. Findings include: Review of medical record for Resident #11 revealed admitted [DATE]. Medical diagnoses included dementia without behaviors, chronic pain, non-pressure chronic ulcer, and atrial fibrillation. Review of the transfer admission orders for Resident #11 revealed an order for Milk of Magnesia (laxative) 30 milliliters (ml) every 24 hours as needed. Further review of the physician orders and December 2023 Medication Administration Record (MAR) for Resident #11 revealed no order for Milk of Magnesia. Interview on 12/27/23 at 10:54 A.M. with the Director of Nursing (DON) verified an admission order for Milk of Magnesia 30 ml every 24 hours as needed for Resident #11 was not ordered and not placed on the MAR upon the residents admission. This is a new deficiency based on the post survey revisit for the complaint survey completed on 12/04/23.

Based on record review, staff interview and review of information from Medscape, the facility failed to ensure the physician was notified regarding a residents low blood glucose reading. This affected one (#14) of three residents reviewed for notification of change. The facility census was 45. Findings include: Review of medical record for Resident #14 revealed admitted [DATE]. Diagnoses included acute kidney failure, sepsis, type two diabetes mellitus with hyperglycemia, and bipolar disorder. The quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment and he required moderate assistance with eating, maximum assistance for bed mobility and dependence for transfers. Review of the physician orders for Resident #14 revealed an order for Lantus (long-acting insulin) 20 units subcutaneously two times daily. Hold medication for a blood sugar of less then 80 and contact physician for further instructions. This was scheduled for 8:00 A.M. and 8:00 P.M. with a start date of 12/12/23. Review of Resident #14's Electronic Medication Administration Record (EMAR) note revealed on 12/20/23 at 5:00 A.M. the residents blood glucose was 48, and his Lantus was held. There was no documentation that Resident #14's physician was notified of the low blood sugar reading. Interview on 12/28/23 at 11:44 A.M. with Licensed Practical Nurse (LPN) #102 revealed when he checked the blood glucose of Resident #14 around 6:00 A.M. on 12/20/23 it was 48. LPN #102 confirmed Resident #14 did not have an order for glucose monitoring at 6:00 A.M. and that the residents blood sugar was checked out of habit as the resident previously had an order to check it at 6:00 A.M. but it was changed to 8:00 A.M. LPN #102 stated Resident #14 was alert, oriented and was given apple juice on 12/20/23 at 6:00 A.M. A recheck about ten minutes later revealed a blood glucose of 90. LPN #102 verified he did not contact the physician as ordered. LPN #102 also confirmed the assessment, monitoring and/or intervention provided to Resident #14 for the low blood sugar reading of 48 was not documented. Review of information from Medscape at https://emedicine.medscape.com/article/2087913-overview?form=fpf revealed the normal glucose levels for an adult are between 74-106 milligrams (mg) per(/) deciliter (dl) with possible critical values for an adult male as less than 50 mg/dl. This is a new deficiency based on the post survey revisit for the complaint survey completed on 12/04/23.

Based on observations, resident record reviews, review of the emergency squad run report, review of hospital records, review of policy, review of the website Medscape, staff interviews, resident representative interview, physician interview, and interview with pharmacy staff, the facility failed to ensure one newly admitted resident (Resident #02) was free from significant medication errors, when Resident #02 who had a [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries and/or death, when Resident #02 began having [CONDITION(S)] activity at the facility which required the resident be sent to the hospital for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Subsequently, once the resident was stabilized, he was then transferred to another hospital where the attending neurologist was practicing. In addition, the facility failed to ensure other medications were available for administration to Resident #02 as ordered by the physician. This affected one (#02) of five residents reviewed for medication errors. The facility census was 35. On 09/20/22 at 4:52 P.M., the Administrator, Director of Nursing (DON), and Chief Clinical Officer (CCO) #1002 were notified Immediate Jeopardy began on 08/17/22 when Resident #02 was admitted to the facility from the hospital with a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Consequently, on 08/21/22, Resident #02 began having [CONDITION(S)] activity at the facility and was sent to a local hospital for evaluation and treatment. At the local hospital, the resident was administered multiple medications, was intubated, and ultimately sent to another hospital, where the resident's attending neurologist was practicing, for further treatment. The Immediate Jeopardy was removed on 09/14/22 when the facility implemented the following corrective actions: On 08/18/22 at 10:55 A.M., Licensed Practical Nurse (LPN) #102 contacted the Pharmacy via the telephone regarding controlled medications not being available for Resident #02. On 08/18/22 at 10:55 A.M., LPN #102 texted Certified Nurse Practitioner (CNP) #01 via text message and asked CNP #01 and Physician Assistant (PA) #02 to send prescriptions and CNP #01 replied at 10:57 A.M. via text yes. On 08/18/22 at 9:00 P.M., LPN/Charge Nurse #107 contacted the pharmacy via telephone requesting medications be drop shipped for Resident #02. On 08/19/22, the DON notified CNP #01 and PA #02 via telephone that controlled scripts (prescriptions) were needed for Resident #02. On 08/21/22 at 7:51 A.M., Resident #02 was transferred to the hospital due to [CONDITION(S)] activity, and Physician #03 and the resident's responsibly party were notified by staff nurse LPN #175 at 7:55 A.M. On 08/23/22, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with administration to review medication concerns. The administrator, DON, Regional Nurse Consultant (RNC) #150, and the Medical Director were in attendance. On 08/23/22 at 2:00 P.M., the DON was provided education by RNC #150 on receiving prescription hard copy of controlled substance on new admissions and on the importance of receiving all medications prescribed to a resident by the next day. On 08/24/22, all newly admitted residents (Resident #15) were audited by the DON to ensure all narcotics and all other medications were available. No negative findings were identified. Audits will be completed by the DON and/or designee for five days a week for four weeks. On 09/14/22 at 2:00 P.M., the DON and RNC #150 reviewed all 35 current residents' Medication Administration Records (MAR) and medications to ensure all medications were present and available. A total of four medications were missing, two of the medications were ordered from pharmacy and a family supplies the other resident medication. All medications were available for administration at the next ordered administration time. On 09/14/22 at 2:00 P.M., the DON and RNC #150 initiated education of 100% of the 24 licensed nursing staff by telephone on the following: Abuse/neglect policy, administering medication per physician order, medication availability, what to do when medications are not available, notification of the physician, administering critical medications, conducting resident assessments, documentation standards, documentation of medication administration, process for obtaining controlled medications, and admission /readmission medication ordering and receipt. On 09/14/22 at 3:30 P.M., the Regional Director/Minimum Data Set (MDS)/RN #112 reviewed the plan of care for the five residents (#17, #12, #07, #18, #06) identified by the facility as residents with [CONDITION(S)] medications. No negative findings were identified. On 09/14/22 at 4:00 P.M., the DON and RNC #150 reviewed the other five current residents (#17, #12, #07, #18, and #06) receiving anticonvulsants to ensure all ordered medications were administered per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/14/22, an ad hoc QAPI meeting was held with administrative staff to formulate the correction plan. On 9/15/2022 at 10:00 A.M., the DON initiated an audit of the MARs to ensure all medications were available and had been administered per physician order. Beginning 09/15/22, the DON and/or designee will audit ongoing all resident MARs five times a week for four weeks to ensure medications are available for administration per physician order. Results of the audits will be submitted to the QAPI committee for review and further recommendations. On 09/21/22, an ad hoc QAPI meeting was held with administrative staff to evaluate the progress of the plan. On 09/21/22, between 10:52 A.M. and 3:45 P.M., interview with LPN #113 and LPN #202 revealed acknowledgement of receiving in-servicing and were able to verbalize procedures for obtaining medication, administering medications and documentation of medications. Review of in-servicing documentation for licensed nursing staff revealed all in-servicing was completed on 08/24/22 and 09/14/22 by the DON related to Abuse/neglect policies, administering medication per physician order, medication availability, what to do when medications are not available, notification of physician, administering critical medications, conducting resident assessments, documentation standards, documentation of medication administration, process for obtaining controlled medications and admission /readmission medication ordering and receipt. Record review of Residents #06, #07, #11, #12, and #15 revealed no concerns with medications being available for medication administration and were administered per physician orders. Observation of medication administration on 09/15/22 revealed 26 opportunities to three residents were completed. No medication errors were identified. Although the Immediate Jeopardy was removed on 09/14/22, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not immediate jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #02 revealed the resident was admitted to the facility on [DATE] at 12:30 P.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a five-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #02 had severe impaired cognition. Review of the assessment revealed additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 9:00 P.M. The [MEDICATION(S)] was not documented as administered on 08/17/22 at 9:00 P.M., the place for the nurse's initials was left blank. On 08/18/22 at 9:00 A.M., the signature box for administration contained the number nine (9), which indicated other/see nurses notes and at 9:00 P.M., the signature box contained the number five (5), which indicated to hold/see nurses notes. Continued review of [MEDICATION(S)] administration revealed on 08/19/22 and 08/20/22 at 9:00 A.M., the signature box contained the number 9. Review of the 9:00 P.M., administration on 08/19/22 and 08/20/22, revealed the medication was documented as administered. On 08/21/22 at 9:00 A.M., the signature box contained the number three (3) which indicated the resident was absent from home. Continued review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 9:00 P.M. The [MEDICATION(S)] was not documented as administered on 08/17/22 at 9:00 P.M., the place for the nurse's initials was left blank. On 08/18/22 at 9:00 A.M., the signature box for administration contained the number 9, which indicated other/see nurses notes and at 9:00 P.M., the signature box contained the number 5, which indicated to hold/see nurses notes. Continued review of [MEDICATION(S)] administration revealed on 08/19/22 at 9:00 A.M., the signature box contained the number 9 and at 9:00 P.M., the medication was documented as administered. Continued review revealed on 08/20/22 at 9:00 A.M. and 9:00 P.M., the medication was documented as administered. On 08/21/22 at 9:00 A.M., the signature box contained the number 3 which indicated the resident was absent from home. Continued review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. The [MEDICATION(S)] was documented as administered on 08/18/22, 08/19/22, and 08/20/22. Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a progress note for Resident #02 dated 08/18/22 at 5:41 A.M., revealed the facility was awaiting arrival of medications from the pharmacy. Review of a progress note dated 08/18/22 at 8:13 A.M., revealed the facility was waiting on the prescription for [MEDICATION(S)] tablet 200 mg. Review of the progress notes revealed on 08/18/22 at 7:25 P.M., revealed Resident #02 was yelling I need my pills, I need my pills. Documentation revealed the resident was administered the medications that were available at the facility. Review of a progress note dated 8/18/22 at 9:10 P.M., revealed the medication had not yet arrived from the pharmacy. The pharmacy was notified via telephone of the need for the medication. The progress note revealed the medication was to be drop shipped. Review of a progress note dated 08/19/22 at 8:51 A.M., revealed awaiting medication arrival from the pharmacy. Review of the progress notes revealed there was no evidence of the physician being notified of the [MEDICATION(S)] not available on 08/18/22. Additionally, the progress noted contained no evidence of the physician or pharmacy being notified on 08/19/22 of the need for [MEDICATION(S)]. Review of a document titled iMessage dated 08/18/22 at 10:55 A.M., revealed Certified Nurse Practitioner (CNP) #01 was notified of the need for a [MEDICATION(S)] prescription. The response back was yes. Review of a progress note for Resident #02 dated 08/20/22 at 8:05 A.M., revealed the facility was awaiting medication from the pharmacy. Review of a progress note dated 08/20/22 at 7:39 P.M., revealed there was no [MEDICATION(S)], pharmacy was notified. Review of the progress notes revealed no evidence of the physician being notified of the resident not being administered [MEDICATION(S)]. Further review of the progress notes revealed on 08/21/22 at 7:51 A.M., Resident #02 was having [CONDITION(S)] like activity, each time getting longer. Documentation revealed the physician was aware and a new order was given to send the resident to the hospital for evaluation and treatment. Review of the emergency squad run reported dated 08/21/22, revealed per the facility, Resident #02 started having seizures at 4:10 A.M., the [CONDITION(S)] lasted 4 minutes and then stopped. At 5:46 A.M., the resident had another [CONDITION(S)] that lasted 4 minutes, per the squad report the resident then started having seizures every 4 minutes for 4-minute duration. Documentation revealed the squad was called at 6:31 A.M. and made aware of the need for emergency transportation. The squad arrived at the facility at 6:42 A.M. and left facility at 7:00 A.M. Treatment documented by the squad included oxygen at 15 liters per minute delivered via non-rebreather mask. A 12-lead echocardiogram (ECG) [a diagnostic tool which records the hearts electrical activity] was applied. Review of hospital documentation dated 08/21/22 revealed Resident #02 presented actively seizing, the resident had a known history of seizures but had been off his medication for four days because of an error at the nursing home. The resident was on [MEDICATION(S)] ([MEDICATION(S)]) and [MEDICATION(S)]. Documentation revealed the resident was intubated to protect his airway. The resident had been seizing for almost four hours with [CONDITION(S)] starting at 4:10 A.M., per the emergency medical transportation team and the resident arrived at the hospital at 7:15 A.M., actively seizing. Documentation revealed the resident was administered 1.5 gram (g) of [MEDICATION(S)], which is classified as SV2A Ligands (anti-[CONDITION(S)] medication) which is indicated for myoclonic seizures (brief, shock-like jerks of a muscle or a group of muscles). The document revealed the [MEDICATION(S)] did not stop the seizures prior to intubation. The resident was administered another 3 g of [MEDICATION(S)] for a total of 4.5 g. The resident was intubated and started on a [MEDICATION(S)] (a general anesthetic) drip per intravenous (IV). Documentation revealed the resident had to receive a bolus multiple times with versed (anti-anxiety agent) to control seizures, despite 50 g of [MEDICATION(S)] drip. The resident was switched to a versed drip. The resident was accepted at another hospital at which the resident consults with a neurologist and was being transferred. Documentation revealed critical care was indicated and the resident's condition at discharge was fair. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M., an order was created to send Resident #02 to the hospital for evaluation and treatment, ordered 08/21/22. Interview on 09/14/22 at 11:31 A.M., the DON verified the medication [MEDICATION(S)] was never administered to Resident #02 while at the facility. The DON stated the pharmacy was notified of the need for the medication on 08/17/22, 08/18/22, and 08/20/22. The DON reported, the 9:00 P.M. doses of [MEDICATION(S)] that were documented as administered were documented administered in error as the medication was not available to be administered. Continued interview with the DON revealed CNP #01 was notified on 08/18/22 of the [MEDICATION(S)] not being available for administration to Resident #02. The DON verified the medical record contained no evidence of physician notification on 08/19/22 or 08/20/22 of the [MEDICATION(S)] not being available for administration to Resident #02. Interview on 09/15/22 at 10:02 A.M. with RNC #150, revealed the pharmacy received Resident #02's prescription for [MEDICATION(S)] on 08/21/22. RNC #150 reported CNP #01 remembered sending the prescription on 08/19/22 but did not recall if the prescription was sent to the facility or the pharmacy. RNC #150 reported in either case the prescription was never received by the facility or pharmacy on 08/19/22. Interview on 09/15/22 at 10:06 A.M. with the DON verified the physician was not notified of Resident #02 not being administered [MEDICATION(S)] or the need for the prescription. The DON reported CNP #01, and PA #02 were notified via text of the need for the prescription on 08/18/22 and only the CNP #01 responded to the text. Interview on 09/15/22 at 12:54 P.M. with LPN #175 revealed LPN #175 was the charge nurse the morning of 08/21/22. The nurse was scheduled to work from 3:00 A.M. to 3:00 P.M. LPN #175 revealed early in the shift Resident #02 had a [CONDITION(S)]. LPN #175 reported Resident #02 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #175 was not able to recall the time of the [CONDITION(S)] or the time of [MEDICATION(S)] administration. LPN #175 reported the [CONDITION(S)] activity stopped for about an hour and restarted around 6:00 A.M. or possibly 6:30 A.M. LPN #175 revealed the physician was notified of Resident #02's [CONDITION(S)] activity and a new order was received to send to the hospital for evaluation. LPN #175 could not recall the time of physician notification or emergency medical transportation arrival. LPN #175 reported the only documentation of the event was in the progress notes and no other details could be recalled. Interview on 09/15/22 at 1:30 P.M. with the DON, revealed LPN #175 had no way to administer [MEDICATION(S)] to Resident #02. The DON revealed the resident's supply of [MEDICATION(S)] had not been delivered and per the pharmacy nothing was pulled from the E Box (emergency box of medications). The DON revealed the nurse consulted with the DON on 08/21/22 and [MEDICATION(S)] was discussed but never actually administered. Interview on 09/20/22 at 1:58 P.M. with Physician #03 regarding Resident #02, revealed CNP #01 and PA #02 were notified of the need for a prescription for [MEDICATION(S)] for Resident #02 on 08/18/22. Physician ##03 revealed on 08/18/22, CNP #01 sent a prescription for [MEDICATION(S)] to the pharmacy via fax. Physician #03 revealed the pharmacy did not find the prescription for [MEDICATION(S)] until 08/21/22. Physician #03 reported the current process was to call or fax the pharmacy with orders/prescriptions. Physician #03 further reported the current process of faxing the pharmacy orders was no longer going to be utilize and a new process would be discussed with the facility staff. Continued interview with Physician #03 revealed it was the expectation of the physician to be notified immediately of any medication that would need a prescription to be filled by the pharmacy and of any medication that was not administered to a resident. Physician #03 reported the facility staff should have notified the physician on 08/17/22 of any medication prescriptions that were needed for Resident #02. Physician #03 verified CNP #01, and PA #02 were made aware of the [MEDICATION(S)] not being available for Resident #02 on 08/18/22. Physician #03 reported it would be expected of the facility staff to have notified the physician, CNP #01, or the PA #02 of the need for the prescription for [MEDICATION(S)] and the medication not being available on 08/17/22, 08/19/22, and 08/20/22. Interview on 09/21/22 at 10:16 A.M. with Resident Representative (RR) #400 for Resident #02 revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . RR #400 revealed Resident #02 had been taking the medication [MEDICATION(S)] for approximately six years. RR #400 reported [MEDICATION(S)] is what stabilized Resident #02's seizures. RR #400 revealed when the resident started taking [MEDICATION(S)] seizures were decreased to about two seizures a year and in the last three years the resident had no seizures. RR #400 stated the resident has had no seizures up until the resident was admitted to the facility and the [MEDICATION(S)] was not administered. RR #400 revealed being at the facility to visit the resident on either 08/18/22 or 08/19/22 and not being made aware of the need for the [MEDICATION(S)]. RR #400 reported Resident #02's medications were always with RR #400 and had RR #400 known of the need for the [MEDICATION(S)], RR #400 would have given the facility the resident's home supply. Interview on 09/21/22 at 10:58 A.M. with the DON, verified the medication [MEDICATION(S)] was not available from the pharmacy and also not administered to Resident #02. Interview on 09/21/22 at 1:52 P.M. with Pharmacy Customer Care Representative (PCCR) #825 revealed a valid prescription for [MEDICATION(S)] for Resident #02 was received at the pharmacy on 08/21/22 at 6:19 P.M. PCCR #825 revealed on 08/17/22, Resident #02's medication orders were entered into the system at the pharmacy, but valid prescriptions were not received for [MEDICATION(S)], [MEDICATION(S)], or [MEDICATION(S)]. The procedure for medication that does not have a valid script would be to notify the facility or the physician of the need for a valid prescription. PCCR #825 revealed the notification of the need for the prescription would happen the same day as the orders were enter, so in this case the notification would have happened on 08/17/22. PCCR #825 revealed there were different ways to order medication which include electronic (ordering the medication through a computer program), by telephone, and via fax machine. All medication orders are then entered into the system and checked for valid prescriptions. If the pharmacy gets a medication that does not have a valid prescription, then that information would be put into the profile with the request for the needed prescription. PCCR #825 revealed the physician can then electronically send the prescription through the website or the facility could contact the physician and get the prescription. PCCR #825 revealed generally the pharmacy staff does not call the physician to request prescription unless the facility makes that request which does not happen very often. Review of the website titled; Medscape revealed withdraw [MEDICATION(S)] ([MEDICATION(S)]) gradually over one week; do not discontinue abruptly because of risk for increased frequency of seizures. Stopping [MEDICATION(S)] suddenly can cause serious problems. The elimination half-life of [MEDICATION(S)] is approximately 13 hours. Review of a policy titled, Unavailable Medications dated 06/17/22, revealed the facility shall use uniform guidelines for unavailable medication. Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable: a. determine the reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication.; b. notifies the physician of inability to obtain the medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring resident while medication is on hold. This deficiency substantiates Complaint Number OH 503.

Based on medical record review, staff interview, and review of facility policy, it was determined the facility failed to administer an enteral tube feeding per physician orders. This resulted in actual harm for Resident #46 who experienced a 11.3 percent (%) severe weight loss in three months when enteral feedings were not administered as ordered by the physician upon a resident refusal of meal intakes or when the meal intakes were less than 50%. This affected one (#46) of two residents reviewed for nutrition/weight loss. The facility identified three residents with enteral feedings. The facility census was 60. Findings Include: Review of Resident #46's medical record revealed the resident was admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side muscles, dysphagia, oropharyngeal phase, dysphonia specified lack of coordination, major depressive disorder, heart failure unspecified and chronic obstructive pulmonary disease. A stage two pressure ulcer to the coccyx was present since 07/20/18. Review of admission orders, from hospital discharge documents dated 04/29/16, revealed Resident #46 had placement of percutaneous endoscopic gastrostomy tube (g-tube) for the administration of nutrition. Review of the plan of care dated 05/09/16 revealed the resident was at nutritional risk related to her oral diet was not meeting her estimated needs. The goal was for the resident to be free from significant weight changes. Interventions included to administer the enteral feeding Jevity per the physician's order. Review of physician orders revealed Resident #46 had a diet order for pureed texture with honey consistency liquids. The resident also had an order dated 01/12/18 to administer the tube feeding solution of Jevity 1.2 Cal 160 milliliters (ml) per the g-tube tube three times a day at 12:00 A.M., 6:00 A.M. and 6:00 P.M. There was also an order dated 02/21/18 to administer 160 mls of Jevity 1.2 Cal per the g-tube as needed (PRN) if the resident refused breakfast or lunch with 200 ml flush (solution unspecified) as needed for supplement when the resident refuses meals. Review of the State Tested Nurse Aide (STNA) documentation of Resident #46's meal consumption for April 2018 revealed the resident refused her meal on 04/02/18 at breakfast, 04/11/18 and 04/23/18 at dinner, and on 04/30/18 at lunch. Review of the medication administration record (MAR) for April 2018 revealed no PRN Jevity 1.2 Cal was administered for these meal refusals. Review of the STNA documentation of Resident #46's meal consumption for May 2018 revealed the resident refused the evening meal on 13 occasions, 05/05/18, 05/06/18, 05/07/18, 05/13/18, 05/15/18, 05/16/18, 05/18/18/, 05/19/18, 05/20/18, 05/21/18, 05/22/18, 05/23/18, and 05/27/18. The resident refused breakfast on 05/16/18 and 05/19/18, and refused lunch on 05/18/18. Review of Resident #46's MAR for May 2018 revealed the PRN Jevity 1.2 Cal was not administered on these occasions for meal refusals. Review of the STNA documentation of Resident #46's meal consumption for June 2018 revealed the resident refused the lunch meal on 06/05/18, 06/11/18, and 06/21/18. The resident refused the evening meal on 06/04/18, 0/605/18, 06/06/18, 06/07/18, 06/11/18, 06/12/18, 06/13/18 and 06/28/18. Review of Resident #46's MAR for June 2018 revealed the PRN Jevity 1.2 Cal was not administered on these occasions for meal refusal. Review of Resident #46's weight documentation revealed the resident weighed 97.2 pounds (lbs) on 04/08/18 and weighed 86.7 lbs on 07/05/18. This represented a severe weight loss of 11 pounds or 11.3 % weight loss in three months. Review of dietary note, dated 07/12/18, revealed Resident #46's goal for body mass index (BMI) to be 20.9. The dietitian noted the resident receives extra g-tube feedings when she eats less than 50% of meals due to weight loss. Review of Resident #46's physician order dated 07/13/18 revealed the as needed Jevity 1.2 Cal order was changed to 160 mls if the resident consumed less than 50% of her meals followed by a 200 ml flush (solution not specified) for supplement as needed when the resident refuses meals. Review of the STNA documentation of Resident #46's meal consumption for July 2018 revealed on 07/17/18 the resident refused breakfast. On 07/18/18 the resident refused the breakfast meal, the lunch meal , and consumed less than 50% of the evening meal. On 07/21/18 the resident refused the lunch meal. On 07/22/18 the resident consumed less than 50% of the lunch meal Review of Resident #46's MAR for July 2018 revealed the Jevity 1.2 Cal was not administered on 07/17/18 at breakfast, was only administered twice on 07/218/18, and was not administered on the 07/21/18 or 07/22/18 lunch meal. Review of Resident #46's weight on 07/25/18 revealed the resident weighed 88 pounds. Interview with Licensed Practical Nurse (LPN) #400 on 07/24/18 at 4:48 P.M. verified Resident #46 has an order to administer a tube feed if she eats fifty percent or less of her meal. When asked how the nurses know how much the resident has eaten, she stated the STNAs report the intake percentage and the nurses then administer Jevity 1.2 Cal if needed. Interview with LPN #10 on 07/24/18 at 4:50 P.M. revealed there was a nurse in the dining room during meals and the STNAs let the nurses know how much of the meal Resident #46 has consumed to determine if the Jevity 1.2 Cal needs to be administered. Interview on 07/26/18 at 10:45 A.M., the Registered Dietician verified if Resident #46's meal consumption was coded as 25% to 50% of her meals, the resident was to be administered Jevity 1.2 Cal 160 ml per the g-tube. Review of the facility's undated policy titled Nutritional Status-Management Improvement revealed the percentage of food and fluid intake should be recorded at each meal unless an alternative process has been implemented to determine if nutrition is adequate to meet resident/patient's needs (i.e., weighed weekly or appetite documented with each meal).

Based on medical record review, staff interview, and review of facility policy, it was determined the facility failed to administer an enteral tube feeding per physician orders. This resulted in actual harm for Resident #46 who experienced a 11.3 percent (%) severe weight loss in three months when enteral feedings were not administered as ordered by the physician upon a resident refusal of meal intakes or when the meal intakes were less than 50%. This affected one (#46) of two residents reviewed for nutrition/weight loss. The facility identified three residents with enteral feedings. The facility census was 60. Findings Include: Review of Resident #46's medical record revealed the resident was admitted on [DATE]. [DIAGNOSES REDACTED]. A stage two pressure ulcer to the coccyx was present since 07/20/18. Review of admission orders [REDACTED]. Review of the plan of care dated 05/09/16 revealed the resident was at nutritional risk related to her oral diet was not meeting her estimated needs. The goal was for the resident to be free from significant weight changes. Interventions included to administer the enteral feeding [MEDICATION NAME] per the physician's orders [REDACTED].>Review of physician orders [REDACTED]. The resident also had an order dated 01/12/18 to administer the tube feeding solution of [MEDICATION NAME] 1.2 Cal 160 milliliters (ml) per the [DEVICE] tube three times a day at 12:00 A.M., 6:00 A.M. and 6:00 P.M. There was also an order [REDACTED]. Review of the State tested Nurse Aide (STNA) documentation of Resident #46's meal consumption for (MONTH) (YEAR) revealed the resident refused her meal on 04/02/18 at breakfast, 04/11/18 and 04/23/18 at dinner, and on 04/30/18 at lunch. Review of the Medication Administration Record [REDACTED]. Review of the STNA documentation of Resident #46's meal consumption for (MONTH) (YEAR) revealed the resident refused the evening meal on 13 occasions, 05/05/18, 05/06/18, 05/07/18, 05/13/18, 05/15/18, 05/16/18, 05/18/18/, 05/19/18, 05/20/18, 05/21/18, 05/22/18, 05/23/18, and 05/27/18. The resident refused breakfast on 05/16/18 and 05/19/18, and refused lunch on 05/18/18. Review of Resident #46's MAR for (MONTH) (YEAR) revealed the PRN [MEDICATION NAME] 1.2 Cal was not administered on these occasions for meal refusals. Review of the STNA documentation of Resident #46's meal consumption for (MONTH) (YEAR) revealed the resident refused the lunch meal on 06/05/18, 06/11/18, and 06/21/18. The resident refused the evening meal on 06/04/18, 0/605/18, 06/06/18, 06/07/18, 06/11/18, 06/12/18, 06/13/18 and 06/28/18. Review of Resident #46's MAR for (MONTH) (YEAR) revealed the PRN [MEDICATION NAME] 1.2 Cal was not administered on these occasions for meal refusal. Review of Resident #46's weight documentation revealed the resident weighed 97.2 pounds (lbs) on 04/08/18 and weighed 86.7 lbs on 07/05/18. This represented a severe weight loss of 11 pounds or 11.3 % weight loss in three months. Review of dietary note, dated 07/12/18, revealed Resident #46's goal for body mass index (BMI) to be 20.9. The dietitian noted the resident receives extra [DEVICE] feedings when she eats less than 50% of meals due to weight loss. Review of Resident #46's physician order [REDACTED]. Review of the STNA documentation of Resident #46's meal consumption for (MONTH) (YEAR) revealed on 07/17/18 the resident refused breakfast. On 07/18/18 the resident refused the breakfast meal, the lunch meal , and consumed less than 50% of the evening meal. On 07/21/18 the resident refused the lunch meal. On 07/22/18 the resident consumed less than 50% of the lunch meal Review of Resident #46's MAR for (MONTH) (YEAR) revealed the [MEDICATION NAME] 1.2 Cal was not administered on 07/17/18 at breakfast, was only administered twice on 07/218/18, and was not administered on the 07/21/18 or 07/22/18 lunch meal. Review of Resident #46's weight on 07/25/18 revealed the resident weighed 88 pounds. Interview with Licensed Practical Nurse (LPN) #400 on 07/24/18 at 4:48 P.M. verified Resident #46 has an order to administer a tube feed if she eats fifty percent or less of her meal. When asked how the nurses know how much the resident has eaten, she stated the STNAs report the intake percentage and the nurses then administer [MEDICATION NAME] 1.2 Cal if needed. Interview with LPN #10 on 07/24/18 at 4:50 P.M. revealed there was a nurse in the dining room during meals and the STNAs let the nurses know how much of the meal Resident #46 has consumed to determine if the [MEDICATION NAME] 1.2 Cal needs to be administered. Interview on 07/26/18 at 10:45 A.M., the Registered Dietician verified if Resident #46's meal consumption was coded as 25% to 50% of her meals, the resident was to be administered [MEDICATION NAME] 1.2 Cal 160 ml per the [DEVICE]. Review of the facility's undated policy titled Nutritional Status-Management Improvement revealed the percentage of food and fluid intake should be recorded at each meal unless an alternative process has been implemented to determine if nutrition is adequate to meet resident/patient's needs (i.e., weighed weekly or appetite documented with each meal).

Based on review of a closed medical record, interviews with staff and the physician, review of staffing schedules, review of a facility policy, review of the Ohio Revised Code (ORC), and review of the Ohio Administrative Code (OAC), the facility failed to initiate Cardio-Pulmonary Resuscitation (CPR) or contact Emergency Medical Services (EMS) timely for one (#55) resident found unresponsive, without a pulse, respirations or blood pressure, and who was identified as a Full Code status. Life threatening harm and death occurred when Resident #55 did not receive CPR or EMS and expired at the facility. This resulted in Immediate Jeopardy for one (#55) of ten residents reviewed for an emergent change in condition and death. The facility identified a total of ten current residents who were designated as having a Full Code status. The facility census was 61. On [DATE] at 3:33 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 12:45 P.M. when Resident #55 was found unresponsive, without a pulse, respirations, or blood pressure, and Licensed Practical Nurses (LPN's) #102 and #103 failed to initiate CPR or contact EMS. Resident #55 expired at the facility. The Immediate Jeopardy was removed on [DATE] at 1:20 P.M. when the facility implemented the following corrective actions: · On [DATE] at 4:30 P.M., the facility Administrator and DON began in-service training with all nurses regarding the facility's CPR policy in person or via telephone. The training was completed on [DATE] at 1:20 P.M. · On [DATE] between 4:40 P.M. and 6:00 P.M., the Administrator and DON completed medical record audits to ensure correct code status was appropriately identified for all 61 residents residing in the facility. No concerns were identified. · On [DATE] between 9:20 A.M. and 10:10 A.M., Registered Nurse (RN) #108 and LPNs #102 and #103 verified they received in-service education on [DATE] (#103) and [DATE] (#102 and #108) regarding the facility's CPR policy and procedure and when to initiate CPR. · On [DATE] at 11:00 A.M., LPN #102 and LPN #103 received written disciplinary action notices for failing to notify/document physician notification of absence of vital signs regarding Resident #55. An interview with the Administrator and Regional Nurse #110, to clarify the absence of vital signs for notification, revealed the disciplinary action was specifically related to failing to notify the physician of the dependent lividity (purplish color assumed by the lowest-lying parts of a recently dead body due to the downward flow and pooling of blood under the influence of gravity) symptom. The dependent lividity symptom was in LPN #102's typed statement dated [DATE] (no time documented) and was not in the nurses notes dated [DATE]. · On [DATE], the Administrator implemented education of the CPR policy for any newly hired nurse effective [DATE]. Any newly hired nurse must cover the facility's policy on CPR upon orientation and acknowledge receipt of the policy. The acknowledgement will be maintained in the employee's chart and audited by the Quality Assurance (QA) committee monthly for three months, and quarterly thereafter. · Two additional residents who expired in the facility and ten additional current residents were reviewed for code status and no additional concerns were identified. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #55's closed medical record revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #55's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required supervision for bed mobility, transfers, and ambulation. Review of Resident #55's Resuscitation Designation document dated [DATE] revealed the resident did desire CPR to be performed at the facility should the resident suffer cardiac or respiratory arrest. The document was signed by Resident #55. Review of the [DATE] physician orders for Resident #55 revealed an order dated [DATE] indicating Resident #55's advanced directives were a Full Code. Review of Resident #55's comprehensive care plan revealed the Full Code status was not addressed in the care plan. Review of Resident #55's [DATE] Medication Administration Record [REDACTED]. Review of Resident #55's nursing progress notes dated [DATE] at 8:08 A.M. revealed a blood pressure reading of ,[DATE] mm/Hg. A nursing progress note documented by LPN #102 dated [DATE] at 8:45 A.M., indicated Resident #55 was awake and talkative. On [DATE] at 12:02 P.M., a nursing progress note revealed when LPN #102 took Resident #55 her lunch, the resident was asleep and awoke easily. Resident #55 did respond that she would eat in a few minutes and went back to sleep. On [DATE] at 12:45 P.M., the nursing progress note revealed LPN #102 entered Resident #55's room and found the resident sitting in her recliner chair. Resident #55's skin was cool to touch, pale and blue in color. Extremities were mottled, fingernails blue, body limp and jaw was locked. An additional note documented by LPN #102, dated [DATE] at 12:45 P.M., indicated LPN #102 had been called to the resident's room and Resident #55 had no vitals which was confirmed by another nurse (LPN #103). The physician was notified and ordered to release the body to the funeral home. Further review of Resident #55's nursing progress notes revealed an entry by LPN #103, dated [DATE] at 12:48 P.M. The note indicated LPN #103 had been called to the resident's room and documented Resident #55 was in her recliner chair, skin pale in color, cold to touch, lips blue and mottling was noted. Resident #55's vital signs were absent. An interview on [DATE] at 9:50 A.M. with the Administrator and DON revealed Resident #55 expired at the facility on [DATE]. The DON stated Resident #55 had a normal morning, had breakfast in her room and took her morning medications. Dietary Cook #106 went to Resident #55's room to pick up the resident's lunch tray and knew something was wrong with the resident and alerted LPN #102. LPN #102 assessed the resident and felt Resident #55 was gone and then went and got another nurse, LPN #103, to confirm the resident's death. The DON stated an assessment of the resident by the two LPN's determined the resident did not have any vital signs including blood pressure, respirations or heart tones. The DON stated the physician was then notified and the son came within minutes as he had just arrived at the facility to visit the resident. The DON stated Resident #55 was a Full Code but it was obvious to the nurses the resident had expired. She further stated the information LPN #102 and LPN #103 reported to her was the resident had already passed. She confirmed no CPR had been initiated and she verbally spoke with the two nurses (LPN #102 and LPN #103) involved in the incident regarding the facility's policy, however, nothing in writing had been given to the two LPN's regarding disciplinary action. During an interview on [DATE] at 10:15 A.M. with LPN #102, she stated she had worked 7:00 A.M. to 3:00 P.M. on [DATE]. LPN #102 stated Resident #55 slept all morning which she normally does and she took the resident's blood pressure in the morning before giving the resident her morning medications and there were no concerns. LPN #102 stated the resident drank coffee and a health shake for breakfast and then normally likes to sleep until afternoon. LPN #102 stated she took Resident #55 her lunch tray and the resident said she would eat it shortly. LPN #102 stated about 45 minutes to an hour later, Dietary Cook #106 came to her and stated Resident #55 did not look good. LPN #102 stated she then entered the resident's room and noticed the resident was pale, mottled and her jaw was locked. LPN #102 stated she attempted to obtain the resident's vital signs and was unable to obtain a pulse or blood pressure. LPN #102 stated she called LPN #103 to the room and they both agreed the resident had expired. LPN #102 stated she knew Resident #55 was a Full Code but stated it was obvious the resident had passed. LPN #102 stated they always have two nurses confirm when a resident has passed. LPN #102 stated she then notified the resident's physician and her son, who had just walked into the building right after the incident, Resident #55 had expired. Interview on [DATE] at 10:25 A.M. with LPN #103 revealed she had been working 7:00 A.M. to 7:00 P.M. on [DATE]. LPN #103 stated she had been serving in the dining room when State tested Nursing Assistant (STNA) #105 came into the dining room and said she was needed in Resident #55's room. LPN #103 stated when she arrived at the resident's room the resident's lips were blue, she was cold, mottled, and had no blood pressure or apical pulse. LPN #103 stated she was not familiar with the resident and did not know the resident's code status and she did not ask LPN #102 what the resident's code status was. Interview on [DATE] at 11:40 A.M. with Physician #107 revealed Resident #55 was a Full Code. Physician #107 stated the resident should have been resuscitated unless there were physical signs the resident had expired such as rigor mortis or dependent lividity present. Physician #107 stated he had not had a chance to review the resident's chart and was unsure if the physical signs of death were present. Physician #107 stated given the resident's age, he believed the cause of death might have been sudden cardiac death. Interview on [DATE] at 12:00 P.M. with Dietary Cook #106 revealed she had worked on [DATE]. Dietary Cook #106 stated around 1:00 P.M., she went to Resident #55's room to get her menu ticket for the next day. Dietary Cook #106 stated she knocked on the resident's door and when the resident didn't answer she called out her name and she still didn't respond. Dietary Cook #106 stated she entered the room and it looked like Resident #55 had been sleeping in her chair but normally she doesn't sleep that long. Dietary Cook #106 stated she then went to LPN #102 and told her she should check on Resident #55. Interview on [DATE] at 12:15 P.M. with STNA #105 revealed she had been working on [DATE] from 6:00 A.M. until 2:00 P.M. STNA #105 stated Resident #55 had been doing her usual routine and slept most of the morning. STNA #105 stated LPN #102 had taken the resident her lunch tray. STNA #105 stated LPN #102 called to her she needed assistance with Resident #55. STNA #105 then went to the dining room and told LPN #103 that LPN #102 needed her assistance with Resident #55. Review of the facility policy titled, Cardiopulmonary Resuscitation dated [DATE], revealed when cardiac/respiratory arrest occurs, prior to the arrival of EMS, basic life support must be provided via chest compressions, artificial ventilation and use of an Automated External Defibrillator (AED) as indicated. The initiation of CPR to a resident who experiences cardiac/respiratory arrest will be in accordance with that resident's advance directives order by a physician. CPR will be initiated in the case of [MEDICAL CONDITION] unless, the resident has obvious signs of clinical death which were irreversible including rigor mortis, dependent lividity, decapitation, transection or decomposition. Review of the Ohio Revised Code (ORC) Section 4723.36 titled, Determination of Death by Certified Nurse Practitioner or Clinical Nurse Specialist, revealed a RN may determine and pronounce an individual's death, but only if the individual's respiratory and circulatory function are not being artificially sustained and, at the time of the determination and pronouncement of death is made, the RN is providing or supervising the individual's care through a licensed hospice care program or any other entity that provide palliative care. Review of the Ohio Administrative Code (OAC) [DATE] titled, Pronouncement of Death, revealed a physician holding a current certificate to practice medicine or surgery or osteopathic medicine may pronounce a person dead without personally examining the body of the deceased on ly if a competent observer has recited the facts of the deceased 's present medical condition to the physician and the physician is satisfied that death has occurred. According to the OAC [DATE], an LPN is not permitted to pronounce an individual's death. Review of the facility staffing schedule for [DATE] revealed LPNs #102 and #103 were working the first shift at the time of Resident #55's death and there was no RN scheduled on duty for the first shift. Further review of Resident #55's medical record revealed the resident was not receiving hospice and/or palliative care during her stay at the facility. This deficiency substantiates Complaint Number OH 227.

Based on medical record review, staff interview, policy review and review of information from Medscape, the facility failed to provide treatment when Resident #55 experienced a change in condition. This resulted in actual harm when the facility failed to provide Resident #55 with treatment for [REDACTED]. This affected one Resident (#55) out of three residents reviewed for hospitalization . The facility census was 59. Findings include: Review of medical record for Resident #55 revealed an admission date of [DATE] for after care following [MEDICAL CONDITION] humorous and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Resident #55 was a do not resuscitate comfort care arrest (DNRCC-Arrest). Review of Resident #55's physician order [REDACTED]. Further review of the physician orders [REDACTED]. Review of the comprehensive admission/five day Minimum Data Set (MDS) assessment dated [DATE] documented Resident #55 as cognitively intact with oxygen therapy within the last 14 days prior to admission and within 14 days after admission. Review of Medication Administration Record [REDACTED].M. orally via nebulizer as needed for shortness of breath. Further review documented the treatment was effective. Review of Resident #55's skilled nursing note dated 04/27/17 at 10:20 P.M. documented Resident #55 vital signs were blood pressure 134/57 mm/Hg (millimeters of mercury), temperature 96.9 degree Fahrenheit, pulse 77, respirations at a regular rate of 24 and a oxygen saturation level of 91 percent (%). Resident #55 had oxygen via nasal cannula at 2.5 liters per minute. Resident #55 was oriented to person, place and time. Further review revealed it also documented the resident does become short of breath during activities. The resident was documented as receiving [MEDICATION NAME] nebulizer treatment every two hours as needed for shortness of breath. The [MEDICATION NAME] Nebulizer treatments were effective for relieving her shortness of breath. Further review of Resident #55's skilled nursing note dated 04/28/17 at 12:44 A.M. documented Resident #55 vital signs were blood pressure 146/57 mmHg, temperature 96.7 degree Fahrenheit, pulse 73, respirations at a regular rate of 36 and a oxygen saturation level of 86% with oxygen via nasal cannula at 2.5 liters. Resident #55 was oriented to person, place and time. Further review revealed the resident lung sounds were clear and was using accessory muscles/ retractions for breathing. The resident had obvious increased/ labored breathing. There was no documented intervention/treatment or notification of the physician at this time. Review of MAR indicated [REDACTED]. Review of a skilled nursing note dated 04/28/2017 at 1:45 A.M. revealed the Licence Practical Nurse (LPN) #120 entered Resident #55 room to change the oxygen tubing. Resident #55 was observed without oxygen and the oxygen cannula was laying on the floor in front of the resident. Her skin was documented as cool and gray. Resident #55 did not respond, her blood pressure 116/47 mm/Hg, pulse was 60 and respiration rate was 14. The respiration were described as slow and shallow with an oxygen saturation level of 53% on room air. Her oxygen was reapplied immediately. At 2:00 A.M. the residents family and physician was notified of the resident being unresponsive and regarding the low oxygen level. At 2:03 A.M. nine-one-one (911) transport was called and resident was sent to the emergency room for treatment. Review of hospital admission record 04/28/17 documented the Resident #55 was admitted to the hospital for acute on chronic [MEDICAL CONDITION] and hypercarbic failure. Further review of the hospital documentation revealed Resident #55 had advanced [MEDICAL CONDITION]. Resident #55 was place on a bi-level positive airway pressure ([MEDICAL CONDITION]) machine to assist the resident with breathing. Resident #55 remained unresponsive and was later admitted to inpatient hospice per the families request. On 10/07/17 at 2:50 P.M. via telephone interview with LPN #120 revealed she can not remember anything that happen back in April 2017 regarding the care that was provided to Resident #55. LPN #120 revealed she is unable to verify if she gave Resident #55 an [MEDICATION NAME] Nebulizer treatment or notify the physician when she had a change in condition status on 04/28/17 at 12:44 A.M. when she experienced a change in her respiratory status. LPN #120 verified her typical process would be to try [MEDICATION NAME] nebulizer treatment and notify the physician for a respiratory change in condition. LPN #120 verified her documentation for Resident #55 is what occurred and the care provided on 04/28/17 and she was unable to provide any other information related to the events that occurred. On 10/07/17 on 3:40 P.M. interview with Director of Nursing (DON) verified she was the nurse working on 04/27/17 during second second shift but it was so long ago it hard to remember any details. The DON then revealed Resident #55 was capable of taking her oxygen off her self, was ambulatory and had some anxiety. The DON verified there was no respiratory distress was documented on her shift on 04/27/17. The DON verified if Resident #55 had a respiratory change in condition, LPN #120 should have tried an [MEDICATION NAME] treatment and notified the physician for a change in condition and documented it in the record. The DON verified the record lacked any documentation of an [MEDICATION NAME] treatment or physician notification on 04/28/17 at 12:44 A.M. Review of policy and procedure titled Acute Change in Condition undated revealed the facility is to assess the resident for any significant change noted with an example listed as labored or difficulty breathing. The Physician will then be notified immediately for a marked change in relation to usual symptoms and signs unrelieved by measures already prescribed. Additional service can be provided in house or the resident will be transferred to acute care per the physicians orders. Review of information from Medscape revealed the normal respiratory rate for an adult is 16 to 20. Further review that the normal range for pulse oximetry is 95% to 100% with readings less than 90% are considered low.