Every finding on record at Carriage Inn of Steubenville

Based on observation, maintenance ticket reviews, and staff interviews the facility failed to maintain safe flooring when it did not repair an area of flooring that was uneven and cracked on the transition care unit (TCU) utilized by residents. This affected nine mobile residents (#1, #9, #13, #25, #34, #42, #62, #95, and #105) of 20 residents residing on TCU. The facility census was 95.Findings include:Observation on 03/30/26 at 7:35 AM during the initial tour of the transition care unit (TCU) in front of the nurses' station door revealed a dip in the flooring and a piece of the flooring cracked with a hole starting. This was verified by certified nursing assistant (CNA) #481 who reported she would fill out a ticket to let the maintenance department know of concern. CNA #481 confirmed that the dip in the floor and crack have been there for a while. Observation and interview on 04/02/26 at 9:32 A.M. during a return tour of the TCU in front of the nurses' station door revealed a dip in the flooring and a piece of the flooring cracked with a hole starting. This was verified again by registered nurse (RN) #255 who reported that the maintenance department was aware of the concern, and she had told them that the physical therapy team was concerned as residents walk through that hallway during treatments and are having to walk around the area to the side of the hallways to prevent falls. RN #255 further reported that non-emergent maintenance issues are put on handwritten tickets and placed at the nurses' station and they come around daily to get tickets and address concerns. Urgent issues would be called immediately to the maintenance supervisor. RN #255 reported it's been that way for a while.Interview on 04/02/26 at 10:20 AM with Maintenance Director (MD) #148 reported he received a ticket dated 03/30/26 concerning the flooring issues on TCU. The MD #148 further reported that all of the flooring is needing to be replaced but this would require a contractor and they are in the process of getting estimates. The MD #148 was not able to produce records of estimates or tickets prior to 03/30/26 regarding flooring issues on TCU.Interview on 04/02/26 at 1:40 P.M. with the Administrator revealed she was just made aware of the flooring concern on TCU today and maintenance was currently fixing the floor. During interview the MD #148 came into the Administrator's office and reported he had fixed the flooring issues on TCU.

Based on medical record review, resident interview and observation, and staff interview the facility failed to ensure a call light was accessible and within reach to meet resident needs. This affected one resident (#95) of 20 residents residing on the transitional care unit. The facility census was 95.Findings include:Review of the medical record for Resident #95 revealed admission to the facility on [DATE] with diagnoses including sepsis (a whole-body infection), venous ulcers to bilateral lower legs, severe peripheral vascular disease (narrowing of the vessels in the arms and legs decreasing blood circulation), diabetes, heart failure, heart disease, and acute kidney failure. Further review of the medical record for Resident #95 revealed a minimum data set (MDS) comprehensive assessment was completed on 03/25/26 and revealed Resident #95 required supervision and hands on assistance with dressing lower body, supervision with transfers from bed to wheelchair, and was dependent on staff for mobility of his wheelchair. The MDS assessment also revealed that Resident #95 had no cognitive impairment with a brief interview for mental status score of 15/15.Observation and interview on 03/31/26 at 9:53 A.M. revealed the door of Resident #95's room was closed. Resident #95 was found to be sitting up in a wheelchair, with bilateral footrest present, in the middle of his room. Further observation revealed the call light was not within reach of Resident #95 and was attached to the bedside dresser. The dresser was behind Resident #95 and there was not enough space to move the wheelchair into the area to retrieve the call light. Resident #95 then reported I am glad you came in when you did the nurse left me a while ago to get something for my bed and my dressings are falling off my foot and I can't reach my call light and the door was shut. Interview on 03/31/26 at 9:55 A.M. with registered nurse (RN) # 255 verified that Resident #95 could not reach his call light and she would get someone to change Resident #95's foot dressing. Review of the policy titled Call lights: Accessibility and Timely Response, dated 12/08/25, revealed staff will ensure the call lights are within reach of residents and secured as needed.

Based on record review, policy review, and interview, the facility failed to ensure an appropriate diagnosis was indicated for the use of an antipsychotic medication. This affected one resident (#2) of five residents reviewed for unnecessary medications. Findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, non-Alzheimer's disease, unspecified fracture of right lower leg, osteomyelitis of right ankle and foot, diabetes mellitus, cirrhosis of liver, chronic obstructive pulmonary disease, and muscle wasting. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/01/25, revealed Resident #2 had severe cognitive impairment, a diagnosis of non-Alzheimer's dementia, and received an antipsychotic medication. Review of the physician order, dated 10/02/25, revealed the order for Risperdal (antipsychotic medication) oral tablet 0.5 milligrams (mg) one tablet by mouth two times a day for agitation. Review of the Monthly Regimen Reviews (MRR), dated 10/08/25, revealed the pharmacist recommended an appropriate diagnosis to support the use of the antipsychotic medication, Risperdal. Further review revealed the physician did not timely address the recommendation until 11/20/25, and at that time, changed the diagnosis to dementia with mood disturbance. Interview on 04/02/26 at 7:59 A.M with the Director of Nursing (DON) confirmed Resident #2's October 2025 MRR was not addressed timely by the physician and the resident received Risperdal 0.5 mg by mouth two times per day, an antipsychotic, without an appropriate diagnosis. Review of facility policy titled, Addressing Medication Regimen Review Irregularities, dated 12/05/25, revealed it is the policy to provide a Medication Regimen Review (MRR) for each resident in order to identify irregularities and respond to those irregularities in a timely manner to prevent the occurrence of an adverse drug event. The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. The report should be submitted to the Director of Nursing within 10 working days of the review.

Based on review of medical records and facility policy, observation of medication administration, and staff interviews the facility failed to properly administer medications through a feeding tube for Resident #8. This affected one resident (#8) of one resident reviewed for tube feeding management and care. The facility census was 95.Findings include:Review of the medical record for Resident #8 revealed admission to the facility on [DATE] with diagnoses including high blood pressure, paraplegia (unable to use lower legs), aphasia (inability to speak), seizure disorder, depression, gastrotomy tube (for tube feeding and medications), and anoxic brain damage (lack of oxygen to brain leading to death of brain cells). Further review of the medical record for Resident #8 revealed a quarterly assessment of the minimum data set (MDS) completed on 02/13/26. The MDS revealed Resident #8 was unable to speak and communicate needs, was dependent for all cares and mobility, and was unable to complete an evaluation for mental cognition. The MDS also revealed Resident #8 required a feeding tube for nutrition and medication administration. Observation on 04/01/26 at 8:02 AM of the medication administration for Resident #8 with registered nurse (RN) # 466 revealed several medications crushed by registered nurse (RN) # 466 for administration through Resident #8's feeding tube. The medications included Baclofen (a muscle relaxer) 20 milligrams (mg), lisinopril (for blood pressure control) 10 mg, Vitamin D (supplement for bone health) 25 mg, and a multivitamin (supplement for general health) 1 tab. Continued observation revealed RN #466 added the powdered mixture of crushed medications to a cup of approximately 180 milliliters (ml) of water and then immediately used a large syringe to pull up approximately 60 ml of fluid into the syringe to be administered through the feeding tube. RN #466 did not mix the crushed medications in the water and did not allow time for the medications to be completely dissolved into the water. There was a residual layer of medication on top of the water remaining in the cup after RN #466 pulled up the water with the crushed medications. RN #466 then repeated drawing up another 60 ml of water with crushed medications. The medications were still not completely dissolved, and a layer of powder remained on top of the water. RN #466 began to administer the second 60 ml syringe of water and crushed medications when he met residence and the fluid stopped going through the feeding tube. RN #466 assessed the three-way stop cock attached to the end of the feeding tube and visualized undissolved medication particles sitting at the base of the stop cock blocking the flow of the fluid through the feeding tube. RN #466 then attempted to remove the blockage and was able to eventually remove the buildup of undissolved medications from the stop cock to resume flow of fluids. RN # 466 then returned to the cup of water with crushed medications which still had a residual film on top of water of undissolved medications and removed the last 60 ml of fluid and administered the water with crushed medications through the tube feed. RN #466 then made a comment that he would add additional water to cup to rinse it and administered it. RN #466 then added approximately 120 ml of water to the cup which had residual crushed medication attached to the inside of the cup. The cup of water turned a yellow tinted color as the remain crushed medication dissolved into it. RN #466 then administered the remaining fluids and then flushed the feeding tube with an additional 30 ml of water. RN #466 verbalized that he must not have crushed up the medications as good as he thought and verified there was a clog in the three-way stop cock of crushed undissolved medications. Review of the facility policy titled Medication Administration via Enteral Tube, and dated 12/08/25 revealed medications should be crushed and mixed with water and dilute the solid or liquid medications as appropriate.

Based on observation, record review, facility policy review and interview, the facility failed to provide effective and timely pain control for Resident #104 upon admission. This affected one resident (#104) of one resident who was reviewed for pain management. The facility census was 95.Findings include: Review of the medical record for Resident #104 revealed admission to the facility on [DATE] with diagnoses including heart disease with a triple vessel cardiac bypass, anemia (low blood count), depression, high blood pressure, spinal stenosis (narrowing of the vertebrae) of the neck and mid back, bilateral hip replacements, left knee replacement, and uterine cancer with radiation.Review of the hospital active medication list sent on 03/26/26 to the facility revealed Resident #104 was actively prescribed the following medication during hospitalization: Oxycodone (a potent opioid medication used to treat moderate to severe pain) five (5) milligrams (mg) every four hours as needed for post op(erative) pain, Tramadol ( a prescription-only synthetic opioid analgesic used to treat moderate to severe pain) 50 mg every six hours as needed for pain, Tylenol (over the counter analgesic) 500 mg three times a day as well as Tylenol 650 mg every 4 hours as needed for pain. However, upon admission [DATE] at 7:45 P.M.) the resident only had an order for Tylenol 500 mg three times a day for post-op pain management.Review of the nursing admission assessment completed on 03/26/26 at 9:01 P.M. revealed Resident #104 rated her pain a three (3) on a scale of one to 10 with 10 being the most severe pain and described the pain as achy and infrequent. Review of a progress note dated 03/27/26 at 12:30 A.M. revealed a communication to the Telehealth on call physician requesting a new order for Tylenol 1000 mg three times a day instead of the hospital discharge order of 500 mg three times a day. An order was received at that time.A nursing progress note authored by Registered Nurse (RN) #473 and dated 03/27/26 at 1:08 P.M. revealed Resident #104 reported to the RN that she was on Oxycodone five mg every four hours for pain management in the hospital and requested to receive this medication for pain management. The note revealed RN #473 notified Primary Care Physician (PCP) #487 and he declined to prescribe the medication with no rationale noted.Further review of the progress notes for Resident #104 revealed another nursing note authored by RN #473 and dated 03/27/26 at 4:09 P.M. revealed Nurse Practitioner (NP) #486 was in to see Resident #104 and that NP #486 contact PCP #487 and discussed the resident's pain medications.Review of the history and physical assessment for Resident #104 completed on 03/27/26 revealed Nurse Practitioner (NP) #486 recommended Norco (a prescription medication combining hydrocodone (an opioid pain reliever) and acetaminophen, used to treat moderate to severe pain when non-opioid alternatives are insufficient) for severe pain and continue Tylenol for mild to moderate pain. A prescription for Norco 5-325 mg (one tablet) every eight hours as needed for pain was sent to the Remedi Pharmacy on 03/27/26 at 4:13 P.M. by PCP #487.Review of the medication administration record (MAR) for Resident #104 revealed a pain rating of 3/10 on admission on [DATE]. On 03/27/26 the resident's pain was documented to be rated an eight on a scale of one to 10 (which corresponded to the resident's request for pain medications. Additional documentation on the MAR included on 03/27/26 at 7:28 P.M. the resident's pain was documented to be a one on a scale of one to 10, on 03/27/26 at 9:43 P.M. pain was rated a one on a scale of one to 10 and on 03/27/26 at 10:40 P.M. the resident's pain was documented to be a three on a scale of one to 10. However, there were no nursing progress notes or comprehensive assessment completed to corroborate the numerical pain rating number documented on the MAR at these times. Review of the medical record revealed Resident #104 did not receive the requested pain medication until 03/28/26 at 12:11 A.M. when she requested something for severe pain rated a nine out of 10. Further review revealed Resident #104 continued to receive Norco pain medication again on 03/28/26 at 8:23 A.M., 03/28/26 at 4:28 P.M., 03/29/26 at 1:23 A.M., and 03/29/26 at 11:44 A.M. Resident #104 continued to receive Norco pain medication. Review of a nurse progress note dated 03/30/26 at 8:50 A.M. revealed Resident #104 reported her pain management was better, but her pain returned before she was due for the next dose of pain medication. PCP #487 was notified and a new order was provided to stop the Norco 5/325 mg one tab every eight hours and change to Norco 5/325 mg one tab every six hours as needed for pain.On 03/31/26 a review of the (in process) Minimum Data Set (MDS) initial comprehensive assessment revealed the resident had a Brief Interview for Mental Status score of 15/15 indicating the resident had no cognitive impairment. Further review of the MDS assessment revealed Resident #104 required moderate to maximum assistance with dressing, bathing, bed mobility and transfer and ambulation (walking). Continued review of the MDS assessment revealed on admission Resident #104 had surgical pain to the breastbone rated 3/10 on a 0-10 pain scale. The pain was assessed to be frequent and interfered with her ability to perform everyday activities and sleep.On 03/31/26 at 9:23 A.M. Resident #104 was observed sitting up in chair. The resident was noted to be breathing heavily with facial grimacing, and guarded posture (non-verbal signs of pain). During the observation, an interview with Resident #104 revealed ported she was in pain rated an eight out of 10 to her chest from her recent triple cardiac bypass surgery and was waiting on the nurse to bring her pain medications. Resident #104 reported the aide was letting the nurse know about the need for pain medicine. Resident #104 reported Tylenol was not effective and she had a scheduled dose of Tylenol at 5:30 A.M. this morning and her last dose of pain medication (Norco) was around 11:30 P.M. last night. Resident #104 reported she could have it (Norco) every six (6) hours, but she waited too long this morning to ask for pain pill and now her pain had increased. Resident #104 appeared to be in significant pain at this time. During the conversation, Resident #104 reported she had some issues when she first arrived with pain management and the doctor would not prescribe anything other than Tylenol and it took a whole day to get her pain medications figured out. Resident #104 further reported they did increase her pain medication to every six hours yesterday and that had helped but this morning she was trying to go longer than six hours and the pain had caught up with her. Resident #104 was agreeable for further interview later in day after she got her pain meds and some rest.Review of the MAR revealed pain ratings on 03/28/26, 03/29/26, 03/30/26, and 03/31/26 ranging from six to nine out of 10 on the pain scale and relieved with the Norco pain medication.Interview on 04/01/26 at 8:25 A.M. with Licensed Practical Nurse (LPN) #382 revealed if a new medication or pain medication were prescribed late in day or after pharmacy drop off the nurse could get the medication from the emergency supply stock. After the prescription was called to the pharmacy then the nurse could verify with the on-call pharmacist and get an approval code to remove the designated medication from the emergency medication supply. LPN #382 verified this was also the process for obtaining pain medications if new orders were given and if a resident needed the medication sooner than the next pharmacy delivery. LPN #382 confirmed that the pharmacy generally delivers medications in late evening hours but was not sure of exact times.Interview on 04/01/26 at 11:21 A.M. with Registered Nurse (RN) #473 revealed that on 03/27/26 Resident #104 requested something more than Tylenol for pain and had been on Oxycodone five (5) mg every four hours while in the hospital. RN #473 reported she texted PCP #487 (on her personal phone) but he declined to change any medication or give orders for the Oxycodone. RN #473 denied receiving rationale as to why nothing was prescribed at that time. In addition, RN #473 reported she had since deleted all of the communication text from her personal cell phone with PCP #487. RN #473 did confirm NP #486 came in and saw Resident #104 later in the day and believed something was eventually prescribed for better pain control but was unable to recall when that occurred and what it was for.Interview on 04/01/26 at 4:19 P.M. with NP #486 revealed she had seen Resident #104 on 03/27/26 and spoke with her about the expectations of post-operative pain and agreed Resident #104 would need something more than Tylenol for pain. NP #486 said she spoke with PCP #487 and he agreed to call in a script for Norco to the pharmacy that day. NP #486 further revealed the PCP had not prescribed anything earlier because he had limited knowledge provided about the resident from staff and knew that the NP would be seeing Resident #104 later that day. Interview on 04/02/26 at 9:15 A.M. with Resident #104 revealed she was a retired nurse and that she could not understand why the hospital discharged her with only Tylenol for pain control and when she had been getting the Oxycodone every four hours for pain while in the hospital. Resident #104 further reported the nurse notified the doctor on the first night the resident was at the facility to get something stronger for pain control and the doctor would only increase the dose of Tylenol. Further interview with Resident #104 revealed she requested stronger pain medications again around 1:00 P.M. the second day and the doctor would not prescribe anything else. Then the nurse practitioner came in and saw her around 4:00 PM and agreed to order Norco for better pain control. Resident #104 then stated she had to wait almost eight hours to get her pain pill, and it was around midnight when she finally got it. Resident #104 reported she did not know why it took so long to get the medication. Resident #104 went on to report that she had a history of having both hips replaced and a knee replacement and hysterectomy and she had never had this kind of poor pain control. Resident #104 reported that her post operative pain to her breastbone was a steady 8/10 for the first twenty-four hours she was at the facility until she received the Norco. Resident #104 also reported the first night she was at the facility her pain in her chest was so bad she could not even sleep in the bed due to pain trying to lay down and get up and the staff did get her a reclining chair to sleep in and extra pillows to help assist with comfort that night but she did not sleep well.Continued interview with Resident #104 revealed her pain had since improved and was better controlled now that she was getting the Norco every six hours. The pain control allowed her to participate more in daily activities and physical therapy treatments.Review of facility Pain Management policy dated 12/08/25 revealed the health care team in collaboration with the attending physician and the resident would develop, implement, monitor, and revise necessary interventions to prevent or manage each individual resident's pain starting at admission to the facility.

Based on medical record review, staff interview, and policy review the facility failed to ensure safe storage of medication when medications were left on the breakfast tray for Resident #95. This affected one resident (#95) of twenty residents receiving medication on the transitional care unit. The facility census was 95. Findings include:Review of the medical record for Resident #95 revealed admission to the facility on [DATE] with diagnoses including sepsis (a whole-body infection), venous ulcers to bilateral lower legs, severe peripheral vascular disease (narrowing of the vessels in the arms and legs decreasing blood circulation), diabetes, heart failure, heart disease, and acute kidney failure. Further review of the medical record for Resident #95 revealed a minimum data set (MDS) comprehensive assessment was completed on 03/25/26 and revealed Resident #95 required supervision and hands on assistance with dressing lower body, supervision with transfers from bed to wheelchair, and was dependent on staff for mobility of his wheelchair. The MDS assessment also revealed that Resident #95 had no cognitive impairment with a brief interview for mental status score of 15/15.Observation and interview on 04/02/26 at 9:07 A.M. with Resident #95 revealed he was sitting on the side of his bed with his breakfast tray in front of him on the bedside table. Further observation reveled a medicine cup with 30 milliliters of a brownish liquid and another medicine cup containing four pills (1 blue, 1 pink and 2 white) sitting on Resident #95's breakfast tray. Resident #95 reported he had been working on taking the medications and that there were 15 pills, but he can only take 3-4 at a time. Interview on 04/02/26 at 9:09 A.M. with registered nurse (RN) #473 revealed that she did not visualize Resident #95 take all of his medications when she administered them. RN #473 further confirmed that Resident #95 had four pills remaining in the medicine cup and that the brownish liquid in the other medicine cup was his ProSource supplement. RN #473 confirmed she should have observed Residents #95 taking all of his medications and should not have left the medications with Residents #95. RN #473 proceeded to stay with Resident #95 until he completed taking the remainder of his medications.Interview on 04/20/26 at 12:05 P.M. with the Director of Nursing (DON) confirmed the nursing staff are to make sure medications are taken by residents when they are administered and medications are not to be left in the resident's rooms.Review of the facility medication administration storage policy dated 10/01/25 revealed, During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on observation, interview, record review and review of facility policy the facility failed to ensure the lunch menu and spreadsheets were followed as written. This affected 13 residents (#1, #5, #9, #10, #17, #33, #40, #59, #68, #73, #86, #98 and #100) of 88 residents receiving meals from the kitchen. The facility identified one resident (#83) who did not eat by mouth (NPO). The facility census was 102. Findings include:1a. Review of the medical record for Resident #9 revealed an admission date of 11/12/18. Pertinent diagnoses included morbid (severe) obesity, type two diabetes mellitus, major depressive disorder. The physician had ordered on 01/16/24 for the resident to receive a reduced concentrated sweets (RCS), regular texture with regular/thin liquids with additional instructions to give fruit for dessert, skim milk per menu, and no bread at lunch and dinner unless a sandwich per menu or requested.Further review of Resident #9's medical record revealed a quarterly Minimum Data Set (MDS) assessment, dated 01/09/26, which indicated the resident was cognitively intact, required setup or clean up assistance with meals, had no significant weight changes, and was receiving a therapeutic diet.Continued review of Resident #9's medical record revealed a care plan, initiated on 02/11/19, which stated the resident was at nutritional risk due having diagnoses which included morbid obesity and type two diabetes and being on a therapeutic diet with interventions which included to provide diet and fluids as ordered and to assess food preferences and honor choices as able.Observations conducted on 02/27/26 of tray line between approximately 11:50 A.M. and 12:22 P.M. revealed at 12:05 P.M. a plate with a piece of white cake topped with a layer of cherry topping and another layer of whipped topping, which was approximately three inches by three inches and two inches tall, was placed on Resident #9's meal tray. The tray ticket sitting on the meal tray indicated Resident #9 was on a RCS regular consistency diet with regular/thin liquids . Further review of the tray ticket revealed the resident was to receive chilled peaches for the dessert. Continued review of the tray ticket revealed at the bottom under the notes section there was a note indicating the resident was to receive fruit for dessert. An interview with Dietary Aide (DA) #325 at the time of the observation confirmed the white cake with fruit topping and a whipped topping had been placed on Resident #9's meal tray. Continued observation of the tray line revealed fruit had been dished up and was available in the two door reach-in refrigerator by the tray line and had been placed on other residents meal trays.1b. Review of the medical record for Resident #5 revealed an admission date of 02/22/21. Pertinent diagnoses included type two diabetes mellitus, and Alzheimer's. The physician had ordered on 10/21/22 for the resident to receive a RCS, regular texture with regular/thin liquids diet.Further review of Resident #5's medical record revealed a quarterly MDS assessment, dated 01/27/26, which indicated the resident was moderately impaired cognitively, required setup or clean up assistance with meals, had no significant weight changes, and was receiving a therapeutic diet.Continued review of Resident #5's medical record revealed a care plan, initiated on 02/23/26, which stated the resident was at nutritional risk due having diagnoses which included type two diabetes with diabetic neuropathy and morbid obesity and being on a therapeutic diet with interventions which included to provide diet and fluids as ordered and to assess food preferences and honor choices as able.Observations conducted on 02/27/26 of tray line between approximately 11:50 A.M. and 12:22 P.M. revealed at 12:14 P.M. a plate with a piece of white cake topped with a layer of cherry topping and another layer of whipped topping, which was approximately three inches by three inches and two inches tall, was placed on Resident #5's meal tray. The tray ticket sitting on the meal tray indicated Resident #5 was on a RCS regular diet consistency diet with regular/thin liquids . Further review of the tray ticket revealed the resident was to receive chilled peaches for the dessert. An interview with DA #325 at the time of the observation confirmed the white cake with fruit topping and a whipped topping had been placed on Resident #5's meal tray. Continued observation of the tray line revealed fruit had been dished up and was available in the two door reach in refrigerator by the tray line and had been placed on other residents' meal trays.1c. Review of the medical record for Resident #1 revealed an admission date of 01/01/26. Pertinent diagnoses included type two diabetes mellitus with neuropathy and morbid obesity due to excess calories. The physician had ordered on 02/23/26 for the resident to receive a RCS, regular texture with regular/thin liquids diet.Further review of Resident #1's medical record revealed a Medicare Five Day MDS assessment, dated 01/05/26, which indicated the resident was cognitively intact, required setup or clean up assistance with meals, had no significant weight changes, and was receiving a therapeutic diet.Continued review of Resident #1's medical record revealed a care plan, initiated on 02/23/26, which stated the resident was at nutritional risk due having diagnoses which included obesity, diabetes mellitus, dementia, and Alzheimer's and being on a therapeutic diet with an interventions which included to provide diet and fluids as ordered and to assess food preferences and honor choices as able.Observations conducted on 02/27/26 of tray line between approximately 11:50 A.M. and 12:22 P.M. revealed at 12:06 P.M. a plate with a piece of white cake topped with a layer of cherry topping and another layer of whipped topping, which was approximately three inches by three inches and two inches tall, was placed on Resident #1's meal tray. The tray ticket sitting on the meal tray indicated Resident #1 was on a RCS regular diet consistency diet with regular/thin liquids . Further review of the tray ticket revealed the resident was to receive chilled peaches for the dessert. An interview with DA #325 at the time of the observation confirmed the white cake with fruit topping and a whipped topping had been placed on Resident #1's meal tray. Continued observation of the tray line revealed fruit had been dished up and was available in the two door reach in refrigerator and had been placed on other residents' meal trays.1d. Review of the medical record for Resident #68 revealed an admission date of 02/11/26. Pertinent diagnoses included type two diabetes mellitus without complications and chronic kidney disease stage three. The physician had ordered on 02/11/26 for the resident to receive a RCS, no salt packet, regular texture with regular/thin liquids diet.Further review of Resident #68's medical record revealed the admission Five Day MDS assessment was in progress.Continued review of Resident #68's medical record revealed a care plan, initiated on 02/23/26, which stated the resident was at nutritional risk due having diagnoses which included type two diabetes mellitus and chronic kidney disease stage three and being on a therapeutic diet with interventions which included to provide diet and fluids as ordered and to assess food preferences and honor choices as able.Observations conducted on 02/27/26 of tray line between approximately 11:50 A.M. and 12:22 P.M. revealed at 12:15 P.M. a plate with a piece of white cake topped with a layer of cherry topping and another layer of whipped topping, which was approximately three inches by three inches and two inches tall, was placed on Resident #68's meal tray. The tray ticket sitting on the meal tray indicated Resident #68 was on a RCS no salt packet diet regular diet consistency with regular/thin liquids. Further review of the tray ticket revealed the resident was to receive chilled peaches for the dessert. An interview with DA #325 at the time of the observation confirmed the white cake with fruit topping and a whipped topping had been placed on Resident #68's meal tray. Continued observation of the tray line revealed fruit had been dished up and was available in the two-door reach in refrigerator by the tray line and had been placed on other residents' meal trays.1e. Review of the medical record for Resident #59 revealed an admission date of 02/03/26. Pertinent diagnoses included type two diabetes mellitus with foot ulcer. The physician had ordered on 02/09/26 for the resident to receive a RCS, no salt packet, regular texture with regular/thin liquids diet.Further review of Resident #59's medical record revealed the Medicare Five Day MDS assessment, dated 02/07/26, indicated the resident was cognitively intact, required set up or clean up assistance for eating, had no significant weight changes and received a therapeutic diet.Continued review of Resident #59's medical record revealed a care plan, initiated on 02/09/26, which stated the resident was at nutritional risk due to having diagnoses which included type two diabetes and being on a therapeutic diet with interventions which included to provide diet and fluids as ordered and to assess food preferences and honor choices as able.Observations conducted on 02/27/26 of tray line between approximately 11:50 A.M. and 12:22 P.M. revealed at 12:16 P.M. a plate with a piece of white cake topped with a layer of cherry topping and another layer of whipped topping, which was approximately three inches by three inches and two inches tall, was placed on Resident #59's meal tray. The tray ticket sitting on the meal tray indicated Resident #59 was on an RCS no salt packet diet regular diet consistency with regular/thin liquids . Further review of the tray ticket revealed the resident was to receive chilled peaches for the dessert. An interview with DA #325 at the time of the observation confirmed the white cake with fruit topping and a whipped topping had been placed on Resident #59's meal tray. Continued observation of the tray line revealed fruit had been dished up and was available in the two door reach in refrigerator by the tray line and had been placed on other residents' meal trays1f. Review of the medical record for Resident #98 revealed an admission date of 02/06/26. Pertinent diagnoses included chronic kidney disease stage four, severe protein calorie malnutrition and type two diabetes mellitus. The physician had ordered on 02/09/26 for the resident to receive a RCS, no salt packet, regular texture with regular/thin liquids diet.Further review of Resident #98's medical record revealed the admission Medicare five day MDS assessment, dated 02/10/26, indicated the resident was cognitively intact, required set up or clean up assistance for eating, had no significant weight changes and received a therapeutic diet.Continued review of Resident #98's medical record revealed a care plan, initiated on 02/16/26, which stated the resident was at nutritional risk due to having diagnoses which included type two diabetes mellitus, chronic kidney disease stage four, and severe protein calorie malnutrition and being on a therapeutic diet with interventions which included to provide diet and fluids as ordered and to assess food preferences and honor choices as able.Observations conducted on 02/27/26 of tray line between approximately 11:50 A.M. and 12:22 P.M. revealed at 12:19 P.M. a plate with a piece of white cake topped with a layer of cherry topping and another layer of whipped topping, which was approximately three inches by three inches and two inches tall, was placed on Resident #98's meal tray. The tray ticket sitting on the meal tray indicated Resident #98 was on an RCS no salt packet diet regular diet consistency with regular/thin liquids . Further review of the tray ticket revealed the resident was to receive chilled peaches for the dessert. An interview with DA #325 at the time of the observation confirmed the white cake with fruit topping and a whipped topping had been placed on Resident #98's meal tray. Continued observation of the tray line revealed fruit had been dished up and was available in the two door reach in refrigerator by the tray line and had been placed on other residents' meal trays.Review of the facility's fall and winter menu titled Classic Four PB FW 25-26 revealed the menu for lunch on day six (Friday) of week one was fish of the day, roasted sweet potatoes, sauteed cabbage, dinner roll/margarine, and fruit shortcake.Review of the spreadsheet for the facility spring and winter menu for lunch on day six of week one revealed RCS diets were to receive three ounces of fish of the day, one tablespoon tartar sauce, one number eight scoop (four ounces) of roasted sweet potatoes, one four ounce spoodle (a type of serving utensil) of sauteed cabbage, one each dinner roll/margarine, and one number eight scoop (four ounces) of chilled peaches as the dessert instead of the fruit shortcake.Interview on 02/27/26 at 1:57 P.M. with Registered Dietitian #444 and Dietary Technician Registered (DTR) #411 revealed the spread sheet for the RCS diet should have been followed and the resident should have received chilled peaches instead of the fruit shortcake. Interview on 02/27/26 at 3:33 P.M. with Registered Nurse (RN) Supervisor #423 revealed menus were not always followed and went on to state diabetic residents were getting desserts that they shouldn't be getting. RN Supervisor #423 stated everybody got cake today for lunch.Review of the facility policy titled Reduced Concentrated Sweets (RCS) Diet, revised 12/11/25, revealed the RCS diet was designed to moderate simple sugar intake while maintaining adequate nutrition, hydration, resident satisfaction, and quality of life. An RCS diet may limit food high in simple sugars (concentrated sweets) but did not eliminate carbohydrates. Sweetened desserts was one of the examples listed in the policy as an example of a concentrated sweets item. The policy went on to state the facility would provide RCS diets to support blood glucose management for residents with diabetes or impaired glucose tolerance and would prepare meals consistent with RCS guidelines. 2a. Review of the medical record for Resident #86 revealed an admission date of 07/05/25. Pertinent diagnoses included type two diabetes with diabetic neuropathy, dementia, Parkinsons, chronic obstructive pulmonary disease (COPD), and dysphagia (difficulty swallowing). The physician order had ordered on 11/05/25 for the resident to receive a RCS, no salt packet, mechanical soft diet, with regular/thin liquids.Further review of Resident #86's medical record revealed a quarterly MDS assessment, dated 02/07/26, which indicated the resident was cognitively intact, required setup or clean up assistance with meals, had no significant weight changes, and received a therapeutic and mechanically altered diet.Continued review of Resident #86's medical record revealed a care plan, initiated on 07/21/25, which stated the resident was at nutritional risk due to being on a therapeutic and mechanically altered diet with an intervention to provide diet as ordered and to honor choices as able.Observations conducted on 02/27/26 of tray line between approximately 11:50 A.M. and 12:22 P.M. revealed at 12:02 P.M. a small plate with a piece of chocolate cake with white frosting approximately two inches by two inches and one inch tall was placed on Resident #86's meal tray. The tray ticket sitting on the meal tray indicated Resident #86 was on a RCS No Salt Packet diet with a mechanical soft texture. An interview with DA #325 at the time of the observation confirmed the chocolate cake with white frosting had been placed on Resident #86's meal tray.2b. Review of the medical record for Resident #33 revealed an admission date of 02/04/26. Pertinent diagnoses included type two diabetes with diabetic polyneuropathy and oral phage dysphagia. The physician had ordered on 02/24/26 for the resident to receive a reduced concentrated sweets, no salt packet, mechanical soft diet, with regular/thin liquids.Further review of Resident #33's medical record revealed a Medicare five day Minimum Data Set (MDS) assessment, dated 02/08/26, which indicated the resident was moderately impaired cognitively, required setup or clean up assistance with meals, had no significant weight changes, and was receiving a mechanically altered diet but not a therapeutic diet.Continued review of Resident #33's medical record revealed a care plan, initiated on 02/16/26, which stated the resident was at nutritional risk due to being on a therapeutic and mechanically altered diet with an intervention to provide diet as ordered and to honor choices as able.Observations conducted on 02/27/26 of tray line between approximately 11:50 A.M. and 12:22 P.M. revealed at 12:03 P.M. a small plate with a piece of chocolate cake with white frosting approximately two inches by two inches and one inch tall was placed on Resident #33's meal tray. The tray ticket sitting on the meal tray indicated Resident #33 was on a RCS No Salt Packet diet with a mechanical soft texture. Further review of the tray ticket revealed the resident was to receive fruit shortcake for the dessert. An interview with DA #325 at the time of the observation confirmed the chocolate cake with white frosting had been placed on Resident #33's meal tray.2c. Review of the medical record for Resident #73 revealed an admission date of 02/18/26. Pertinent diagnoses included type two diabetes mellitus, dementia, and dysphagia. The physician had ordered on 02/25/26 for the resident to receive a reduced concentrated sweets, no salt packet, mechanical soft diet, with regular/thin liquids.Further review of Resident #73's medical record revealed the admission MDS assessment was in progress of being completed.Continued review of Resident #73's medical record revealed a care plan, initiated on 02/25/26, which stated the resident was at nutritional risk due to diagnoses which included type two diabetes mellitus, having chewing/swallowing problems, and being on a therapeutic and mechanically altered diet being with an intervention to provide diet as ordered and to honor choices as able.Observations conducted on 02/27/26 of tray line between approximately 11:50 A.M. and 12:22 P.M. revealed at 12:21 P.M. a plate with a piece of white cake topped with a layer of cherry topping and another layer of whipped topping, which was approximately three inches by three inches and two inches tall, was placed on Resident #73's meal tray. The tray ticket sitting on the meal tray indicated Resident #73 was on a RCS diet with a mechanical soft texture. Further review of the tray ticket revealed the resident was to receive fruit shortcake for the dessert. An interview with DA #325 at the time of the observation confirmed fruit shortcake had been placed on Resident #73's meal tray.Review of the facility's fall and winter menu titled Classic Four PB FW 25-26 revealed the menu for lunch on day six (Friday) of week one was fish of the day, roasted sweet potatoes, sauteed cabbage, dinner roll/margarine, and fruit shortcake.Review of the spreadsheet for the facility spring and winter menu for day six of week one revealed the spreadsheets were for regular, mechanical soft, pureed, reduced concentrated sweets, or renal modified diets. At the bottom of the spread sheet there were additional instructions for no salt packet on tray and gluten free diets and for when fortified enhanced foods were ordered. There was no additional guidance for when a combination diet such as an RCS mechanical soft diet had been ordered. Continued review of the spreadsheet for the facility spring and winter menu for lunch on day six of week one revealed RCS diets were to receive three ounces of fish of the day, one tablespoon tartar sauce, one number eight scoop (four ounces) of roasted sweet potatoes, one four ounce spoodle ( a type of serving utensil) of sauteed cabbage, one each dinner roll/margarine, and one number eight scoop (four ounces) of chilled peaches as the dessert instead of the fruit shortcake.Interview on 02/27/26 at 1:57 P.M. with RD #444 and DTR #411 revealed there was a glitch in the tray card system the facility was using and the tray tickets for residents on an RCS mechanical soft diet should have stated that the resident would receive canned peaches instead of fruit shortcake. RD #444 stated the dietary menu platform they were using for tray cards either had a spread sheet for RCS diet or a different spread sheet for mechanical soft diet, but confirmed there was no spreadsheet breakdown for combination diet of RCS mechanical soft. Both RD #444 and DTR #411 indicated chocolate cake with icing or the fruit shortcake were not appropriate dessert choices for a resident on an RCS mechanical soft diet.Interview on 02/27/26 at 3:33 P.M. with RN Supervisor #423 revealed menus were not always followed and went on to state diabetic residents were getting desserts that they shouldn't be getting. RN Supervisor #423 stated everybody got cake today for lunch.Review of the spreadsheet for the facility spring and winter menu for day six of week one revealed the spreadsheets were for regular, mechanical soft, pureed, reduced concentrated sweets, or renal modified diets. At the bottom of the spread sheet there were additional instructions for no salt packet on tray and gluten free diets and for when fortified enhanced foods were ordered. There was no additional guidance for when a combination diet such as an RCS mechanical soft diet had been ordered.Review of the facility policy titled Reduced Concentrated Sweets (RCS) Diet, revised 12/11/25, revealed the RCS diet was designed to moderate simple sugar intake while maintaining adequate nutrition, hydration, resident satisfaction, and quality of life. An RCS diet may limit food high in simple sugars (concentrated sweets) but did not eliminate carbohydrates. Sweetened desserts were one of the examples listed as a concentrated sweets. The policy indicated the facility would provide RCS diets to support blood glucose management for residents with diabetes or impaired glucose tolerance and would prepare meals consistent with RCS guidelines. 3. Review of the facility's fall and winter menu titled Classic Four PB FW 25-26 revealed on day 6 (Friday) of the facility's Week One's menu fish of the day, roasted sweet potatoes, sauteed cabbage, dinner roll/margarine, and fruit shortcake was to be served for lunch. Review of the facility's diet spread sheet lunch on day 6 (Friday) of the facility's fall and winter menu revealed residents who were on a puree diet consistency were to receive one number eight scoop (four ounces) of pureed fish of the day, one tablespoon of mayonnaise, one number eight scoop (four ounces) of pureed sweet potatoes, one number 12 scoop (two and two-third ounces) of pureed sauteed cabbage, one number 16 (two ounces) scoop of pureed dinner roll with margarine, and one number six scoop (five and one third ounces) of pureed fruit shortcake.Review of the facility document titled Order Listing Report, dated 02/27/26, revealed Resident #10, #17, #40 and #100 were ordered a pureed texture diet. Observations conducted on 02/27/26 from approximately 11:50 A.M. to 12:22 P.M. of the facility's tray line revealed there was no observation of any pureed fruit shortcake being around the tray line, and staff were observed placing small plastic bowls filled with vanilla pudding on the meal trays of residents who were on a pureed diet consistency. An interview with Dietary Director (DD) #319 at the time of the observation confirmed residents on a puree diet were getting pudding instead of the pureed fruit shortcake for lunch. When asked why those residents who were on a puree diet were not getting the puree fruit shortcake as stated they would be according to the spreadsheet, DD #319 stated my cook didn't prep the puree fruit shortcake, so they are getting vanilla pudding .An interview conducted on 02/27/26 at 1:57 P.M. with RD #444 and DTR #411 revealed spreadsheets needed to be followed and residents on a puree diet consistency should have received pureed fruitcake instead of the vanilla pudding for lunch that day.Review of the facility policy titled Menus and Adequate Nutrition, revised 01/03/26, revealed the facility would provide residents with nourishing, palatable, well-balanced diets, and menus would be followed.This deficiency represents non-compliance investigated under Complaint Number 2748862.

Based on observation, record review, manufacturer guideline review, facility policy review and interview, the facility failed to ensure Resident #7 was comprehensively assessed and appropriate interventions were in place to prevent a burn from a hot liquid. In addition, the facility failed to ensure care planned/physician ordered fall interventions were in place to decrease the resident's risk of falls. This affected one resident (#7) of four residents reviewed for accidents. The census was 78. Actual Harm occurred on 09/19/2025 when Resident #7, who had severe cognitive impairment, required staff assistance with activities of daily living and received occupational therapy for identified upper extremity weakness, sustained large second degree burns to her left thigh requiring pain medication and treatments to the areas after the resident was provided hot tea in a Styrofoam cup that spilled on her lap. Findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (DM), dementia, dysphagia, secondary malignant neoplasm of brain, anxiety, Alzheimer's, atrial fibrillation, history of falls, malignant neoplasm of bronchus or lung, and traumatic subdural hemorrhage. Review of Resident #7's most recent OT evaluation and plan of treatment dated 08/28/25 revealed a goal to increase bilateral upper extremity (BUE) strength. The resident's baseline BUE strength was a 3/5. For functional skill of eating, Resident #7 required set up or clean up assistance. Resident #7's mobility function score (ranges from 0 to 12; 12 being the highest function). Resident #7's mobility score was a 0. Per the OT assessment, therapy needs were identified through weakness of the resident's upper extremities. Review of Resident #7's physician orders revealed an order for acetaminophen oral tablet 325 mg by mouth three times a day for pain.Review of Resident #7's annual Minimum Data Set (MDS) completed 09/02/25 revealed the resident had severe cognitive impairment and exhibited no behaviors. The resident required set-up or clean-up help for eating and partial to moderate assistance with oral hygiene. The resident was dependent on staff assistance with toileting, personal hygiene, lower body dressing and showers. She required maximal assistance from staff with upper body dressing and partial/moderate assistance for mobility and transfers. The resident wore corrective lenses and utilized a wheelchair for mobility. The resident had no impairments to her upper or lower body. Review of Resident #7's quarterly care plan completed 09/02/25 revealed Resident #7 had impaired activates of daily living (ADL) function related to requiring assistance to perform and complete ADL care. Interventions included allowing time for the resident to complete tasks; Allow for rest breaks if the resident tires. Observe for frustration or inability to complete tasks, and intervene to assist as indicated to complete care, and to meet mobility needs. Assist with meal intake.There were no assessments within the medical record to identify the resident's safety with hot liquids. There was no care plan regarding the resident's ability to safely consume hot liquids or interventions to decrease the likelihood of burns from hot liquids. Review of Resident #7's progress note revealed a note authored by Registered Nurse (RN) #86 on 09/19/25 at 12:40 P.M that stated Resident #7 spilled a cup of tea onto (her) lap. (The resident's) left thigh was red and (a) blister formed and burst almost immediately. Cold water was applied to the area, clothes were changed, and (the resident's left) leg was assessed. Director of Nursing (DON), Primary care physician (PCP) and family was notified. Waiting on new orders from (the) provider. Resident reporting some discomfort to (the) left thigh. (The pain was rated a 1 on a scale of 0-10 (0 represents no pain and 10 represents the worst pain ever reported by the resident). Review of Resident #7's progress note dated 09/19/25 at 6:14 P.M., authored by RN #86, revealed Resident #7 had complaints of increased pain due to a beverage burn. Ibuprofen 400 milligram (MG) oral (PO) three times a day (TID) as needed (PRN) ordered. (There was no assessment of the resident's pain at this time).Record review revealed a wound assessment completed 09/19/25 revealed Physician #1004 was notified of a burn in house acquired to Resident #7's left upper thigh, pink epithelia present and wound appeared moist. Small amount of serosanguinous drainage was noted. The wound was 15 centimeters (cm) in length, nine cm in width, peri wound was red with irregular edges. Treatment plan for Silver sulfadiazine External Cream 1.0 % Apply to left thigh topically every shift for burn to left thigh, cleanse with normal saline, apply cream, telfa pads and kerlix. Review of Therapist #6's statement dated 09/19/25 revealed she had just prepared hot tea for the resident and another (unidentified) resident. As she was sitting beside Resident #07 and preparing for the therapy session, the resident began to take a drink (of the hot tea). The therapist believed the resident attempted to balance the cup on her lap, on the dish she had also been holding, resulting in the cup spilling on her leg. Immediately she was able to intervene- pulling the resident's wet clothing up off her skin and the therapist yelled for help and (illegible name) was able to immediately intervene with applying cold water to the area. They (not identified) then took Resident #7 for further assessment, interventions and change of clothes. Review of Resident #7's progress note dated 09/23/25 at 12:50 P.M., authored by RN #106, revealed the resident was on restorative program for communication, toileting, and active range of motion (AROM) to bilateral upper extremities, AROM to bilateral lower extremities, transfer, and ambulation. Resident participated in above program for 15 minutes a day, six to seven days a week. The note included would continue to encourage the resident to participate with the goal of maintaining resident's current level of functional ability. (This had been in place since 03/06/25).Review of Resident #7's progress notes dated 09/23/25 at 3:30 P.M., authored by Registered Nurse (RN) #99, revealed Resident #7's family requested to obtain an order for Tylenol and Ibuprofen alternating to address the resident's pain from the burn. (However, there was no assessment of the resident's pain at this time). Review of Resident #7's progress note dated 09/23/25 at 4:48 P.M., authored by RN #99, revealed Physician #1004 stated it was ok to alternate Tylenol and ibuprofen every three hours.Review of Resident #7's progress note dated 09/23/25 at 7:47 P.M., authored by RN #99, revealed the resident's family requested the resident to be dressed in gowns during the day instead of sweat pants due to the burn on the leg. Review of Resident #7's progress note dated 09/24/25 at 7:13 P.M., authored by the Director of Nursing, revealed Resident #07 was seen in house by Physician #1005 for assessment of left thigh burn. Physician #1005 gave directions to continue same treatment and was informed of and understood daughter's thoughts on changing dressing change to three times a day (TID) rather than twice a day (BID). Physician #1005 explained best practice for Silvadene was to change the dressing and apply Silvadene BID. I (the author of the note) spoke to the resident's daughter and gave her the doctor's orders and explanations and she expressed understanding and was agreeable with this plan. Review of Resident #7 Occupational Therapy (OT) discharge summary revealed Resident #7 was discharged from OT on 10/02/25. The summary revealed the resident had reached her highest practical level of function.Record review of Resident #7 wound assessment completed on 10/14/25 revealed the resident's wound appeared to be healing, treatment was complete with Silver sulfadiazine External Cream 1%, apply to left thigh topically every shift for burn to Left thigh, cleanse with normal saline, apply cream, telfa pads and kerlix. Peri skin appears deep pink, all healed over with pink scar tissue except two open areas on largest site, area 1) 3 cm in length, 2 cm in width, and 0.1 cm in depth. Area 2) 2 cm in length, 2 cm in width, and 0.1 cm in depth. Wound appears beefy red and pink with some yellow centers.On 10/14/25 at 8:34 A.M. interview with Resident #7's power of attorney (POA), POA #1738 revealed on 09/19/25 she received notification Resident #7 suffered a small burn from a hot drink that spilled. The next day, POA #1738 went to visit and was shown the burn, and it was not small and it was in more than one spot. The POA said it looked like a second-degree burn. Resident #07 was handed a Styrofoam cup without a lid; the burn was bad and no one in upper management contacted the family about the incident. The POA said it took a while for the wounds to heal since she's a diabetic. Interview on 10/14/25 at 2:30 P.M. with Registered Nurse (RN) #46 revealed there was recently a situation a Resident was burned by a hot drink. There was no lid on the cup at the time it was in Resident #7's possession, and it spilled onto her leg. The next day when the burn was seen by staff it looked clean, but it was significant. There were blisters, and they had burst she seemed to be bothered by the burn the most during dressing changes. When the drink was initially spilled, another nurse came and dumped cool water on her leg and then Resident #7 was taken to their room. Interview on 10/14/25 at 2:58 P.M. with Registered Nurse # 86 revealed Resident #7 was working with speech therapy at the time of the burn incident. RN #86 heard a shout; Resident #7 had spilled the coffee/tea on herself. RN #86 believed she was trying to set it on her lap possibly. Another nurse poured cold water on her to stop the burning. RN #86 stated Resident #7 was wearing sweat pants at the time, initially the wound looked red/slightly pink, all skin was intact, a while later it was looked at and appeared to be blistering, then she started to peel the skin, she was trying to take the bandage off after the dressing was applied. At the time of the incident Resident #7's power of attorney (POA) #1002 was called but they did not answer, so staff called POA #1003, and Resident #7's primary care physician (PCP) #1004 was notified. RN #86 stated at the time Resident #7 was given the hot beverage there was no lid on the cup, it was a Styrofoam coffee cup. RN #86 stated at that time they had a hot drink dispenser for the hot water, after the incident the Director of Nursing (DON) stated the water coming out of the machine was too hot, all beverages come from the kitchen. Interview on 10/14/25 at 3:02 P.M. with Therapist #6 confirmed therapy staff were working with Resident #7 at the time the drink spilled on her leg. Therapist #6 stated they got Resident #7 tea in a Styrofoam cup that was provided on the floor; using hot water from the hot water dispenser. They sat down, with another resident present, to do their speech therapy session. Therapist #6 confirmed there was no lid on the cup at the time Resident #7 had it. Therapist #7 stated they were working and suddenly the cup spilled, a nurse dumped cold water onto Resident #7's leg and proceeded to take her to her room to get changed and assessed. All water dispensers were made out of order and cannot be used, for hot water. Therapist #6 stated they spoke with DON in Quality Assurance Performance Improvement (QAPI) and they recommended all hot liquids for residents have a lid. The therapist stated it happened so fast, she wasn't sure what the resident was doing with the cup prior to the tea being spilled on her leg. Interview on 10/14/25 at 3:33 P.M. with Certified Nursing Assistant (CNA) #26 revealed on 09/19/25 Resident #25 did spill a cup of hot liquid onto her leg causing a burn. Initially the area was just red, nothing was open, but after some time it did begin to bubble and blister. When it happened, a nurse dumped cool water onto her leg, Resident #7 was then taken to her room to get changed and be assessed by the nurse. CNA #26 confirmed there was no lid on Resident #7's cup at the time it spilled. CNA #26 confirmed there was no way to regulate the temperature from the hot water machine, they couldn't check the temperature. The CNA reported the resident generally received hot liquids in a mug with a handle, given from the kitchen. Interview on 10/14/25 at 3:36 P.M. with CNA # 31 revealed on 09/19/25 Resident #7 was working with speech therapy. Speech therapy and Resident #7 were sitting with another resident at that time (at a table). Suddenly everyone got up and went towards Resident #7, who had spilled hot liquid on her leg. The liquid was in a smaller Styrofoam cup, and there was no lid. Resident #7 was immediately taken to their room to be changed and assessed. At the time there were hot water dispensers available on the floor, they are no longer allowed to use them. The CNA reported the resident generally received coffee from the kitchen, in a mug with a handle during breakfast and not in a Styrofoam cup. The CNA was unsure if lids for the Styrofoam cups were available where the hot water dispenser was located.Interview on 10/15/25 at 8:55 A.M. with Dietary Director #49 revealed the kitchen did not do temperature monitoring on the hydroz hot water dispenser (where the water was obtained for Resident #7's tea). The facility current policy was that all hot liquids must come from the kitchen. Director #49 stated they were not sure what the policy was for hot liquid temperatures but they would look into it. The Dietary Director never provided additional information. Interview on 10/15/25 at 9:00 A.M. with Maintenance Director #603 revealed maintenance did not monitor or regulate the hot water dispensers for resident beverages. Director #603 stated the dispenser comes pre-set and how they come is how they stay, they can't manipulate the settings. Observation on 10/15/25 at 10:57 A.M. of Licensed Practical Nurse (LPN) #18 changing Resident #7 dressing to the burn on the left thigh. LPN #18 cleansed the area with normal saline, applied Silver sulfadiazine External Cream 1%, applied telfa, secured the dressing with Medi pore tape. Observation of Resident #7 wound revealed a red area to the left lateral thigh, two open areas that were moist and beefy red. There were intact, reddened skin areas spread from lateral to medial thigh. Observation on 10/15/25 at 11:06 A.M. with Registered Nurse #107 revealed hot water temperature from the Hydroz machine into a Styrofoam cup was verified with a thermometer from the facility's kitchen. RN #107 confirmed the temperature of the water from the machine was 176 degrees Fahrenheit Review of Hydroz H20-2500 manufacturer guide revealed heating of the hot water tank was up to 180 degrees Fahrenheit. Review of facility policy titled Safety of Hot Liquids implemented 10/2014 revealed residents would be evaluated for safety concerns and potential injury from hot liquids upon admission, readmission and on change of condition. Appropriate precautions would be implemented to maximize choice of beverages while minimizing the potential for injury. The potential for burns from hot liquids was considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal conditions. Interventions include serving hot beverages in a cup with a lid, maintaining a hot liquid serving temperature of no more than 180 degrees, encouraging residents to sit at a table while drinking or eating hot liquids and staff supervision or assistance with hot beverages. Food service staff would monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. In addition, review of Resident #7's active care plans revealed the resident had a care plan in place for the potential for falls related to a history of falls, medication use, and requiring assistance with transfers. The goal was for the resident to remain free of falls. Interventions included the use of Dycem (a tacky piece of material placed in a chair to prevent sliding out of the chair) to her wheelchair. Review of Resident #7's physician's orders revealed the resident had an order (originated 05/24/24) for the use of Dycem to the resident's wheelchair. On 10/14/25 at 2:31 P.M., an observation of Resident #7 revealed the resident was sitting up in her wheelchair. CNA #104 was asked to take the resident back to her room so she could be assisted into a standing position out of her wheelchair, to see if fall prevention interventions, including the use of Dycem to her wheelchair were in place. CNA #104 received assistance from the facility's Director of Nursing (DON) to stand the resident up from a seated position in her wheelchair. A gait belt and the assistance of the CNA and DON were used to have the resident stand from her wheelchair. The resident was observed to only have a cushion in the seat of her wheelchair with no evidence of Dycem being above or below her cushion. There was a piece of Dycem draped over the armrest of a stationary chair in her room. Findings were verified by the DON.On 10/14/25 at 2:40 P.M., an interview with CNA #104 revealed the resident was assisted up into her wheelchair by the night shift staff, as the resident was already up when she came on duty at 6:00 A.M. She had not known the resident to fall in the month or so that she had been there, but did feel the resident was at risk for falls. She acknowledged the resident's plan of care for fall prevention included the use of Dycem when she was up in her wheelchair and was not sure why it was not in place. This deficiency demonstrates non-compliance investigated under Complaint Number 2630029.

Based on record review, observation, and staff interview, the facility failed to ensure a resident at risk for dehydration had water maintained at her bedside. This affected one (Resident #7) of three residents reviewed for dehydration. Findings include: Review of Resident #7's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease with a late onset, unspecified dementia, adult onset diabetes mellitus, personal history of malignant neoplasm of the pancreas, malignant neoplasm of an unspecified part of an unspecified bronchus/ lung with metastasis to the brain, chronic kidney disease, unsteadiness on feet, and a history of falls. Review of Resident #7's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and her cognition was severely impaired. She was not indicated to have displayed any behaviors and was not known to reject care. She required a partial to moderate assist with transfers and ambulation. The resident was coded as having received a diuretic medication during the seven day assessment period. Review of Resident #7's care plans revealed the resident had the potential for fluid imbalance related to kidney disease and diuretic use. The goal was for the resident to demonstrate adequate hydration as evidenced by laboratory values within normal range for the resident. The interventions included the need to maintain water at the resident's bedside.On 10/14/25 at 2:31 P.M., an observation of Resident #7 noted her to not have any water made available to her in her room as per her plan of care. There was no evidence of her being provided a Styrofoam cup, with a lid and straw, as was noted in other residents' rooms providing them with ice water. Her room was absent of any cups or other sources of a beverage for her to drink to help keep her hydrated per her plan of care. Findings were verified by Certified Nursing Assistant (CNA) #104. On 10/14/25 at 2:40 P.M., an interview with CNA #104 revealed she had provided Resident #7 with ice water earlier that morning, when they were getting residents up for the day. She denied she had assisted Resident #7 with getting up that morning, as she was already up when she came on duty at 6:00 A.M. She reported night shift got Resident #7 up that morning. She was not able to locate a Styrofoam cup for the resident in her room or any other beverage for the resident to drink when she wanted. She suspected that maybe housekeeping had thrown it away when they were in the resident's room cleaning it earlier. She acknowledged housekeepers were in other residents' rooms cleaning their rooms without throwing their Styrofoam cups away. She further acknowledged Resident #7's plan of care indicated the staff were to maintain water at her bedside at all times. On 10/15/25 at 8:40 A.M., further observations of Resident #7 noted her to be lying in bed in her room. She was noted to have a Styrofoam cup dated 10/15/25 that had water in it, but the Styrofoam cup was sitting on the overbed table that was placed near the entry door to the room and out of the resident's reach. On 10/15/25 at 8:43 A.M., an interview with CNA #26 confirmed Resident #7's water that was in a Styrofoam cup on her overbed table was not left in the resident's reach. She further confirmed with the placement of the overbed table away from the resident's bed, the resident would not be able to reach her Styrofoam cup if she wanted or needed a drink. This deficiency demonstrates non-compliance investigated under Complaint Number 2630029.

Based on record review, staff interview, and policy review, the facility failed to ensure an effective antibiotic stewardship program was implemented, when a resident returned from the hospital on an antibiotic for the treatment of a urinary tract infection, and the facility's infection preventionist failed to ensure an appropriate antibiotic was ordered to adequately treat the infection. This affected one (Resident #7) of three resident's reviewed. Findings include: Review of Resident #7's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease with late onset, unspecified dementia, and chronic kidney disease. Review of Resident #7's nurses' progress notes revealed the resident was sent to the emergency room (ER) on 08/26/25 at 5:00 P.M. for complaints of chest pain. She complained of mid-sternum burning and heaviness. She returned to the facility on [DATE] at 1:40 A.M. with the diagnoses of a urinary tract infection (UTI). She returned to the facility with a new order for Keflex 500 milligrams (mg) by mouth every eight hours for seven days for the treatment of a UTI.Review of Resident #7's hospital records for her emergency room (ER) visit on 08/26/25 revealed the resident was seen for complaints of chest pain not relieved by gastroesophageal reflux disease (GERD) medications. She was diagnosed with a UTI and was started on Keflex 500 mg by mouth every eight hours for seven days for a UTI. Review of a urinalysis (U/A) with a culture and sensitivity (C&S) that was collected on 08/26/25 at 10:31 P.M., while Resident #7 was in the hospital, revealed the resident's U/A showed her urine was positive for nitrites (typically caused by a bacterial infection in the urinary tract) and was also positive for bacteria. The final culture report on 08/29/25 revealed the resident's urine had greater than a 100,000 colony count/ milliliter of heavy Enterobacter Cloacae (gram negative bacterium that's a natural part of the human gut, but could cause various infections including UTI's). The sensitivity report indicated Keflex was not one of the seven antibiotics that the organism causing the resident's UTI was sensitive to. Review of an Antibiotic Time Out report for Resident #7 dated 08/29/25 at 2:07 P.M. pertaining to the resident's use of Keflex 500 mg by mouth three times a day revealed the resident was sent to the ER for chest pain and returned with a UTI diagnosis. The resident was indicated to be showing no signs or symptoms of a UTI, but the U/A C&S returned positive for Escherichia Coli (E. coli). The Antibiotic Time Out report did not accurately reflect the organism identified on the C&S as having caused the UTI, which was Enterobacter Cloacae. The report further showed the antibiotic use was reviewed with the physician, but informed him of the incorrect organism identified as causing the infection. The physician responded on 09/02/25 (the day the seven day course of the antibiotic treatment was completed) and provided instructions to finish and complete the antibiotic, when she only had one dose of the antibiotic left to take. Review of Resident #7's medication administration record (MAR) for August and September 2025 revealed the resident received the full course of the ordered antibiotic (Keflex) for seven days between 08/27/25 and 09/02/25. The first dose was given on 08/27/25 at 2:00 P.M. and the last dose was administered on 09/02/25 at 10:00 P.M. There was no evidence of the antibiotic being changed to one of the seven antibiotics identified on the sensitivity report as being effective in treating the UTI caused by the specific organism identified on the culture report. The resident received a full seven day course of Keflex that was not effective in treating a UTI caused by Enterobacter Cloacae. On 10/15/25 at 10:35 A.M., an interview with LPN #62 revealed she was the facility's acting Infection Preventionist (IP) when Resident #7 was treated for a UTI following her ER visit on 08/26/25. She reported she was responsible for reviewing residents who were sent to the hospital and was started on an antibiotic to treat an infection as part of her IP role. She stated she reviewed to see if an antibiotic had been started and also obtained the labs to ensure an antibiotic was warranted. She claimed to have identified Resident #7 was started on an antibiotic for the treatment of a UTI, after the resident returned from the hospital on [DATE]. She reported she identified the organism causing the resident's UTI was not sensitive to the antibiotic that had been ordered at the hospital. She indicated she completed an antibiotic time-out and reached out to the resident's physician. She stated the physician wanted to continue the antibiotic as ordered even though it was not an effective treatment for the organism identified. She further indicated that particular physician, who was their prior medical director at the time, was one of the few physicians she dealt with that was not good about following the facility's ATB Stewardship program. He would often want antibiotics continued that had been ordered without supporting documentation confirming the resident had an active infection. He also did not always change the antibiotic that had been previously ordered when it was made know that antibiotic was not effective in treating the infection. She acknowledged the Antibiotic Time Out report improperly identified the organism that was causing the resident's UTI as being E. coli, which Keflex would have been an appropriate antibiotic to treat a UTI caused by that organism. She further acknowledged the physician's response to her Antibiotic Time Out was not received until 09/02/25, after the antibiotic therapy had already been completed. Review of the facility's Antibiotic Stewardship Program policy revised 05/30/23 revealed it was the policy of the facility to implement an Antibiotic Stewardship program as part of the facility's overall infection prevention and control program. The purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The Medical Director and the facility's Director of Nursing (DON) was to serve as leaders of the Antibiotic Stewardship program. The Medical Director was to set the standards for antibiotic prescribing practices for all healthcare providers prescribing antibiotics, overseeing adherence to antibiotic prescribing practices, and was to review antibiotic use data and ensure best practices were followed. The IP was to utilize expertise and data to inform strategies to improve antibiotic use to include tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections. Monitoring of the antibiotic was to include monitoring the response to antibiotics, and laboratory results, when available, to determine if the antibiotic was still indicated or adjustments should be made. Antibiotics orders obtained from emergency providers should be reviewed for appropriateness. This is an incidental finding discovered during the complaint investigation.

Based on observation, interview, and review of maintenance work orders the facility failed to maintain a safe and comfortable home like environment. This had the potential to affect one (Resident #07) of five residents rooms observed. the census was 78. Observation on 10/15/25 at 10:02 A.M. revealed a hole in the wall behind the head of Resident #7's bed. The hole was observed to be located behind the head of the resident's bed, near the baseboard. The hole was approximately eight inches by eight inches.Review of facility maintenance work orders for the past six months revealed no documentation of an order to repair the hole in the wall of Resident #7's room.Interview on 10/15/25 at 10:48 A.M. with Certified Nurses Assistant (CNA) #42 and Licensed Practical Nurse (LPN) #18 confirmed there was a larger hole in the wall of Resident #7's room. The hole was located behind the head board near the bottom of the wall. CNA #42 and LPN #18 stated they had not noticed the hole in the wall prior to it being pointed out. This deficiency demonstrates non-compliance investigated under Complaint Number 2630029.

Based on observation, medical record review, and interview, the facility failed to notify hospice of a resident refusal of respiratory treatments. This affected one (#83) of three residents sampled. The census was 84. Findings include: Medical record review revealed Resident #83 was admitted to the facility on [DATE] with diagnosis including Parkinson's disease. Review of the significant change Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #83 was severely impaired for daily decision-making, was receiving hospice services and had two or more falls resulting in no injuries and two or more falls resulting in injuries. Review of the electronic Physician Orders dated 07/11/24 revealed Continuous Positive Airway Pressure (CPAP) machine (a treatment for sleep apnea that involves wearing a mask while you sleep that delivers mild air pressure to keep breathing airways open during sleep) to be worn at bedtime and continue home settings. Review of the hospice Physician Plan of Care dated 10/16/24 revealed physician orders including to start oxygen via nasal cannula two liters to five liters per minute continuously. On 12/17/24 at 9:32 A.M., observation revealed Resident #83 was lying in bed. An oxygen concentrator was observed beneath the window with nasal cannula (oxygen tubing that delivers oxygen through your nose) laying on the floor. The oxygen tubing was dated 11/09/24. A CPAP machine was observed sitting on the window sill. On 12/18/24 at 9:03 A.M., interview with Certified Nursing Assistant #206 stated Resident #83 uses oxygen when he gets short of breath but would need to speak to the nurse about that. On 12/18/24 at 9:22 A.M., interview with Licensed Practical Nurse (LPN) #208 verified there were no current physician orders in the computer for Resident #83's oxygen to be administered and the resident does not wear the oxygen continuously. LPN #208 also verified the CPAP order did not have the ordered settings and had been refused all but one day between 11/01/24 and 12/18/24 without notifying hospice or the physician. This deficiency was an incidental finding discovered during the complaint investigation.

Based on observation, medical record review, policy review and interview, the facility failed to ensure fall interventions were implemented. This affected one (#83) of three residents sampled. The census was 84. Findings include: Medical record review revealed Resident #83 was admitted on [DATE] with diagnosis including Parkinson's disease. Review of the significant change Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #83 was severely impaired for daily decision-making, was receiving hospice services and had two or more falls resulting in no injuries and two or more falls resulting in injuries. Review of the care plan: Potential for Falls: Resident is at risk for falls and fall related injury related to impaired vision, medication use, requires assist with transfers, and history of falls revised 10/30/24 revealed interventions including to keep call light within reach, assist with wearing proper footwear, assist with wearing glasses and encourage him to wear non-skid gripper socks when not wearing shoes. Review of Resident #83's Progress Notes on 12/16/24 at 12:06 P.M. revealed Licensed Practical Nurse (LPN) #204 witnessed Resident #83 leaning to his left and appeared to be trying to get to his shoes. The resident fell to the floor and no injuries were observed. The physician and family were notified of the fall and staff were notified the resident was to be in a geri-chair at all times. On 12/17/24 at 12:16 P.M. Resident #83's fall intervention was changed from a geri-chair to keeping a grabber (reach extender that increases the range of a person's reach and grasp when grabbing objects) within reach. The resident was already utilizing a geri-chair for comfort as ordered by hospice services. Review of the Fall Risk Evaluation dated 12/16/24 revealed Resident #83 was at high risk for falls. Review of the Learning Circle In-Service dated 12/16/24 revealed a new intervention for Resident #83 was to be in a geri-chair when up. Further review of the Inservice revealed no evidence Certified Nursing Assistant (CNA) #206 was educated of the resident's fall or signed the Inservice sheet as acknowledgment of the new intervention. Review of Resident #83's fall care plan revealed no evidence the fall care plan was revised after his fall on 12/16/24 with the new intervention to have a grabber within reach or for the resident to be in a geri-chair when out of bed. On 12/17/24 at 9:32 A.M., observation revealed Resident #83 was lying in bed wearing only an incontinence product with a sheet draped across his lower abdomen. The resident was not wearing gripper socks, no gripper socks were observed in the bed, his touch pad call light was not within reach and was positioned at the end of the bed, resting against the foot board. On 12/18/24 at 9:02 A.M., observation revealed Resident #83 was lying in bed, was not wearing gripper socks or his glasses and his touchpad call light was positioned between the mattress and the footboard. Interview with Housekeeping #207 at the time of the observation verified the call light was not within reach of the resident. On 12/18/24 at 9:03 A.M., interview with Certified Nursing Assistant (CNA) #206 revealed she was caring for Resident #83 and he was a high fall risk. CNA #206 verified Resident #83's touchpad call light was not within reach and stated his fall interventions included for the call light to be within reach, wearing his glasses, in a low bed with a floor mat and the bed against the wall. CNA #206 stated the resident was to be up in his specialized tilt-n-space wheelchair when out of bed. CNA #206 stated she was not aware of any recent falls or other interventions she should be checking. On 12/18/24 at 9:11 A.M., interview with LPN #208 stated Resident #83 had a fall from his chair on 12/16/24 and the new intervention was for a grabber to be in reach to assist the resident in picking up items off the floor. LPN #208 stated after a resident fall, the nursing staff completes an investigation and starts education on the new interventions implemented to try to prevent the resident from falling again. On 12/18/24 at 9:13 A.M., observation of Resident #83's room with LPN #208 revealed there was no grabber (extended reacher) in his room for use and the resident glasses were not on. LPN #208 verified without his glasses, Resident #83 would not be able to see the posted reminder on the wall that stated Please hit call light for assistance getting up! On 12/18/24 at 10:00 A.M., interview with the Director of Nursing (DON) verified there was no grabber or reach extender available for use currently in the facility. The DON stated the grabbers were on order, had not been delivered yet and Resident #83 has not had one to use yet. The DON verified no other intervention had been implemented to prevent further falls since the 12/16/24 fall. Review of the policy: Falls and Fall Risk, Managing reviewed 12/18/24 revealed staff was to identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Fall risk factors included footwear that was unsafe or absent. Staff was to implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. This deficiency represents non-compliance investigated under Complaint Number OH00159914.

Based on observation, medical record review, policy review and interview, the facility failed to provide appropriate care for oxygen and respiratory equipment. This affected one (#83) of three residents sampled. The census was 84. Findings include: Medical record review revealed Resident #83 was admitted on [DATE] with diagnoses including Parkinson's disease, generalized anxiety disorder, pneumonia and acute respiratory failure with hypoxia. Review of the electronic Physician Orders dated 07/11/24 revealed Continuous Positive Airway Pressure (CPAP) machine (a treatment for sleep apnea that involves wearing a mask while you sleep that delivers mild air pressure to keep breathing airways open during sleep) to be worn at bedtime and continue home settings. Review of the hospice Physician Plan of Care dated 10/16/24 revealed physician orders including to start oxygen via nasal cannula two liters to five liters per minute continuously. Review of the significant change Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #83 was severely impaired for daily decision-making and was receiving hospice services. On 12/17/24 at 9:32 A.M., observation revealed Resident #83 was lying in bed. An oxygen concentrator was observed beneath the window with nasal cannula (oxygen tubing that delivers oxygen through your nose) laying on the floor. The oxygen tubing was dated 11/09/24. A CPAP machine was observed sitting on the window sill and the face mask was observed to have speckled black spots on the cushion of the face mask as it was resting on the window sill. The face mask was not covered or resting on a barrier. On 12/18/24 at 9:02 A.M., observation revealed Resident #83's oxygen tubing was laying on the floor and CPAP mask was laying on the window sill without a barrier. On 12/18/24 at 9:03 A.M., interview with Certified Nursing Assistant #206 stated Resident #83 uses oxygen when he gets short of breath but would need to speak to the nurse about that. On 12/18/24 at 9:13 A.M., interview with Licensed Practical Nurse (LPN) #208 verified Resident #83's oxygen and CPAP equipment should be kept in a bag and changed when used. LPN #208 verified the oxygen tubing was dated 11/09/24 and should be changed weekly by the nursing staff. At 9:22 A.M., LPN #208 stated there were no current physician orders in the computer for Resident #83's oxygen and the CPAP order did not have the ordered settings just to continue home settings but she did not know what those were. LPN #208 stated she would have to contact the physician for clarification. Review of the policy: Oxygen Administration revised 12/18/24 revealed oxygen was to be administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans and the resident's goals and preferences. Oxygen was to be administered under orders of a physician and cleaning and care of equipment shall be in accordance with facility policies. This deficiency was an incidental finding discovered during the complaint investigation.

Based on observation, medical record review, policy review and interview, the facility failed to administer medications as ordered. This affected two (#50 and #58) of four residents observed for medication administration during 29 opportunities for error resulting in a 13.7% medication error rate. The census was 84. Findings include: 1. Medical record review revealed Resident #50 was admitted on [DATE] with diagnoses including hypertension, congestive heart failure, coronary artery disease and anxiety. Review of the electronic Physician Orders dated December 2024 revealed to administer medications including a chewable aspirin (ASA) 81 milligrams (mg), Isosorbide Dinitrate 30 mg once a day with physician parameters to hold if her systolic blood pressure (SBP) was less than 100, and Lopressor 25 mg with physician parameters to hold if her SBP was less than 100. On 12/17/24 between 9:39 A.M. and 9:48 A.M., observation of Resident #50's medication administration revealed Registered Nurse (RN) #209 assessed Resident #50's blood pressure and stated it was 108/72 millimeters of mercury (mmHg). RN #209 went back to the medication cart and dispensed medication into a medication cup including ASA enteric coated (EC) 81 milligrams. During the medication administration, RN #209 stated she was not going to administer Isosorbide or Lopressor due to the resident's blood pressure reading of 108/72 mmHg. RN #209 verified the two medications were not administered despite the resident's blood pressure exceeding the parameters to withhold the medications. 2. Medical record review revealed Resident #58 was admitted on [DATE] with diagnoses including cerebral infarction. Review of the electronic Physician Orders dated December 2024 revealed to administer medications including ASA 81 mg. On 12/17/24 at 9:50 A.M., observation revealed RN #209 administered ASA EC 81 mg to Resident #58. On 12/17/24 between 9:50 A.M. and 9:55 A.M., interview with Registered Nurse #209 verified ASA EC 81 mg was administered to Resident #58 and not an ASA 81 mg as ordered. Review of the policy: Administering Medications revised April 2019 revealed medications were to be administered as prescribed. This deficiency represents non-compliance investigated under Complaint Number OH00159914.

Based on medical record review and interview, the facility failed to maintain a complete medical record. This affected one (Resident #85) of three residents sampled. The census was 84. Findings include: Closed medical record review revealed Resident #85 was admitted on [DATE] and discharged on [DATE]. Review of the closed record revealed a handwritten Physician's Progress Notes dated 10/25/24 by Nurse Practitioner #210 and Physician's Progress note dated 10/31/24 by Physician #201. The progress note sheet was not labeled with a resident name, identification number or room number. There was no identifying information on the Physician's Progress Note sheet to indicate who the note was for. On 12/18/24 at 2:30 P.M., interview with the Director of Nursing (DON) verified the Physician Progress Note was in the closed record for Resident #85; however, with no resident information he could not verify what resident it was for without the physician and nurse practitioner to verify. The DON verified the medical record was not complete. This deficiency is an incidental finding discovered during the complaint investigation.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a facility self-reported incident (SRI), review of the facility investigation, facility policy review, and interview, the facility failed to ensure residents were free from misappropriation of medications. This affected 13 (Resident #1, #3, #4, #8, #12, #15, #16, #17, #18, #19, #20, #21, and #22) of 13 residents reviewed for misappropriation. The facility census was 99. Findings include: Review of the Self-Reported Incident (SRI) Tracking Number 251396, dated 08/31/24, revealed on 08/31/24, a concern was reported related to missing medications from Licensed Practical Nurse (LPN) #400's medication cart. On 08/31/24 at approximately 1:00 P.M. the Administrator was watching video cameras and noticed suspicious activity by LPN #400 while she was administering medications. LPN #400 was observed going through the narcotics drawer but not having the medication administration record (MAR) pulled up or documenting on the narcotic count sheets. LPN #400 was immediately suspended pending investigation. An immediate investigation was initiated. During a medication audit on 08/31/24 at 4:30 P.M., completed by the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), it was determined that medications in the cart were unaccounted for, and several routine medications were found in the top drawer of the medication cart. These medications were identified by their imprint code on the medication and compared with resident medication profiles to establish who the medications belonged to. Routine medications in Paxits (a secure bag containing medications scheduled at a specific time of the day with clearly labeled medication information printed on the bag) were found discarded in the trash. Controlled substances were unaccounted for and not documented on MARS or on narcotic count sheets. 1. Review of the medical record for the Resident #1 revealed an admitted [DATE]. Diagnoses included dementia, psychotic disorder with hallucinations, adult failure to thrive, acute respiratory failure, and myasthenia gravis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/24/24, revealed the resident had severe cognitive impairment. Review of the facility's SRI investigation revealed Resident #1 was not administered risperidone 0.5 milligrams (mg) on 08/31/24 at 12:00 P.M. or buspirone 15 mg on 08/31/24 at 2:00 P.M. as ordered by the physician. 2. Review of the medical record for the Resident #3 revealed an admitted [DATE]. Diagnoses included dementia, muscle wasting and atrophy, depression, anxiety disorder, and irritability and anger. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/08/24, revealed the resident had severe cognitive impairment. Review of the facility's SRI investigation revealed Resident #3 was not administered Prednisone 10 mg and sertraline 25 mg on 08/31/24 at 9:00 A.M. as ordered by the physician. Further review of Resident #3's Controlled Drug Receipt/Record/Disposition Form for oxycodone 5 mg indicated there should have been 47 pills remaining, however, there were only 46 pills remaining without documentation of administration of the oxycodone. 3. Review of the medical record for the Resident #4 revealed an admitted [DATE]. Diagnoses included metabolic encephalopathy, diabetes mellitus, chronic kidney disease, cerebral vascular disease, and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/09/24, revealed the resident had moderate cognitive impairment. Review of the facility's SRI investigation revealed Resident #4 was not administered metoclopramide 5 mg on 08/31/24 at 11:00 A.M. and gabapentin 400 mg on 08/31/24 at 2:00 P.M. as ordered by the physician. 4. Review of the medical record for the Resident #8 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia, muscle wasting and atrophy, anxiety disorder, dysphagia, and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/08/24, revealed the resident had severe cognitive impairment. Review of the facility's SRI investigation revealed Resident #8 was not administered Depakote Sprinkle 125 mg, two tablets, on 08/31/24 at 9:00 A.M. as ordered by the physician. 5. Review of the medical record for the Resident #12 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dementia, muscle wasting and atrophy, anxiety disorder, dysphagia, and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/04/24, revealed the resident had moderate cognitive impairment. Review of the facility's SRI investigation revealed Resident #12's Controlled Drug Receipt/Record/Disposition Form for oxycodone 10 mg indicated there should have been 11 pills remaining, however, there were only nine pills remaining and without documentation of administration. During interview on 08/31/24 with Resident #12, she stated she had not requested pain medication on that day. 6. Review of the medical record for the Resident #15 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, adult failure to thrive, anxiety disorder, dysphagia, and unsteadiness on feet. Review of the annual Minimum Data Set (MDS) assessment, dated 06/08/24, revealed the resident had severe cognitive impairment. Review of the facility's SRI investigation revealed Resident #15's Controlled Drug Receipt/Record/Disposition Form for lorazepam 0.5 mg indicated there should have been 53 pills remaining, however, there were only 52 pills remaining and without documentation of administration. 7. Review of the medical record for the Resident #16 revealed an admitted [DATE]. Diagnoses included dementia, depression, catatonic disorder, anxiety disorder, morbid obesity, and weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/30/24, revealed the resident had severe cognitive impairment. Review of the facility's SRI investigation revealed Resident #16's Controlled Drug Receipt/Record/Disposition Form for lorazepam 0.5 mg indicated there should have been 55 pills remaining, however, there were only 52 pills remaining and without documentation of administration. Further review of Resident #16's Controlled Drug Receipt/Record/Disposition Form for Oxycodone 5 mg indicated there should have been 51 pills remaining, however, there were only 48 pills remaining without documentation of administration. 8. Review of the medical record for the Resident #17 revealed an admitted [DATE]. Diagnoses included metabolic encephalopathy, anemia, heart failure, neuropathy, chronic kidney disease, and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/20/24, revealed the resident had intact cognition. Review of the facility's SRI investigation revealed Resident #17 was not administered Gabapentin 800 mg on 08/31/24 at 2:00 P.M. as ordered by the physician. Further review revealed Resident #17's Controlled Drug Receipt/Record/Disposition Form for oxycodone 10 mg indicated there should have been 28 pills remaining, however, there were only 26 pills remaining without documentation of administration. 9. Review of the medical record for the Resident #18 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis, aphasia, chronic obstructive pulmonary disease, anxiety disorder, and alcohol abuse. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/01/24, revealed the resident had severe cognitive impairment. Review of the facility's SRI investigation revealed Resident #18 was not administered Baclofen 20 mg on 08/31/24 at 2:00 P.M. as ordered by the physician. Further review revealed Resident #18's Controlled Drug Receipt/Record/Disposition Form for oxycodone 5 mg indicated there should have been 20 pills remaining, however, there were only 19 pills remaining without documentation of administration. 10. Review of the medical record for the Resident #19 revealed an admitted [DATE]. Diagnoses included metabolic encephalopathy, anemia, heart failure, neuropathy, chronic kidney disease, and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/18/24, revealed the resident had moderate cognitive impairment. Review of the facility's SRI investigation revealed Resident #19 was not administered Hydralazine 50 mg on 08/31/24 at 2:00 P.M. as ordered by the physician. 11. Review of the medical record for the Resident #20 revealed an admitted [DATE]. Diagnoses included dementia, depression, anxiety disorder, dysphagia, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/09/24, revealed the resident had severe cognitive impairment. Review of the facility's SRI investigation revealed Resident #20's Controlled Drug Receipt/Record/Disposition Form for tramadol 50 mg indicated there should have been 38 pills remaining, however, there were only 37 pills remaining and without documentation of administration. 12. Review of the medical record for the Resident #21 revealed an admitted [DATE]. Diagnoses included schizophrenia, anxiety disorder, anemia, and obesity. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/23/24, revealed the resident had severe cognitive impairment. Review of the facility's SRI investigation revealed Resident #21's Controlled Drug Receipt/Record/Disposition Form for lorazepam 0.5 mg indicated there should have been 24 pills remaining, however, there were only 22 pills remaining and without documentation of administration. 13. Review of the medical record for the Resident #22 revealed an admitted [DATE]. Diagnoses included malignant neoplasm if rectosigmoid junction and lung, anxiety disorder, muscle wasting and atrophy, and anemia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/22/24, revealed the resident had intact cognition. Review of the facility's SRI investigation revealed Resident #22's Controlled Drug Receipt/Record/Disposition Form for lorazepam 0.5 mg indicated there should have been 42 pills remaining, however, there were only 41 pills remaining and without documentation of administration. Further review of Resident #22's Controlled Drug Receipt/Record/Disposition Form for oxycodone 10 mg indicated there should have been 32 pills remaining, however, there were only 30 pills remaining without documentation of administration. Further review of Resident #22's Controlled Drug Receipt/Record/Disposition Form for hydromorphone 2 mg indicated there should have been 4 pills remaining, however, there were only 3 pills remaining without documentation of administration. Review of the facility investigation, initiated on 08/31/24, revealed LPN #400 was suspended immediately pending further investigation. LPN #400 denied misappropriating medications and resigned from employment at the facility via text messages sent to the DON. The allegation of misappropriation of medication was substantiated due to routine medications found in the trash without documentation of medication refusals (Controlled substances were also unaccounted for per SRI Tracking Number 251396). The facility could not prove without a reasonable doubt that LPN #400 had committed drug diversion. During interview on 09/19/24 at 9:39 A.M., the DON confirmed the LPN #400 did not properly administer medications and a medication cart audit revealed numerous routine pills, still in medication packets, had been thrown in the trash during LPN #400's shift, loose pills were found in the medication cart, and narcotic count sheets revealed discrepancies with unaccounted for medications. During interview on 09/19/24 at 12:39 P.M. the Administrator stated during observation of the facility's camera she noticed suspicious activity by LPN #400 during the medication administration pass. The medication cart was audited by the DON and ADON and numerous discrepancies were noted, and medications documented as having been administered were thrown in the trash. The Administrator stated LPN #400 was immediately suspended and ultimately resigned via a text message that was sent to the DON. The Administrator further stated the local police department was notified, and an investigation was initiated, incident number 24-009327. Review of the facility policy titled, Abuse, Neglect, and Exploitation, dated 06/30/23, revealed misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. As a result of the incident, the facility took the following actions to correct the deficient practice on 08/31/24: On 08/31/24, the Administrator immediately notified the Director of Nursing (DON) and Assistant Director of Nursing (ADON) of the potential misappropriation of resident medications. An SRI was filed through the Ohio Department of Health and an investigation completed. LPN #400 was immediately suspended. The investigation provided information that led the facility to believe that LPN #400 misappropriated resident medications by throwing them in the trash. On 08/31/24, the DON and ADON conducted medication cart audit for LPN #400's medication cart and found medications discarded in the trash and in top drawer of cart or not properly documented. On 08/31/24, the DON and ADON conducted physical assessments and interviews for all potentially affected residents with no negative findings. On 08/31/24, the DON and ADON reviewed medical records for discrepancies or missing medications and completed facility wide medication cart audits with no additional significant findings. On 08/31/24, all staff were educated on Abuse, Neglect, Misappropriation by the Administrator. Beginning on 08/31/24, all nursing staff had received training by the DON and/or ADON, before their shift on Medication Management, Administering Medications, Controlled Substance Administration and Accountability, and the Six Medication Rights. On 09/03/24, the Interdisciplinary Team (IDT) completed an Ad hoc Quality Assurance (QA) to discuss the incident and corrective action plan. DON or designee to complete random shift to shift narcotic count, random medication cart and medication administration audits daily for seven days, then weekly for three weeks, and then monthly for three months and as needed. All findings will be reviewed by the IDT weekly then reported to QAPI weekly and as needed. This deficiency represents non-compliance investigated under Complaint Number OH00157695

Based on medical record review, interview, observation, and policy review the facility failed to trend and identify infections/organism. The facility also failed to use proper hand hygiene and glove use during suprapubic catheter care. This had the potential to affect all 102 residents residing in the building for infections and one resident (#78) of one observed for catheter care. Findings include: 1. Review of the infection control logs, and facility floor plans dated 10/2023 to 03/2024 revealed no evidence the facility was trending and identifying all infections/organism. The facility was utilizing floor plans to trend the infection. The October 2023 floor plan revealed the facility was trending genito- urinary (GU), gastro-intestinal (GI), skin, respiratory, eye, and others. Review of the October 2023 infection control log revealed there was two sepsis, one otitis media, one tonsillitis, three conjunctivitis, two clostridium difficile (C-diff), one methicillin resistant staphylococcus aureus (MRSA) one Vancomycin Resistant Enterococcus (VRE), four pneumonia, two cellulitis, two wound infection, one skin infection, and 10 Urinary Tract Infections (UTI) however the UTIs did not include the organisms. B. The November 2023 floor plan revealed the facility was trending GU, GI, skin, respiratory, eye, influenza A, and others. Review of the November 2023 infection control log revealed there was one osteomyelitis, two C-diff, two MRSA, one Extended Spectrum Beta Lactamase (ESBL), one enterovirus gastrointestinal, one otitis media, and six unknown infections. There were 22 influenza A, two bronchitis, eight pneumonia, and one upper respiratory infection tract infection. There were three cellulitis, three skin infections, one cystitis, and eight UTI, however there was no evidence of the type of organisms. C. The December 2023 floor plan revealed the facility was trending skin, UTI, LRI, URI, GI, eye, and others. Review of the December 2023 infection control log revealed there was one C-diff, one enterovirus gastrointestinal, four MRSA, seven unknown, 29 COVID, seven pneumonia, one bronchitis, two influenza A, three cellulitis, one skin infection, one cystitis, and 29 UTI, however no indication of the organism. D. The January 2024 floor plan revealed the facility was trending GI, GU, eye, respiratory, skin, and other. Review of the January 2024 infection control log revealed one osteomyelitis, one strep throat, one periodontitis, one c-diff, three MRSA, one herpes zoster, one unknown infection, seven pneumonia, two bronchitis, five COVID, one skin infection, one cellulitis, and one wound infection. E. The February 2024 floor plan revealed the facility was trending GI, GU, eye, respiratory, skin, and other. Review of February 2024 infection control log revealed one bacteremia, three osteomyelitis, two periodontitis, one strep throat, three conjunctivitis, one herpes zoster, two bronchitis, five bronchitis, four COVID, three skin infections, and 10 UTI's, however no indication of the organism. The March 2024 floor plan revealed the facility was trending skin, UTI, LRI, URI, GI, eye, and others. Review of March 2024 electronic infection control log revealed there was one bacteremia, one strep throat, one conjunctivitis, two unknown, one bronchitis, one cellulitis, one UTI. Review of March 2024 paper infection control log revealed on 400 hall there was one MRSA, one prophylactic for UTI, one unknown fever. The 200-hall had two UTI's, however no indication of the organism, one osteo, and one respiratory. The 300-hall had five UTI's without evidence of organisms, one dental prophylactic, one bacteremia, one strep throat, and one conjunctivitis. The electronic logs only included room number, date of infection onset, infection, signs and symptoms, status, pharmacy order, and comments. There was no indication if the infection was community or hospital acquired. Review of the facility policy titled Infection Prevention and Control Program (dated 05/12/23) revealed a system of surveillance would be utilized for prevention, identified, reporting, investigation, and controlling infections and communicable disease for all residents, staff, volunteers, visitors, and other individual providing services under a contractual arrangement based upon a facility assessment and accepted national standards. The policy didn't include directive or guidance on completing the infection control log or trending infection. Interview on 03/13/24 at 9:30 A.M., with Licensed Practical Nurse (LPN) #286 confirmed she was trending infection by using a floor plan of the facility. The facility currently has three floors. The floor plan only includes the site of infection and not the infection/organism. The LPN confirmed if you looked at the floor plan there was no indication on which resident had MRSA since MRSA could be in several different body sites. The LPN confirmed the printed log did not indicate which logs were community or facility acquired nor did the UTI include the type of organism. The facility was looking into other alternatives to log infections due to there were identified issues. 47568 2. Review of medical record for Resident #78 revealed an admitted [DATE]. Medical diagnoses included neuromuscular dysfunction of bladder, spinal stenosis, benign prostatic hyperplasia, and personal history of urinary tract infections. Review of Medicare Five Day Minimum Data Set (MDS) 3.0 dated 02/14/24 revealed Resident #78 had moderate cognitive impairment, utilized an indwelling urinary catheter and was frequently incontinent of bowel. Review of Resident #78's care plan dated 01/09/23 revealed Resident #78 utilized urinary catheter related to neurogenic bladder. Review of physician orders for Resident #78 revealed an order dated 05/28/23 to cleanse supra pubic site with wound cleanser and apply antifungal cream and absorbent dressing daily. Observation of catheter care on 03/11/24 at 3:52 P.M. for Resident #78 revealed Registered Nurse (RN) #338 gathered supplies, knocked on door, entered resident's room, and had shut resident's door for privacy. RN #338 placed supplies on prepared bedside table. RN #338 washed hands and donned gloves removed soiled dressing around supra pubic catheter site, cleansed site with gauze pads soaked in wound cleanser, dried with clean dry gauze pads and with soiled gloves applied new split gauze dressing over supra pubic catheter site. RN #338 was not observed to doff gloves perform hand hygiene and don new gloves after removing soiled dressing and prior to applying new dressing. Interview on 03/11/24 at 4:00 P.M. with RN #338 confirmed gloves were not changed, and hand hygiene was not completed prior to applying clean dressing after soiled dressing was removed from Resident #78's supra pubic catheter site. Review of facility policy titled Personal Protective Equipment dated 07/10/23 revealed gloves were to be changed and hand hygiene was to be completed between clean and dirty tasks.

Based on observation, interview, record review, and review of the facility policy the facility failed to ensure Resident's #8, #43, and #197's insulin pens had a date they were first opened and used recorded on the pen. This affected three residents (Resident's #8, #43 and #197) who received insulin and resided on the second floor nursing unit. Findings include: 1. Review of Resident #8's medical record revealed an admitted [DATE] and diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus without complications and anxiety disorder. Review of Resident #8's physician orders dated 11/16/23 revealed Novolin 70/30 FlexPen subcutaneous suspension pen-injector (70-30) 100 units per milliliter (ml) (insulin NPH isophane and regular (human), inject 50 units subcutaneously one time a day for diabetes. 2. Review of Resident #43's medical record revealed an admitted [DATE] and diagnoses included diabetes mellitus without complications, Parkinson's disease and dysphagia. Review of Resident #43's physician orders 07/06/23 revealed Levemir FlexPen subcutaneous solution pen-injector 100 units per ml (insulin detemir), inject 20 units subcutaneous two times a day related to type two diabetes mellitus without complications. 3. Review of Resident #197's medical record revealed an admitted [DATE] and diagnoses included type two diabetes mellitus without complications, morbid obesity due to excess calories, congestive heart failure. Review of Resident #197's physician orders dated 02/28/24 revealed Lantus SoloStar 100 units per ml solution pen-injector, inject 70 units subcutaneously at bedtime related to type two diabetes mellitus without complications. Observation on 03/11/24 at 10:39 A.M. of Licensed Practical Nurse (LPN) #262 revealed she opened the top drawer of her medication cart, and checked the insulin pens of residents residing on the second floor nursing unit for dates when the insulin pens were first opened and used. Further observation revealed LPN #262 checked Resident #43's Levemir FlexPen 100 units per ml and noted there was no date the FlexPen was first opened and used written on it. Further review revealed LPN #262 checked the date on Resident #197's Lantus SoloStar 100 units per ml pen-injector and noted there was no date Resident #197's Lantus pen-injector was first opened and used written on it. Observation revealed LPN #262 checked the date on Resident #8's Novolin 70/30 insulin pen 100 units per ml and confirmed there was no date it was first opened and used written on it. Interview on 03/11/24 at 10:39 A.M. of the Director of Nursing (DON) confirmed Resident #8, #43 and #197's insulin pens did not have the date they were first opened and used written on the pens. The DON stated the insulin pens needed to be discarded and she would have the pharmacy send Resident's #8, #43 and #197 replacement insulin pens. The DON indicated Resident's #8, #43 and #197 would not be charged for the insulin pens, and the facility would pay to replace them. Review of the facility policy titled Administering Medications revised 04/2019 included medications were administered in a safe and timely manner, and as prescribed. The expiration or beyond use date on the medication label was checked prior to administering. When opening a multi-dose container, the date opened was recorded on the container. Insulin pens containing multiple doses of insulin were for single-resident use only.

Based on medical record review, interview, and policy review the facility failed to ensure residents met criteria for antibiotic treatment. This affected four residents (#29, #30, #78, and #82) of five reviewed for infections. Findings include: 1. Record review revealed Resident #82 was admitted to the facility on [DATE] with diagnoses including pulmonary fibrosis, heart disease, and history of urinary tract infection (UTI). Review of Resident #82's nursing note dated 03/04/24 revealed the resident had complaints of dysuria. New order from physician for Macrobid 100 milligram (mg) twice daily for five days and Pyridium 100 mg three times a day for four days. Review of Resident #82's infection screening evaluation note dated 03/04/24 revealed the resident did not have an indwelling catheter and was afebrile. She had acute dysuria, and no other symptoms were noted. Review of Resident #82's infection note dated 03/05/24 revealed the resident had possible UTI. No diagnostic test was performed, and the resident was ordered antibiotic therapy of Macrobid 100 milligrams (mg) for five days. Review of Resident #82's antibiotic time out note dated 03/08/24 revealed on 03/04/24 the resident had complaints of dysuria and the hospice doctor placed the resident on antibiotics without obtaining urine. The resident had no complaints at this time. Per secure conversation with hospice doctor the resident needs to finish antibiotic as ordered due to history of recurrent UTI's. Interview on 03/13/24 at 9:37 A.M., with Licensed Practical Nurse (LPN) #286 confirmed the resident did not meet criteria for antibiotic treatment nor was urine collected to ensure an antibiotic was warranted and appropriate. The facility had identified concerns with facility staff not completing the proper paperwork, however hospice was not provided education on antibiotic stewardship program. 2. Record review revealed Resident #30 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including stage III kidney disease, benign prostatic hyperplasia with lower urinary tract symptoms, neuromuscular dysfunction of bladder, acute cystitis without hematuria, and heart disease. Review of Resident #30's physician telehealth note dated 03/10/24 revealed the resident had complaints of bladder distention and uncomfortable pressure. Requested a straight cath for comfort. The straight cath was obtained and 450 cc plus a full sample cup of urine was obtained. The urine was malodorous, muddy yellowish green with a lot of mucus and sediment. The resident sees a urologist regularly. The resident had vomited once at the beginning of the shift and had watery liquid stools twice this shift. The abdomen was soft per staff and didn't look distended. The assessment and plan included diagnoses of acute cystitis, diarrhea, nausea and vomiting, and history of recurrent UTI's. Plan to order Zyvox 600 mg for seven days and contact precautions until urine culture results. Check stool for C-diff and as needed Zofran 4mg four times a day. Review of Resident #30's health status note dated 03/10/24 revealed telehealth was contacted due to the resident having complaints of bladder distention and pressure. The resident also had nausea, vomiting, and diarrhea. New order for stat urinalysis for culture and sensitivity and stool sample for suspected c-diff, Zofran 4 mg every six hours and Zyvox 600 mg twice daily for five days for suspected UTI. The urine sample was taken to the lab for testing. Review of Resident #30's infection screening evaluation dated 03/10/24 revealed the resident was afebrile and had acute dysuria, costovertebral angle pain or tenderness, diarrhea, nausea, and vomiting. Review of Resident #30's infection note dated 03/11/24 revealed the resident urine was still pending. The resident was on Zyvox 600 mg twice a day for five days with no adverse reaction noted. The resident had no voiced complaints of pain or nausea and was afebrile. Interview on 03/13/24 at 9:48 A.M., with LPN #286 revealed the resident did not meet criteria for antibiotics, however the telehealth doctor started the resident on antibiotics with justification. The culture was still pending. The facility has not educated the telehealth doctors on the antibiotic stewardship program. 3. Record review revealed Resident #78 was originally admitted to the facility on [DATE] with diagnoses including type II diabetes, long term use of antibiotics, history of UTI's, benign prostatic hyperplasia without lower urinary tract symptoms, and neuromuscular dysfunction of the bladder, and suprapubic catheter for neurogenic bladder. Review of Resident #78's infection screening evaluation note dated 12/09/23 revealed the resident had supra-pubic tenderness and no other symptoms noted. Review of Resident #78's infection note dated 12/11/23 revealed the resident was ordered Cefdinir 300 mg twice a day until 12/12/23 for UTI. Review of Resident #78's antibiotic time out note dated 12/12/23 revealed the resident has returned from the emergency room with orders for antibiotics for three days for a UTI. The resident was not having any symptoms or signs of infection at this time. The resident supra-pubic catheter was draining clear yellow urine at this time. The antibiotic was completed today and doesn't require any further treatment. Review of Resident #78's medical record revealed no evidence of a urine culture. Review of Resident #78's infection screening evaluation dated 01/25/24 revealed the resident had an indwelling catheter and no symptoms. Review of Resident #78 infection note dated 01/27/24 revealed the resident was ordered Augmentin 500/125 mg twice daily for five days for UTI from the hospital. Review of Resident #78's antibiotic time out note dated 01/29/24 revealed the resident was readmitted to the facility on [DATE] with intravenous antibiotics, however the order was changed to Augmentin by mouth on 01/26/24. The resident urine was dark colored. The physician was notified and wanted the antibiotic continued due to recurrent UTI's and hospitalization related to UTI. Review of Resident #78's medical record revealed no evidence of a urine culture. Review of Resident #78's infection screening evaluation dated 03/06/24 revealed the resident had visible hematuria. Review of Resident #78's orders dated 03/07/24 revealed Bactrim DS 800-160 mg once a day prophylactic. Review of Resident #78 infection note dated 03/08/24 revealed the resident had possible UTI and was ordered Bactrim DS 800-160 mg twice daily for seven days. The urinalysis was pending. Review of Resident #78's urinalysis results dated 03/07/24 revealed the resident had plus four leukocytes and many bacteria. A culture was indicated. Review of Resident #78's urine culture results dated 03/09/24 revealed the organism was proteus mirabilis and resistant to Bactrim. There was a handwritten note to discontinue the Bactrim and start Keflex 500 mg every six hours for seven days. Review of Resident #78's orders dated 03/10/24 revealed Keflex 500 mg by mouth every six hours for UTI for seven days. Interview on 03/13/24 at 9:56 A.M. and 10:03 A.M., with LPN #286 confirmed the Resident was treated for an UTI on 12/09/23 and 01/25/24, however the urine culture was never obtained to ensure the resident received appropriate treatment for a UTI. The LPN confirmed on 03/05/24 the doctor was visiting and noted gross hematuria in the resident foley bag and ordered a urinalysis and started the resident on antibiotics prior to receiving the urine culture. Once the urine culture came back the antibiotic had to be changed due to the Bactrim being resistant against the organism. The LPN confirmed the resident did not meet criteria for antibiotic treatment on 12/09/23 and 01/25/24 and the resident was started on antibiotics on 03/06/24 before the culture returned. The physician should have waited for the culture to return. The physician has not been educated on the antibiotic stewardship program. 4. Record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including dementia, history of UTI, and spinal stenosis. A. Review of Resident #29's health status note dated 02/16/24 revealed the resident returned form the emergency room with order for Keflex 500 mg twice daily for five days for UTI. Review of Resident #29's infection screening evaluation dated 02/17/24 revealed the resident had delirium, new onset confusion, and new onset functional decline. The resident did not meet criteria for antibiotic treatment. Review of Resident #29's antibiotic time out form dated 02/21/24 revealed the resident had gone to the emergency roiagnom on [DATE] due to being lethargic and functional decline and was diagnosed with UTI. The resident had two more days left on treatment and had no signs or symptoms of infection noted. The physician wanted antibiotic continued as ordered from the emergency room and if any signs and symptoms after completion of antibiotic to notify physician. Review of Resident #29's medical record revealed no evidence of a urine culture. Interview on 03/13/24 at 9:52 A.M., with LPN #286 revealed the resident did not meet criteria for antibiotic treatment, however the doctor wanted the antibiotic continued due to the resident had altered mental status. Review of Resident #29's health status note dated 03/02/24 revealed a family member came to the nurse's station requesting to have the resident temperature taken due to the resident was flushed. The resident temperature was 102.2 otherwise good. The doctor was notified, and new orders were received for laboratory testing and chest x-ray on Monday and to start Rocephin 1 gram (gm) IM for seven days. Review of Resident #29's Medication Administration Record (MAR) dated 03/2024 revealed the resident received Ceftriaxone Sodium Powder one gram IM for infection from 03/03/24 to 03/05/24. The order was originally 7 days. Review of the infection screen note dated 03/02/24 revealed the resident one single temperature greater than 102. The resident had no other noted symptoms. Review of Resident #29's health status note dated 03/05/24 revealed the resident had no signs or symptoms of infection and her labs were within normal limits and the chest x-ray was negative. The resident had only one temperature and all other temperatures were within normal limits. New orders to discontinue the Rocephin. Interview on 03/13/24 at 7:20 A.M. and 9:52 A.M., with LPN #286 confirmed the resident did not meet criteria for antibiotic treatment. Review of the facility policy and procedure titled Antibiotic Stewardship Program (dated 05/30/23) revealed it was the facility policy to implement and Antibiotic Stewardship Program as part of the facility overall infection prevention and control program. The Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics. Clinical justification for the use of an antibiotic beyond the initial duration ordered such as a review of laboratory reports/cultures in order to determine if the antibiotic remains indicated or of adjustments to therapy should be made. Education regarding the program would be provided at least annually to facility staff, prescribing practitioner, residents, and families.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, facility policy and procedure review and interview, the facility failed to ensure medications were administered to Resident #50 without significant errors. Actual harm occurred to Resident #50 on 08/22/22 when the resident was administered medications ordered for another resident resulting in the resident becoming hypotensive and requiring hospitalization with treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include Review of Resident #50's closed medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan, initiated on 08/09/22 revealed the resident had a care plan for potential cardiac complications related to [CONDITION(S)], congestive heart failure and pacemaker with interventions including to administer medications per orders. Review of the five-day Minimum Data Set (MDS) 3.0 assessment, dated 08/22/22 revealed the resident had severe cognitive impairment and required extensive assistance from two staff for bed mobility, dressing and toilet use, total dependence from two staff for transfers and total dependence from one staff for locomotion and personal hygiene. The assessment revealed the resident was occasionally incontinent of bladder and always incontinent of bowel. Review of Resident #50's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's August 2022 (08/01/22 to 08/21/22) blood pressure monitoring revealed the resident's blood pressure readings ranged from 107/72 to 153/88. Review of a Medication and Treatment Errors and Omissions form, dated 08/22/22 revealed Resident #50 received the following medications in error, that were prescribed for Resident #44: Vitamin D, [MEDICATION(S)] 1000 milligrams (mg), [MEDICATION(S)] 40 mg subcutaneous injection, Aspirin 325 mg, [MEDICATION(S)] (to treat [CONDITION(S)]) five mg, Fish Oil 1000 mg, [MEDICATION(S)] (diuretic) 40 mg, Losartan (blood pressure medication) 20 mg and Potassium 20 milliequivalents. The incident occurred on 08/22/22 at 8:00 A.M., the physician and family were notified at 8:10 A.M. and the supervisor was notified at 8:11 A.M. The medication error type included wrong drug, wrong strength and wrong patient. The form indicated the nurse would write a separate statement. Review of the handwritten statement provided by Licensed Practical Nurse (LPN) #400 on 08/22/22 revealed the nurse started the morning medication pass and had a packet (of medication) for the resident in her hand. She was distracted, grabbed the wrong packet and gave the wrong medications to the resident. LPN #400 realized her mistake and notified LPN #450 of what happened and what was given. The statement and Medication Error Form did not provide further details as to how the nurse was distracted or why. Review of a nursing progress note, dated 08/22/22 at 8:00 A.M. revealed a medication error was discovered, vital signs were obtained and within normal limits. Review of a nursing progress note, dated 08/22/22 at 8:10 A.M. a medication error was discovered, vitals were within normal limits and Physician #475 was paged but no answer. A telehealth practitioner (Physician #500) was contacted with new orders to administer Resident #50's [CONDITION(S)] medication ([MEDICATION(S)]) and to hold all other medications with the exception of Resident #50's [MEDICATION(S)] if the resident's systolic blood pressure (the top number of the reading) dropped below 100. The resident's daughter was notified. Further review of the nursing progress notes revealed a note, dated 08/22/22 at 9:15 A.M. the resident's blood pressure was 82/42 and [MEDICATION(S)] 2.5 mg was administered per previous order. The resident was placed in trendelenburg position (with feet up and head down to translocate blood to the central compartment). The physician was updated and ordered to monitor and recheck the resident's blood pressure within 20 minutes and if the resident was still hypotensive, he needed sent to the emergency room for evaluation. All other vital signs were stable. A follow-up progress note, at 9:30 A.M. revealed the resident's blood pressure was 116/64. Review of a nursing progress note, dated 08/22/22 at 10:30 A.M. revealed the resident was placed on five liters oxygen per minute via nasal cannula. The resident's oxygen level dropped while being assisted with activities of daily living by the aide. The resident was placed on his [CONDITION(S)] (a respiratory machine that helped push air into your lungs) and his oxygen saturation returned to 95% (normal 92%-100%). The resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a progress note, dated 08/22/22 at 10:53 A.M. revealed the resident's daughter arrived and she wanted the resident to go to the emergency room for an evaluation (due to the medication error and his current difficulty breathing). The resident was then transferred to the hospital. A nursing progress note, entered at 6:28 P.M. revealed the resident was admitted (to the hospital) for observation for side effects of the medication error. Review of hospital documentation, dated 08/22/22 revealed the resident presented to the emergency room from the facility with acute [CONDITION(S)] and [CONDITION(S)]. emergency room (ER) blood pressure readings included the following hypotensive (low blood pressure) results: 12:30 P.M. 83/54, 1:00 P.M. 91/55 and 2:30 P.M. 85/61. The resident received 500 milliliters (ml) of normal saline (intravenous solution) in the emergency room . The assessment/plan noted the resident had acute hypoxic [CONDITION(S)] most likely secondary to cardiac history and medication error. The ER note also indicated the resident had possible exacerbation of congestive heart failure but due to receiving 40 mg of [MEDICATION(S)] with the wrong bundle of medications and the patient's blood pressure still being on the soft side, additional [MEDICATION(S)] was not given and the patient was in no acute distress at that time (due to his exacerbation of congestive heart failure). A hospital progress note dated 08/23/22 revealed the resident's condition was exacerbated due to receiving the wrong medications at the facility. As of 09/05/22 the resident remained hospitalized . On 09/06/22 at 5:00 P.M. interview with the Director of Nursing (DON) revealed the nurse involved in the medication error, Licensed Practical Nurse (LPN) #400 no longer worked at the facility. Further interview verified the resident received all 9:00 A.M. medications intended for Resident #44 in error. The resident's blood pressure dropped and staff administered his routine medication ([MEDICATION(S)]) for low blood pressure and he was placed in trendelenburg position and his blood pressure initially improved. The DON revealed the facility planned to continue to treat/monitor the resident in house, but when the resident's daughter arrived at the facility, she wanted him sent to the emergency room . The resident was then transferred and subsequently admitted for observation due to the medication error. The DON verified the resident received intravenous normal saline in the hospital for his low blood pressure as well. Lastly, the DON verified the LPN should not have been distracted during her medication administration and should have followed the rights of medication administration (right resident, right time, right dose, right method and right medication) to prevent the medication error occurring. The DON revealed the nurse did not share details as to why she was distracted during the med pass. Review of the Administering Medications Policy, dated 2001 and revised 2019 revealed medications were administered in a safe and timely manner and as prescribed. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. The deficiency was corrected on 08/24/22 after the facility implemented the following corrective actions: On 08/22/22 Resident #50 was assessed by the LPN for potential side effects of medication error. On 08/22/22 telehealth notified, telehealth gave new instructions to administer scheduled [MEDICATION(S)] and hold all other medications, beside [MEDICATION(S)] unless systolic drops below 100. Vital signs to be monitored every four hours for 12 hours. On 08/22/22 LPN #400 was educated by the DON/Assistant Director of Nursing (ADON) on proper medication administration, eliminating distractions and the six rights of medication administration On 08/22/22 the medical director was notified of the medication error. On 08/22/22 all residents LPN #400 was responsible to provide medications were assessed by DON with no significant issues noted. On 08/23/22 at 5:00 A.M. all licensed nursing staff were educated on the rights of medication administration and proper medication administration by the ADON. On 08/23/22 through out the day multiple medication administrations were observed by the DON. Audits continued daily for seven days and were scheduled to continue weekly for three weeks by DON/designee. A plan for the audits to be be reviewed in the monthly facility QAPI meeting on 09/23/22 and when needed thereafter was initiated. On 08/23/22 an Ad hoc QAPI meeting was held to ensure medications were administered correctly and free of error. There were no identified medication errors between 08/23/22 and 09/01/22 the time of the onsite complaint investigation. This deficiency substantiates Complaint Number OH 472.

Based on record review and resident and staff interview the facility failed to ensure one resident (Resident #74), who was assessed to require two staff assistance for transfers using a mechanical (Hoyer) lift, was transferred properly to prevent a fall with fracture. Actual Harm occurred on 11/19/19 when one nursing assistant, (NA, not yet State tested ) #309 began to transfer Resident #74 from the shower chair to bed without first ensuring the Hoyer lift pad was properly placed under the resident. The resident subsequently sustained [REDACTED]. This affected one resident of three reviewed for falls. Findings Include: Review of Resident #74's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the plan of care, dated 11/28/17 revealed the resident was at risk for falls due to medication use and required assist with transfers. Interventions included the use of bilateral half side rails as an enabler and call light within reach. Interventions also included the resident was lifted mechanically (Hoyer lift) and used a wheelchair. Record review revealed Resident #74 had a current physician's orders [REDACTED]. A fall risk assessment, dated 09/10/19 revealed the resident was at risk for falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #74 had intact cognition and required total assistance of two staff members for transfers. Review of the progress note, dated 11/19/19 at 4:55 P.M. revealed Resident #74 was being transferred from the shower chair into bed with the Hoyer lift. The note indicated the Hoyer lift pad was improperly placed and was halfway down the resident's back. The note indicated the resident was being swung into bed and the Hoyer must have been unequal and the resident slid out of the Hoyer. The resident hit her head on the foot of the bed and had a knot on her head. The resident was lifted into bed by therapy and the nurse. The doctor was notified and ordered the resident be sent to the emergency room (ER) for further evaluation. At 7:18 P.M. a follow up call was made to the ER which revealed the resident had a computed tomography scan (CT scan) which came back negative for head injury. However, the resident had a right tibia and fibula fracture. Review of the Hospital ER report dated 11/19/19 revealed Resident #74 was in a Hoyer lift, but missed the bed and landed on the floor. The resident stated she landed on her left side and had not lost consciousness. The resident was unsure if she was on any blood thinners. The resident was complaining of head pain as well as pain to her right ankle. The resident had a right tibial and fibular fracture. Review of the x-ray report dated 11/19/19 revealed Resident #74 had a spiral [MEDICAL CONDITION] tibia with intra-articular extension and some displacement of the medial malleolus. There was also mildly displaced distal fibular fracture. The bones were osteopenic. The ankle mortise grossly congruent. Review of the fall incident report dated 11/19/19 revealed at 4:15 P.M. Resident #74 fell out of the Hoyer pad due to improper positioning. The resident was being transferred from the shower chair to the bed. Review of Resident #73's (Resident #74's roommate at the time of the fall) statement dated 11/20/19 revealed a NA was assisting Resident #74 from her shower. Resident #73 stated she heard a crash behind the curtain and felt something hit her bed. She further reported another aide, (STNA #302) came running into the room to help and then the nurse was called to come and help. Resident #73 reported Registered Nurse (RN) #300 and Therapy #301 used a sheet to lift Resident #74 back into bed. Review of statement from STNA #302 revealed the STNA was called to help assist NA #309 to put Resident #74 to bed after her shower. The statement revealed NA #309 already had the resident hooked up to the Hoyer lift before she walked into the room. NA #309 was in front of the lift with the control in her hand. STNA #302 was behind the residents' chair. NA #309 was lifting the resident up when STNA #302 noticed the resident's shower Hoyer lift pad was down behind her in the middle of her back. STNA #302 told NA #309 to wait but it was too late, the resident slipped out of the Hoyer lift pad onto the floor and hit her head on the bed. Review of the statement from NA #309 revealed she got Resident #74 out of the shower at approximately 3:30 or 4:00 P.M. and took her to her room. She hooked the loops to the Hoyer lift and then called for STNA #302 to come help with the transfer of Resident #74 to her bed. While lifting her the shower pad was sliding down her back. NA #309 told STNA #302 they should put the resident back in her seat and fix the pad but STNA #302 stated the resident was fine and to continue to lift her. As they were lifting her up, she slid out of the Hoyer pad, hitting the bed and slid down the bed to the floor. The resident hit her head on the bed. The nurse came in to check her vital signs. Interview on 12/02/19 at 1:45 P.M. with Resident #74 revealed she had not received her shower on Monday, so the staff were giving her one on Tuesday (11/19/19). She indicated when the NA was transferring her from the shower chair to the bed, she fell out of the lift pad. She stated the (lift) pad was all the way under her butt and when the nursing assistant lifted her into the air, she flipped out the of the lift pad. She stated she landed on her head. She stated there was only one aide (NA #309) in the room using the Hoyer lift when she fell but she did not know the nursing assistant's name. She indicated a male nurse and a male therapist got her back into the bed after she fell . Interview on 12/02/19 at 4:00 P.M. with Resident #73 revealed she recalled the incident in which Resident #74 fell out of the lift. Resident #73 revealed the NA was lifting her roommate out of the bath chair with the Hoyer lift and she fell out of it and hit her head on the floor. She stated the NA ran out of the room to get help. She indicated the aide was the only person in the room Interview on 12/02/19 at 4:30 P.M. with the Director of Nursing (DON) verified Resident #74 sustained a fall with fracture during a staff assisted mechanical lift transfer on 11/19/19. The DON revealed NA #309 was hired on 09/12/19 but was not yet State tested . The DON indicated the NA had taken the STNA class at their sister facility and passed the class and was working within the first four months of completing the class. However, she was not State tested as of 11/19/19. This deficiency substantiates Complaint Number OH 513.

Based on medical record review, policy review, observation and interview, the facility failed to ensure fall interventions were in place for four residents (Resident #73, #38, #92 and #153) and failed to complete fall investigations for three (Resident #73, #38, and #153) of five residents reviewed for falls. Actual Harm occurred on 05/15/19 when Resident #73, who was determined to be at a high risk for falls, attempted to transfer himself, resulting in an acute, closed head injury, hematoma to the back of his head, and skin tears requiring emergency care and on 05/12/19 and when Resident #153, who was confused and determined to be at risk for falls, attempted to toilet himself resulting in a [MEDICAL CONDITION] requiring surgical intervention. There was no evidence planned interventions were in place prior to the fall. Findings include: 1. Medical record review revealed Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a nursing progress note, dated 02/17/19, revealed the resident was found lying on the floor of his room. A skin tear was noted to his left elbow, and he stated that he bumped his head. A new intervention for visual reminders, to ask for assistance when getting out of bed was initiated. A fall investigation was not completed by the facility. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/07/19, revealed the resident required extensive, one-person assistance for mobility, transfers, and dressing. Review of a nursing progress note, dated 05/15/19, revealed the resident was found in his room, lying on his back on the floor, with his head near the foot of the bed. The resident stated that he was trying to get up and didn't make it to the chair. The resident received skin tears to the right and left forearms, and a hematoma to the back of his head. Review of a nursing progress note, dated 05/15/19, revealed the resident was sent to the emergency room and diagnosed with [REDACTED]. A fall investigation was not completed by the facility. Review of Resident #73's physician order, dated 05/15/19, revealed an order for [REDACTED]. Review of a nursing progress note, dated 05/22/19, revealed the resident was found sitting on the floor, leaning against his bed. The resident was wearing plain, cotton socks with no shoes. Bruising was noted to the resident's neck. The physician ordered an x-ray of the right shoulder and clavicle due to the resident complaining of pain in that area and cervical x-rays of the spine. Review of the cervical spine x-ray findings, dated 05/22/19 revealed no acute findings. A fall investigation was not completed by the facility. There were no fall investigations following the falls on 02/17/19, 05/15/19 and 05/22/19. During interview on 07/11/19 at 11:40 A.M., the Director of Nursing (DON) reviewed the progress notes and confirmed the fall intervention for non-skid socks was not in place at the time of the fall on 05/22/19. The DON further confirmed there was no fall investigation following the falls on 02/17/19, 05/15/19 and 05/22/19, resulting in no investigation to attempt to determine the root cause of the falls, if planned interventions were in place at the time of the falls, if appropriate interventions were in place after the fall, and there was no monitoring to ensure planned interventions were put into place. The DON stated that fall investigations were not completed for every fall, prior to three weeks ago, when she assumed the role of DON. Review of the facility's policy titled, Managing Falls and Fall Risk, revised (MONTH) 2019, revealed if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 2. Resident #153 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was mobile in a wheelchair. Review of the baseline care plan dated 05/08/19 revealed the goal was for the resident to be free from fall related injury, provide side rails, assist the resident with mobility as needed, ensure proper footwear, assist with toileting needs and incontinence care on routine rounds and as needed, keep bed in the lowest position, ensure call light was within reach, keep fluids and frequently used items within easy reach, observe medication use for side effects that may increase fall risk, and provide verbal reminders to not transfer or ambulate without assistance. There was no evidence the resident and/or family participated in the plan. Review of the 05/08/19 nurse's note revealed the resident was only oriented to person and place. Review of the fall risk assessment dated [DATE] revealed the resident was at risk for falls. Review of the 05/09/19 nurse's note revealed the resident was oriented to person and place with confusion. Review of the five-day MDS 3.0 assessment dated [DATE] revealed the resident's cognition was not assessed but he required extensive assistance of two or more staff for bed mobility, transfers and toileting. The resident did not walk. The resident was not steady, only able to stabilize with staff assistance for surface to surface transfers. Review of the nurse note dated 05/12/19 at 12:00 P.M., revealed the staff was notified by a visitor the resident had fallen. Upon entering the resident's room the resident was found laying on the floor outside of the bedroom door in the common area on his left side with his back facing the door. The resident had on slipper socks. The resident stated he was going to the bathroom and complained of left hip pain. The resident presented with severe pain and decreased range of motion to the left leg. The resident was sent to the hospital. Review of the hospital x-ray dated 05/12/19 revealed the resident had a left femoral neck fracture with impaction. Further review of the hospital consultation note dated 05/12/19 revealed the resident would be scheduled for surgery to perform a left [MEDICAL CONDITION] hemiarthroplasty. The resident was discharged back to the facility after recovering from the surgery on 05/16/19. Review of the interdisciplinary team meeting (IDT) note dated 05/13/19 revealed the intervention was going to be to move the residents room for easier access to the restroom and closer to the nurse. The resident would also be placed on every two hour toileting. Further review of the medical record revealed there were no further documentation related to the fall, interventions, causes or evidence interventions were in place prior to the fall. There was no investigation completed for the fall. Review of the census indicated prior to the fall the resident was in room [ROOM NUMBER] and after the fall, when the resident returned from the hospital on [DATE] the resident was placed in room [ROOM NUMBER] which did not follow the above intervention. Review of the fall risk care plan initiated 05/17/19 revealed on 05/12/19 the resident was to be toileted every two hours per order. Further review revealed there were no further interventions initiated until 05/17/19 which included to assist the resident with mobility as needed, assist the resident with wearing proper footwear, assist with toileting needs and incontinence care on routine rounds and as needed, include the resident and/or family in the treatment plan, keep call light in reach, keep fluids and frequently used items within easy reach, observe medications use for side effects that may increase fall risk, remind resident and assist with use of mobility devices as needed and therapy screens as needed. Review of the fall risk assessment dated [DATE] revealed the resident was at risk for falls. Review of the nurse's note dated 06/20/19 at 2:30 A.M., revealed the resident was found on the floor in the bathroom. Further review of the IDT note revealed the resident was educated on safety awareness when transferring. No interventions were put into place nor was it determined if prior interventions were in place at the time of the fall. There was no investigation completed for the fall nor any additional information available in the medical record. There was no order for or evidence the resident was toileted every two hours as planned. On 07/08/19 at 4:04 P.M., the resident was observed being pushed back to his room in his wheelchair by staff, he had socks on his feet. On 07/08/19 at 5:35 P.M., the resident was observed in bed which was not in the lowest position and he was bare foot. On 07/08/19 at 5:36 P.M., attempted interview with the resident revealed he had no recollection of either of the above falls. On 07/09/19 at 9:11 A.M., the resident was observed in his recliner in the room without a call button available if he needed assistance. On 07/09/19 at 2:50 P.M., the resident was observed in bed which was not in the lowest position and the resident was bare foot. On 07/11/19 at 11:20 A.M., interview with the Director of Nursing (DON) verified the fall investigations were to be completed in the computer system but none were completed for the 05/12/19 or 06/20/19 falls. The DON verified there was no investigation to attempt to determine the root cause of the falls, if planned interventions were in place at the time of the fall, if appropriate interventions were in place after the fall and no monitoring to ensure planned interventions were put into place. On 07/11/19 at 11:35 A.M., interview with the MDS and care plan Licensed Practical Nurse (LPN) #56 revealed the admitting nurse completed the baseline care plan and it was not discussed as a team and then she completed the subsequent care plans based on the data from the MDS. She verified the two hour toileting was initiated prior to the development of the 05/17/19 falls care plan because it was a fall intervention. 3. Medical record review revealed Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 3.0 assessment, dated 06/30/19, revealed the resident required limited, one-person assistance for mobility and transfers and supervision, one-person assistance for dressing. Review of a Fall Incident Audit Report, dated 09/05/18, revealed Resident #92 was found lying face-down on the floor, beside her bed on 08/27/18. A hematoma and abrasion were noted to the right, upper arm, and a skin tear was noted to the right and left forearms. No further injuries were observed. The resident stated she was reaching to get a drink of water when she lost her balance and fell on the floor. A new intervention to ask for assistance when getting out of bed was initiated. Review of a Fall Incident Audit Report, dated 07/10/19, revealed a fall occurred on 07/07/19 when the resident was overheard yelling help and found in her room, lying face down on the floor in front of her wheelchair. The resident stated that she was trying to wheel to the bathroom when her foot got stuck. The resident was observed wearing slide sandals with slick soles. The resident received an abrasion and two superficial lacerations to the forehead. The new intervention initiated was for the resident to wear non-skid socks, when not wearing non-skid shoes. An x-ray was ordered of the left ankle on 07/08/19, which revealed no fracture or dislocation. Review of Resident #92's Plan of Care, dated 08/28/18, revealed a new fall intervention to assist the resident with ensuring she was wearing proper footwear. During interview on 07/11/19 at 11:40 A.M., the Director of Nursing (DON) reviewed Resident #92's progress notes and confirmed the fall intervention for appropriate, non-skid footwear was not in place at the time of the fall on 07/07/19. Review of the facility's policy titled, Managing Falls and Fall Risk, revised (MONTH) 2019, revealed if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 4. Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 02/05/19 MDS 3.0 assessment revealed the resident was not able to be interviewed. The resident required assistance from staff with activities of daily living (ADL) including bed mobility, transfers and toileting. The resident was unsteady without the assistance of staff. Review of the nurse's note dated 04/14/2019 at 1:45 A.M. indicated the resident was heard shouting out from her room, Help. The resident was found sitting upward on floor. The resident had missed her wheelchair to use the bathroom and was sitting on the floor. The resident was educated to use her call light for assistance when she wanted to use the restroom. Further review of the IDT note dated 04/15/19 revealed a dycem, a sticky pad used to reduce sliding potential, was placed in the seat of the wheelchair. There was no further documentation of the fall in the medical record. It was unclear were the resident was prior to the fall and there was no evidence the call light was within reach or what if any other fall interventions were in place. Review of the fall risk assessment dated [DATE] indicated the resident did not have any falls in the last 90 days. Review of the nurse's note dated 06/18/2019 at 1:45 A.M., revealed the resident was observed on the floor on her back on the left side of the bed. No injuries were noted. Review of a nurse's note dated 06/20/19, revealed the resident was trying to get to her chair and indicated the resident was currently in skilled therapy for function decline in ADL. The IDT note indicated to ensure the bed was locked and in the lowest position. On 07/08/19 at 11:20 A.M., interview with the resident revealed she had fallen and had gotten hurt but she was not able to describe her injuries. On 07/08/19 at 4:20 P.M., 5:47 P.M. and 6:35 P.M., the resident was observed in her wheelchair with socks on that were not non-skid. On 07/09/19 at 9:19 A.M., 10:46 A.M., 12:30 P.M. and 1:15 P.M., the resident was observed in her wheelchair with socks on that were not non-skid. On 07/09/19 at 1:16 P.M., interview with LPN #16 verified the resident did not have on non-skid socks. On 07/09/19 at 3:20 P.M., the resident was observed in her wheelchair with socks on that were not non-skid. 7/10/19 at 11:12 A.M. and 12:58 P.M., the resident was observed in her wheelchair with socks on that were not non-skid. On 07/11/19 at 11:20 A.M., interview with the DON verified the fall investigations were available and located in the computer system but none were completed for the 04/14/19, 06/18/19 or 06/20/19 falls. The DON verified there was no investigation to attempt to determine the root cause of the falls, if planned interventions were in place at the time of the fall, if appropriate interventions were in place after the fall and no monitoring to ensure planned interventions were put into place.

Based on observation, interviews, medical record review and review of the facility policy At Risk for Wandering, the facility failed to provide adequate supervision to prevent elopement of one resident (Resident #97) who resided on the secured unit and was assessed at risk for elopement. This resulted in Immediate Jeopardy when the resident was unable to be located in the facility on 04/26/18 at 5:55 P.M. The potential for serious harm occurred when Resident #97's safety was not ensured until she was discovered on 04/26/18 at 8:40 P.M. in her wheelchair in the parking lot by a visitor. This affected one of nine residents identified to be at risk for elopement who resided on the secured unit (Resident #68, #78, #97, #82, #18, #20, #8 and #73). The facility census was 104. On 05/10/18 at 2:35 P.M., the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) were notified Immediate Jeopardy began on 04/26/18 at 5:55 P.M. when Resident #97, who was assessed at risk for elopement and exhibited exit seeking behaviors, exited the facility without knowledge of staff. The Immediate Jeopardy was removed on 05/11/18 when the facility implemented the following corrective actions: On 05/10/18 by 5:00 P.M., the Corporate Maintenance man, Maintenance Director (MD) #16, Maintenance Assistant #34 and Administrator inspected all the doors equipped with the wander guard system to ensure the door alarm was functioning properly. On 05/10/18 by 5:30 P.M., MD #16 adjusted the audibility of the wander guard management panel at the second floor nurse's station so the alarm could be heard at the end of the halls when staff were in a residents' room with the door closed. On 05/10/18 by 8:00 P.M., the DON, ADON, Clinical Supervisor #10, corporate Minimum Data Set 3.0 (MDS) nurse, Registered Nurse (RN) #12 and the Medical Director assessed all of the residents residing in the facility. Residents #68, #78, #97, #82, #18, #20, #8 and #73 were all assessed to be at risk for elopement. The care plans were updated to ensure appropriate interventions were in place. On 05/10/18 by 8:00 P.M., the DON, Administrator in Training, Dietetic Technician #33, Clinical Supervisor #35, ADON, corporate MDS nurse, RN #12 Social Service Designee, Therapy Director, Regional Therapy Director and Activity Director provided training to five RNs, 30 licensed practical nurses (LPN), 35 state tested nurse aides (STNA), two hospitality aides, 18 administrative staff, three activities staff, nine housekeeping and laundry staff, 15 dietary staff and 25 therapy staff on the At Risk for Wandering Resident and Missing Resident and/or Elopement of a Resident policies, elopement prevention procedures which included elopement drills, the elopement identification book and response to the door alarms. Five STNAs and one LPN were not able to be reached but will be educated prior to returning to work. On 05/10/18 at 5:36 P.M. an elopement drill was conducted for all staff on the day shift and at 7:58 P.M., an elopement drill was conducted for all staff on the night shift. The facility will continue to complete the drills quarterly. On 05/11/18 at 1:40 P.M., MD #16 tested all the doors equipped with the wander guard system to ensure proper function and tested the second floor nurses' station wander guard alarms for adequate audibility. On 05/11/18 by 1:50 P.M., interviews were conducted with three STNAs, three LPNs, one dietary aid, two housekeepers and one speech therapist to ensure knowledge of the elopement prevention procedures. Staff interviews revealed knowledge in all areas except who was permitted to disable the alarm and when it was appropriate to disable the alarm. On 05/11/18 at 1:55 P.M., interview with the Vice President of Clinical Services (VPCS) verified staff needed further education on who was able to disable the alarm and when it was appropriate to disable the alarm. On 05/11/18 at 2:24 P.M., review was completed of the new policy regarding responding to the alarms which included who was able to disable and when it was appropriate to disable the alarm. On 05/11/18 at 4:20 P.M., the VPCS, the ADON and the Administrator started educating staff on the new policy about responding to the alarms. All staff would be educated by 6:00 P.M. and if staff was unable to be reached they would be educated prior to reporting to work. On 05/11/18 MD #16 obtained a quote for estimated cost to upgrade the wander guard system. Although the Immediate Jeopardy was removed on 05/11/18, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that was not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan to ensure all residents at risk for elopement were monitored appropriately for on-going compliance. Findings include: Resident #97 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 dated 03/02/18 indicated Resident #97 was cognitively intact. Review of a 04/21/18 nursing note revealed Resident #97 had [MEDICAL CONDITION] (high Blood Sugar) a change in mental status, anuria (not producing urine) and [MEDICAL CONDITION](rapid heart rate) and was sent to the hospital for evaluation. Review of the hospital note dated 04/21/18 revealed Resident #97 was admitted with diabetic ketoacidosis (a life threatening complication associated with diabetes causing elevated blood acids, high blood sugar and not enough insulin production changing normal function of internal organs.) and recent [MEDICAL CONDITION]. Resident #97 was readmitted , to her third floor room, on 04/24/18 following hospital treatment for [REDACTED]. Review of the wandering/elopement risk assessment dated [DATE] revealed Resident #97 was at risk for elopement. The summary indicated Resident #97 returned from the hospital highly confused. She moved about the unit with no rational purpose, verbalizing to staff that she wanted to leave the building and was observed hanging around near the exit doors. Review of a physician order dated 04/25/18 revealed Resident #97 was ordered a wander guard to alert staff when the resident was trying to exit the facility. Review of the care plan that addressed elopement (updated 04/26/18) revealed interventions including offer activities, schedule regular activities, observe for signs the resident may be planning on leaving the facility, intervene and offer the resident an activity, offer food and drinks, spend one to one time with the resident and observe Resident #97's movements on the unit and in the facility. Review of the nursing note dated 04/25/18 at 1:50 A.M., revealed Resident #97 was wandering the halls going towards the exits. She had increased confusion including talking about kids going to school. The resident was easily redirected but only for several minutes at a time. Resident #97 was walking, forgetting to use her wheelchair and wandering into other residents' rooms. There were no further nursing notes related to the resident's behaviors until 04/27/18. Review of the nursing note dated 04/27/18 at 12:59 A.M., revealed at 8:30 P.M. on 04/26/18, Resident #97 was brought back to the facility by Visitor #200 when the resident was found unsupervised, outside the building in the parking lot and trying to go up the driveway in her wheelchair. On 05/09/18 at 4:55 P.M., interview with Housekeeper (HK) #21 revealed he worked from 4:00 P.M. until midnight. He stated each night as part of his assignment he took the garbage out to the back of the building using the employee entrance which was in a corridor across from the reception desk and the main entrance. He stated on the evening of 04/26/18 when he came back in through the double doors towards the receptionist area he saw Visitor #200 bringing Resident #97 into the vestibule at the main entrance and heard the wander guard system alarm. He met Visitor #200 and Resident #97 in the vestibule, where the wander guard activation panel was located between two sets of double doors, and disarmed the alarm. Visitor #200 told HK #21 he'd found Resident#97 close to the bottom of the hill of the driveway and it could have been tragic. HK #21 verified he turned off the alarm but did not notify staff. HK #21 assumed Visitor #200 would notify the third floor staff about finding the resident outside in the parking lot because he was the one who took the resident back up to the third floor. HK #21 verified no other staff responded to the alarm and the receptionist was not at the desk. On 05/09/18 at 6:40 P.M., interview with STNA #15, revealed on 04/26/18 he worked the third floor on second shift. He stated there were two STNAs working He verified he did not know the Resident #97 was off the unit until he saw Visitor #200 and the resident getting off the elevator on the third floor. STNA #15 could not say the last time he saw the resident that evening but thought she ate dinner in the common area. He indicated the exit seeking behavior was new for the resident following a recent hospital stay. On 05/09/18 at 6:56 P.M., interview with LPN #25 revealed she worked on the third floor the evening of 04/26/18 and stated she did not know Resident #97 was off the unit until STNA #15 told her Visitor #200 brought the resident back from outside the building. She couldn't say for sure when she last saw the resident but it was sometime during her 4:00 P.M. medication pass. LPN #25 said the resident was following her around and she asked the STNAs to keep an eye on her because of attempts by the resident to leave the unit earlier in the day. Resident #97 had told LPN #25 earlier that day that she was going to leave and no one could stop her. LPN #25 did not recall any staff from the second floor calling to report the wander guard alarm was activated. On 05/09/18 at 7:15 P.M., interview with LPN #26 revealed she and LPN #27 both worked on the second floor on 04/26/18, the night Resident #97 got out of the building. LPN #26 said she must have been in a resident's room giving medications or providing care because she did not hear the wander guard alarm on 04/26/18 until she was approaching the nurses station around 8:00 P.M. or 8:30 P.M. She went to the elevator because she was going to respond to the alarm and while she was waiting the alarm stopped. She was still standing by the elevator when the doors opened she saw HK #21 getting off the elevator who told her Visitor #200 found Resident #97 outside and had taken her back up to the third floor. LPN #26 verified the alarm could only be heard about half way down the hall on the second floor. She verified MD #16 knew the alarm could not be heard at the end of the hall but the sound had not been adjusted. On 05/09/18 at 7:26 P.M., interview with LPN #27 revealed she worked the evening of 04/26/18 on the second floor and did not hear the wander guard alarm. On 05/09/18 at 7:30 P.M., interview with STNA #28 revealed she worked on the third floor on 04/26/18 when Resident #97 was found out of the building. STNA #28 stated it was just herself and STNA #15 working the third floor that evening and they were not able to keep an eye on the residents known to wander. STNA #28 was not aware of any of the details such as where the resident was found or who brought her back into the building. STNA #28 could not recall the last time she saw the resident before she got out that evening. On 05/10/18 at 8:33 A.M., phone interview with Visitor #200 revealed he was at the facility every Thursday to play piano for the residents on the ground floor near the receptionist desk and the front entrance from 6:00 P.M. until 8:30 P.M. He knew Resident #97 and her family. He stated on 04/26/18 at 5:55 P.M., he went to the third floor and could not find the resident. When he asked staff the whereabouts of the resident they did not know and did not stop to look for her, but indicated she must be around somewhere on the unit. He returned to the ground floor where he was until 8:34 P.M. Visitor #200 did not see the resident at any time during his stay. Visitor #200 stated he then got in his car and as he was leaving he saw something in the shadows which turned out to be Resident #97. The resident was in her wheelchair approaching the steep inclined part of the driveway. It appeared she was going to try to get up the hill. He put his car in park and asked the resident what she was doing and she said going home. He knew she was very confused and she was arguing with him saying you are really ticking me off. He was able to persuade her to go back inside the building at which time the wander guard pendant that was on her ankle triggered the alarm. Visitor #200 said HK #21 disarmed the alarm and he (Visitor #200) took the resident back to the third floor. He saw no other staff on the ground floor. The receptionist was usually there until 8:30 P.M. but had left early that evening. No one asked him about finding Resident #97 in the parking lot until 05/09/18 when he received a call from the Administrator. There was no evidence any new interventions were put in place following the elopement on 04/26/18 until 05/01/18 when Resident #97 again attempted to leave. Review of a nursing note dated 04/29/18 at 2:40 P.M., revealed Resident #97 was pleasantly confused. Additional nursing notes on 04/29/18 revealed the resident continued to wander in and out of other residents' rooms, was delusional (talking to people that were not physically present) and becoming more and more confused. The resident's blood sugar was tested and found to be elevated. The physician was notified and insulin doses were adjusted. Review of a nursing note dated 04/30/18 at 3:43 A.M., revealed Resident #97 was very confused, wandering the halls yelling for her sister and stating she had to leave for court. One on one was ineffective. Review of the significant change MDS 3.0 dated 05/01/18 revealed Resident #97 had severe cognitive impairment. Review of the nursing note dated 05/01/18 at 10:54 A.M., revealed the 15 second delayed egress door alarm sounded at the end of the hall and staff responded to find Resident #97 had opened the door and was walking down the steps without assistance. The nurse assisted the resident the rest of the way to the second floor. The resident was able to ambulate back to the third floor with hand held assistance. The resident stated she was looking for her new red car outside. Staff began every 15 minute checks. Review of the 05/02/18 nursing note revealed the resident was exit seeking, trying to open the exit doors. She was confused and delusional seeing turkeys under the medication carts. At times unable to redirect. The resident constantly needed someone to be with her. Review of the 05/03/18 nursing note revealed the resident was propelling everywhere in the wheelchair. She very confused and delusional, seeing things that were not there, and kept attempting to get on the elevator. Review of the 05/07/18 nursing note revealed Resident #97 continued to be confused and was propelling the wheelchair aimlessly looking for the exits and elevator. She verbalized she wanted to leave and kept asking about her mom and dad. One on one was provided but the resident quickly forgot. The resident required constant supervision. Observation on 05/08/18 at 8:30 A.M., revealed Resident #97 was propelling her wheelchair throughout the unit and staff was frequently redirecting the resident back to the common area. The resident wore a wander guard pendant on her right wrist. There was no evidence diversional activities were attempted. Review of the 05/09/18 nursing note revealed at 1:30 A.M., the resident was exit seeking trying to leave the facility. On 05/09/18 at 10:30 A.M., interview with MD #16 verified the wander guard system was installed to alarm when approached by a resident wearing a wander guard pendant. The system did not secure the doors. He verified none of the three stairwell exit doors were alarmed for the wander guard but each had 15 second delayed egress panic hardware with all stairwells leading to the ground level inside the building. MD #16 verified one of the three stairwell exit doors on the second floor had the wander guard system installed outside the stairwell in the vestibule. The remote annunciator panel was installed at the second floor nurses station only. The only other location the alarm sounded was at the egress door that was activated by the pendant. No alarms were installed on the third floor. He verified all of the ground floor egress doors had the wander guard system installed and he tested the doors weekly. MD #16 verified he had no trouble with the system in (YEAR). He verified staff had informed him the second floor annunciator panel sometimes could not be heard when activated if staff were not close to the nurses' station. He verified he had the ability to adjust the sound level but he had not adjusted it. He verified the alarm was not able to be turned off on the second floor remote annunciator but only at the door that was alarming. The code had to be entered into the panel at the door that was alarming. On 05/09/18 at 10:50 A.M., interview with LPN #17, who worked the third floor revealed she was familiar with Resident #97 and said before the resident went to the hospital on [DATE] she was cognitively intact. When Resident #97 came back from the hospital on [DATE], she was severely confused. LPN #17 verified she was working when Resident #97 exited the stairwell on 05/01/18 and made it to the second floor before staff got to her. The resident left her wheelchair at the top of the third floor stairwell. She stated after that incident the resident was put on every five minute checks for six hours and then every 15 minute checks for 24 hours. LPN #17 added the resident was currently not on every 15 minute checks but remained very confused and exit seeking. On 05/09/18 at 10:55 A.M., interview with LPN #13, who worked the third floor, verified Resident #97 had a new onset of confusion since her recent stroke in (MONTH) (YEAR). The resident sometimes said things like she wanted to go down town and required frequent redirection. Resident #97 was not permitted off the unit unsupervised. On 05/09/18 at 1:15 P.M., Resident #97 was observed in the common area in her wheelchair looking around with her wander guard pendant on her wrist. She then propelled herself to the elevator and LPN #13 redirected her back to the common area. The resident was saying she wanted to leave and LPN #13 asked her to stay a little longer. No diversional activities were offered. On 05/09/18 at 3:40 P.M., STNA #18 was observed filling out the every 15 minute checks on the form. The form was blank and had not been initialed since 11:45 A.M. LPN #17 verified the above. On 05/09/18 at 3:41 P.M., interview with STNA #18 revealed no one had initialed the every 15 minute checks since 11:45 A.M. that morning and she was filling them in from 11:45 A.M. through 3:45 P.M. When asked who was responsible for completing the forms and she stated everyone but no one was specifically assigned to do it so she usually ended up completing the form. On 05/09/18 at 3:42 P.M., interview with LPN #17 verified STNA #18 was initialing the every fifteen minute checks form from 11:45 A.M. through 3:45 P.M. and it should have been initialed every 15 minutes when the person actually checked on the resident. The LPN was not aware the resident was still on every 15 minute checks and she did not monitor the STNAs to ensure checks were completed as planned. On 05/09/18 at 3:52 P.M., interview with STNA #19 verified Resident #97 was exit seeking and everyone was responsible for watching her but no one was responsible for completing the every 15 minute check form. On 05/09/18 at 5:50 P.M., interview with the Administrator revealed there was video surveillance of Resident #97 leaving the building on 04/26/18 but it was for internal use only and the surveyor was not permitted to view it. The Administrator verified there was not a thorough investigation completed to determine when or how the resident was able to leave the third floor and subsequently exit the building into the parking lot without staff knowledge on 04/26/18. On 05/09/18 at 6:10 P.M., interview with Receptionist #23 revealed she worked 4:30 P.M. until 8:30 P.M. Monday through Friday. She verified she worked the evening of 04/26/18 but did not see Resident #97 leave the building. Receptionist #23 added she was not always at the front desk because she could be in the back filing papers. She could hear and see the wander guard alarm which was located between the set of double doors when she was at the desk. However, she might not hear the alarm if she was in the back filing papers. She verified no one was scheduled to be at the receptionist desk from 8:30 P.M. until 8:30 A.M. On 05/09/18 at 6:15 P.M., check of the wander guard system with MD #16 and the administrator indicated it was working. The alert could be heard at the end of the hall on the second floor. MD #16 verified he turned up the audibility of the second floor panel last evening. On 05/09/18 between 6:45 P.M. and 6:53 P.M., Resident #97 was in her wheelchair near the nurses' station trying to get the wander guard pendant off her wrist. She was asking staff to remove it, and they were trying to distract her but were not successful. On 05/10/18 at 8:20 A.M., interview with the ADON revealed neither nursing staff nor Visitor #200 were interviewed in an attempt to determine how and when Resident #97 got off the third floor and into the parking lot on 04/26/18 or how long the resident was out of the building unsupervised. She verified no interventions were put into place after the resident eloped on 04/26/18 to ensure the resident's safety and prevent future elopement. The ADON verified the facility did not follow the resident's wandering and/or elopement care plans including offering activities and diversional activities. On 05/11/18 at 1:40 P.M., tour with MD #16 revealed the facility had three floors. The ground floor did not house residents but they used the main dining room located there. The kitchen, therapy department and offices were also on the ground floor. Resident rooms were all located on the second and third floors. Each of the floors had two elevators that were not equipped with the wander guard system. There were also three stairwell exits and those doors were equipped with 15 second delayed egress panic bars which sounded when the panic bar was pushed for three seconds and released the door in 15 seconds. On the second floor, after exiting the 15 second delayed egress door into the stairwell, there was a vestibule with an emergency exit door and a stairwell door. The emergency exit door was equipped with a wander guard system. None of the other egress doors on the second or third floors were equipped with the wander guard system. All the ground floor emergency exits were equipped with the wander guard system. The only remote annunciator panel was located on the second floor at the nurses' station. Observation in the parking lot on 05/11/18 revealed when exiting the facility at the main entrance there was a long walkway to a large turn around that connected to the driveway. The driveway doubled as the only entrance and exit to a community athletic complex which was heavily trafficked. The driveway to exit the facility campus was located up a steady incline and the building was surrounded with thick dense woods with a ravine on one side. On 05/21/18 at 10:55 A.M., per phone interview, when asked what the weather was like and if he recalled what Resident #97 was wearing when he found her in the parking lot on 04/26/18, Visitor #200 revealed it was a pleasant evening about 60 degrees Fahrenheit. The resident was appropriately dressed in sweat pants, a short sleeved shirt and had shoes on her feet. The resident did not appear to be cold. Review of the At Risk for Wandering Resident policy dated 01/05/18 revealed the facility should assess residents at risk for wandering and implement interventions to maintain their safety. At-risk was a situation that puts the resident on a higher alert level for staff monitoring because of previous history of dangerous behaviors. The facility should maintain a safe environment for residents with cognitive disabilities, identify at risk residents and implement interventions. Interventions to prevent wandering to unsafe areas may include but are not limited to wander guards, locked units and distraction programs or activities.

Based on medical record review and resident and staff interviews the facility failed to complete comprehensive bladder and bowel assessments and implement bladder and bowel training programs for residents with noted decline in bladder and bowel function. This affected four (Resident #14, Resident #27, Resident #93, and Resident #127) of four residents reviewed for incontinence. Harm occurred when Resident #27 who was identified on admission to be always continent of bladder and bowel had declined to always incontinent of bladder and frequently incontinent of bowel without appropriate assessment or training program to prevent declines. Findings include: 1. Review of Resident #27's medical record revealed Resident #27 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #27's admission assessment revealed the resident was always continent of urine and bowel. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] also indicated Resident #27 was always continent of urine and bowel and required extensive assistance of two or more with toileting. Review of Resident #27's care plan revealed Resident #27 was presently continent of bowel and bladder; she was at risk for decline related to limited physical mobility with her [DIAGNOSES REDACTED]. Further review revealed to notify the nurse of any episodes of incontinence. Review of the seven day tracker dated 10/13/16 to 10/19/16 revealed it was incomplete but the days that were marked indicated Resident #27 was continent of urine and bladder. The state tested nurses aide (STNA) documentation dated 10/12/16 to 10/31/16 revealed Resident #27 was always continent of bowel and bladder. Resident #27 was discharged on [DATE] and readmitted on [DATE] for a dislocated left hip after left hip replacement. Review of the re-admission bladder and bowel assessment dated [DATE] revealed Resident #27 was occasionally incontinent of urine and used incontinence briefs and was always continent bowel. Review of the seven day bowel and bladder tracker dated 11/21/16 to 11/27/16 revealed it was incomplete for afternoon shift the entire seven days, incomplete for nights for six days, and incomplete for days shift for four days. The STNA documentation for December, 2016 revealed Resident #27 was always incontinent of urine. Resident #27 was non-weight bearing on the left lower extremity. Review of Resident #27's quarterly bladder and bowel assessment dated [DATE] revealed Resident #27 was always incontinent of bladder and occasionally incontinent of bowel. Further review revealed Resident #27 was unwilling to participate in program due to resident stating the bed pan hurt due to a leg brace. The facility did not initiate a toileting program at this time. Review of the quarterly MDS 3.0 assessment dated [DATE] indicated Resident #27 was not on a toileting program, was always incontinent of bladder, and frequently incontinent of bowel. Resident #27 remained an extensive assistance of two or more with toileting. Review of March, 2017 STNA documentation revealed Resident #27 was always incontinent of urine and frequently incontinent of bowel. Resident #27 was on 30-40 pound weight restriction on left lower leg. On 03/29/17 at 3:57 P.M., interview with STNA #45 confirmed Resident #27 was always incontinent of urine and was not on a toileting program. On 03/30/17 at 10:25 A.M., interview with Resident #27 revealed she refused to use the bedpan because it was sticking to her and was uncomfortable. Resident #27 said the facility did not offer her other options such as a fracture bed pan but they did mention something they could put on the toilet but never brought it. Resident #27 reported although she was not ordered bedrest, the staff told her they could not get her out of bed because of the hip dislocation. Resident #27 was okay with the staff telling her they could not get her up because she didn't feel safe being alone on the toilet; however, she would have gotten up if staff stayed with her. The resident reported she relieved herself in an incontinence brief then called staff to let them know she needed changed. Resident #27 said she had not been on a toileting program. On 03/30/17 at 10:45 A.M., interview with Licensed Practical Nurse (LPN) #5 and the Assistant Director of Nursing (ADON) confirmed Resident #27 had declined from always continent of urine to always incontinent and from continent of bowel to frequently incontinent. LPN #5 confirmed the residents were not assessed for type of incontinence nor were care plans individualized. The ADON confirmed Resident #27's seven day bladder assessments were not complete. The ADON and LPN #5 reported they were new to their positions and there was lack of communication. The facility was not following up on residents with bowel and bladder declines. The ADON reported starting today she would be responsible for following up on declines in resident bowel and bladder functions. On 03/30/17 at 12:15 P.M., interview with director of nursing (DON) revealed the facility did not have a bowel and bladder policy; they were in the process of writing a policy. 2. Review of Resident #93's medical record revealed Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #93's admission bladder and bowel assessment dated [DATE] revealed Resident #93 required limited assistance and was always continent of bladder and bowel. Review of Resident #93's MDS 3.0 assessment dated [DATE] revealed Resident #93 had a Foley (urinary) catheter and was always incontinent of bowel. Resident #93 was totally dependent for toileting. Review of Resident #93's quarterly bowel and bladder assessment dated [DATE] revealed Resident #93 was always incontinent of bladder and bowel. The resident was a fair candidate for a restorative bladder and bowel program. There was no evidence a restorative program was initiated. Review of the quarterly MDS 3.0 assessment dated [DATE] also revealed Resident #93 was always incontinent of bladder and bowel and the resident was not a toileting program. The resident was extensive assistance of two with toilet use. Review of the STNA bowel and bladder documentation dated March, 2017 confirmed Resident #93 was always incontinent of bowel and bladder. Review of Resident #93's care plan revealed Resident #93 was incontinent of bowel and bladder and any changes would be reported to the physician. On 03/29/17 at 8:00 A.M., interview with Resident #93 revealed she was currently incontinent of bladder and bowel and she usually relieved herself on the bed pad and then called for staff. Resident #93 said she was not on a toileting program and did not feel the urge to urinate. On 03/30/17 at 10:15 A.M., interview with Licensed Practical Nurse (LPN) #7 confirmed Resident #93 was always incontinent of bladder and bowel and was not on a toileting program. On 03/30/17 at 10:45 A.M., interview with Licensed Practical Nurse (LPN) #5 and the Assistant Director of Nursing (ADON) confirmed Resident #93 had declined from always continent of urine to always incontinent of bowel and bladder. LPN #5 revealed the residents were not assessed for types of incontinence nor were incontinence care plans individualized. The DON confirmed Resident #93's seven day bladder assessments were not completed and a bowel and bladder program was not initiated to prevent a decline. The ADON and LPN #5 reported they were new to their positions and there was lack of communication. The facility was not following up on residents with bowel and bladder declines. The ADON reported starting today she would be responsible to follow up on declines in resident bowel and bladder functions. 3. Review of Resident #127's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #127 was discharged to the hospital on [DATE], returned to the facility on [DATE] and discharged home on[DATE]. Review of Resident #127's MDS 3.0 assessment dated [DATE] indicated the resident was occasionally incontinent of urine and always continent of bowel. Review of Resident #127's MDS 3.0 assessment dated [DATE] indicated the resident was frequently incontinent of urine and always continent of bowel. Review of Resident #127's MDS 3.0 assessment dated [DATE] indicated the resident was frequently incontinent of urine and frequently incontinent of bowel. Review of Resident #127's Bladder Evaluation form dated 11/22/16 indicated the resident was a good candidate for a restorative bowel and bladder program, willing to participate and a program would be initiated. Interview on 03/30/17 at 8:58 A.M. with the DON confirmed Resident #127 was not assessed for the type of urinary incontinence and the urinary continence care plan was not individualized for the resident's urinary or bowel incontinence. Further interview with the DON confirmed Resident #127 was not placed on a restorative bowel or bladder retraining program to improve and prevent further decline in the resident's bowel or urinary continence. 4. Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE], sent to the hospital on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #14's MDS 3.0 assessment dated [DATE] indicated the resident was frequently incontinent of urine and frequently incontinent of bowel. Review of Resident #14's MDS 3.0 assessment dated [DATE] indicated the resident was frequently incontinent of urine and frequently incontinent of bowel. Review of Resident #14's MDS 3.0 assessment dated [DATE] indicated the resident was always incontinent of urine and always incontinent of bowel. Interview on 03/30/17 at 8:18 A.M. with LPN #5 indicated the resident experienced a decline in activities of daily living including urinary and bowel incontinence and the administrative staff were informed. Interview on 03/30/17 at 8:58 A.M. with the DON confirmed Resident #14 was not assessed for the type of urinary incontinence and a urinary incontinence care plan was not individualized for the resident's urinary or bowel incontinence. Further interview with the DON confirmed Resident #14 was not evaluated to determine if the resident was appropriate for a restorative bowel or bladder retraining program to improve and prevent further decline in the resident's bowel or urinary continence.

Based on observation, record review and interview the facility failed to ensure Resident #1, who was totally dependent on two or more staff for transfers, received the necessary assistance to transfer. This affected one resident (Resident #1) of two residents reviewed for transfers. Harm occurred on 08/11/16 at 7:30 P.M., when Resident #1 was transferred from a chair into bed by staff using a sit to stand lift, without a physician's orders [REDACTED]. Findings include: Record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively impaired. The resident was assessed to be totally dependent on two or more staff for transfers, the resident was not steady and only able to stabilize with staff assistance for moving from seated to standing position and moving from surface to surface. Review of the plan of care initiated 01/13/16 revealed the resident had impaired physical mobility due to impaired cognition, weakness, impaired safety awareness, impaired vision, decreased strength and endurance and decreased physical activity. An intervention was for the use of a Hoyer lift for transfers as needed. There was no plan for the use of a sit to stand lift. Review of the physician orders [REDACTED]. There was no order for the use of a sit to stand lift for transfers. Review of the state tested nursing assistant (STNA) kardex revealed an entry dated 01/18/16 that stated, may use Hoyer lift for transfers when needed. There was no other indication how the resident was to be transferred if the Hoyer lift was not utilized. Review of the self reported incident form, tracking number 0, revealed it was determined Resident #1, despite not being able to bear weight, was transferred using a sit to stand lift on 08/11/16 resulting in an acute oblique proximal left humeral fracture with angulation deformity. Further review of the investigation revealed Licensed Practical Nurse (LPN) #58's witness statement dated 08/12/16 indicated on 08/07/16 she assisted an STNA transferring the resident from bed to the wheelchair using the sit to stand lift. Review of STNA #52's witness statement dated 08/12/16 revealed on 08/08/16 the resident was in the wheelchair without the sling (from the Hoyer pad) in the chair. She asked STNA #59 how the resident got out of bed and STNA #59 indicated they had used the sit to stand lift. STNA #52 indicated she transferred the resident back into bed by herself utilizing the sit to stand lift. Review of STNA #54's phone statement, written by the director of nursing (DON)), dated 08/15/16 revealed on 08/11/16 she put the resident back into bed with the sit to stand lift with another STNA. When attempting to transfer the resident she was unable to assist with standing. Her weight was completely resting on the straps of the sit to stand lift. When completing care throughout the night bruising to the upper left arm was noted. When getting the resident up the morning of 08/12/16, the STNA noticed resident #1's arm was swollen and range of motion was decreased. This was reported to the nurse. On 08/26/16 at 1:30 P.M., STNA #51 and LPN #50 were observed transferring Resident #1 with a mechanical (Hoyer) lift. The resident was being transferred from the wheelchair into the bed. During the transfer after the resident was elevated over the bed the resident began to lean out of the sling toward the left side. The resident hit her head on the metal lift bar. LPN #50 and STNA #51 grabbed the resident and lowered her into bed. On 8/26/16 at 1:45 P.M., interview with STNA #53 verified the resident required the use of the mechanical (Hoyer) lift for transfers. On 08/26/16 at 1:50 P.M., interview with STNA #51 verified she utilized the mechanical (Hoyer) lift to transfer the resident. On 08/26/16 at 1:55 P.M., interview with LPN #50 revealed when she would assist STNAs transferring the resident the mechanical (Hoyer) lift was utilized. LPN #50 revealed she did not feel the sit to stand lift would be safe for the resident. She stated she never observed anyone using the sit to stand lift for the resident but stated she heard night shift used it. LPN #50 stated the resident had a restorative sit to stand exercise program and felt maybe the STNAs were confusing this with being able to use the sit to stand lift to transfer the resident. LPN #50 verified in the morning on 08/12/16 STNA #54 came to her to inform her of the residents bruising and swollen left arm. On 08/26/16 at 3:05 P.M., phone interview with STNA #54 verified she worked night shift on 08/11/16 and herself and STNA #56 utilized the sit to stand lift to transfer the resident into bed about 7:30 P.M. The resident was not bearing any weight and she was being held up in the lift by her arm pits, which were hanging over the sling straps. After the resident was transferred into bed bruising was notified on her left shoulder, about the size of a baseball. STNA #54 indicated during her checks on the resident throughout the night the bruising was getting larger, going down the arm and the arm down to the fingers was swelling. STNA #54 revealed she did not report it to the nurse until in the morning after herself and STNA #56 transferred the resident from bed into the wheelchair using the sit to stand lift, at approximately 5:30 A.M. By that time her fingers were swollen like sausages. STNA #54 revealed she used the sit to stand lift because that was the physician order. Sometimes the resident hangs there and was not weight bearing during the transfer and other times she was able to bear some weight. On 08/26/16 at 3:15 P.M., phone interview with STNA #56 revealed she assisted with transferring the resident the evening of 08/11/16 and the morning of 08/12/16 with the sit to stand lift. On 08/26/16 at 3:40 P.M., interview with the DON verified the resident did not have a physician's orders [REDACTED]. The DON verified the investigation determined the resident sustained [REDACTED]. This deficiency substantiates Control Number OH 312.