Every finding on record at Cedarview Care Center

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the medication error log, review of the incident report, staff and resident interview, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #25) out of 22 sampled residents. The facility census was 70. Findings Include: Review of the medical record for Resident #25 revealed an admission date of 10/03/25 with diagnosis including chronic obstructive pulmonary disease, type two diabetes, and chronic pain.Review of the Minimum Data Set (MDS) assessment for Resident #25 dated 01/22/26 revealed the resident had moderate intact cognition. Resident was also assessed to be dependent on staff for activities of daily living (ADLs).Review of the physician's orders for Resident #25 revealed an order dated 11/15/25 to 11/17/25 for oxycodone oral tablet 5 milligrams (mg) one tablet every six hours. Resident #25 had another order dated on 11/18/25 to 12/26/25 for oxycodone hydrochloride oral tablet 5 mg a half tablet (2.5 mg) every six hours.Review of Resident #25's narcotic documentation/log revealed from 11/18/26 to 11/26/26 she received oxycodone oral tablet 5 mg one tablet every six hours instead of the ordered half tablet dose of 2.5 mg.Review of the medication error log revealed the facility had a medication error involving Resident #25 on 11/18/25.Review of the incident report dated 11/26/25 revealed the facility Medical Director and the Director of Nursing (DON) notified and assessed Resident #25 due to being their own responsible party.Interview on 03/18/26 at 5:50 P.M. the DON verified from 11/18/25 to 11/26/25 staff administered oxycodone oral tablet 5 mg one tablet every six hours. The DON stated the facility nurses gave Resident #25 the wrong dose of oxycodone hydrochloride due to not knowing the order changed. The medical provider noticed the error and alerted the facility. The DON stated Resident #25 had 29 wrong doses of oxycodone 5 mg tablets instead of oxycodone oral tablet 5 mg one half tablet (2.5 mg) every six hours.Interview on 03/19/26 at 8:45 A.M Resident #25 verified the facility managed her medications. Review of facility policy titled, Administering Medications dated 02/14/24 revealed 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 deficient practice was corrected on 11/26/25 when the facility implemented the following corrective actions: On 11/26/25, the DON was made aware of a medication error.On 11/26/25, the DON made the Administrator aware of the medication error.On 11/26/25, the DON completed a head to toe assessment on Resident #25 no abnormal findings.On 11/26/25, the DON interviewed Resident #25 who stated, I'm doing good.On 11/26/25, the DON audited all residents receiving narcotics to ensure new orders were transcribed correctly. On 11/26/25, the DON completed education with the Registered Nurses (RNs) and the Licensed Practical Nurses (LPNs) on transcribing medication orders and residents' rights to medication.On 11/28/25, the DON completed a chart audit and any medications needing reorders were reorder and any orders not matching the cart were updated as well as the physician.On or before 11/26/25, the DON/designee educated all staff on the abuse policy, including requirements for reporting abuse.On 11/26/25, the DON/ designee started conducting the following audits:Audit one resident three times a week for four weeks, then once a month for three months. Review of the audits completed revealed no additional errors.There had been no other allegations of medication error per staff towards residents since Resident #25's medication error on 11/18/25.

Based on medical record review, observation, staff interview, review of the facility document Stability of Common Insulins in Vials and Pens, and policy review, the facility failed to ensure the safe storage of insulin. This affected two (Resident #07 and #19 ) out of 17 residents with insulin orders. In addition, the facility failed to ensure ophthalmic medication was labeled with an open date. This affected one (Resident #39) out of 12 residents with ophthalmic orders. The facility census was 70.Findings Include:1. Review of the medical record for Resident #07 revealed an admission date of 01/20/26. Diagnoses included bipolar disorder, diabetes mellitus, and schizophrenia.Review of the minimum data set (MDS) assessment dated [DATE] revealed Resident #07 had severe cognitive impairment and was dependent on staff for activities of daily living (ADL).Review of Resident #07's physician orders revealed an order dated 02/17/26 for Insulin Lispro subcutaneous solution pen-injector 100 unit per milliliter (unit/mL) (insulin Lispro) and insulin glargine subcutaneous solution 100 unit/mL (insulin Lantus).Observation of a medication cart on 03/18/26 at 10:40 A.M with Registered Nurse (RN) #96 revealed Resident #07's Lantus and Lispro insulins had an open date of 02/17/26.Interview on 03/18/26 at 10:41 A.M. RN #96 verified the open date for Resident #07's Lantus and Lispro was 02/17/26 and the medication should have been discarded.2. Review of the medical record for Resident #19 revealed an admission date of 09/19/25. Diagnoses included type two diabetes, seizures, and hyperlipidemia.Review of the MDS assessment dated [DATE] revealed Resident #19 had severe impaired cognition and was dependent on staff for ADLs.Review of Resident #19's current physician orders revealed an order for a NovoLog flex pen subcutaneous solution pen-injector 100 unit/mL (insulin aspart).Observation on 03/18/26 at 10:45 A.M. of the medication cart with RN #96 revealed Resident #19's Novolog had an open date of 02/15/26.Interview on 03/18/26 at 10:50 A.M. RN #96 verified Resident #19's Novolog had an open date of 02/15/26 and the medication should have been discarded.3. Review of the medical record for Resident #39 revealed an admission date of 04/12/24 with diagnosis including amyotrophic lateral sclerosis, chronic allergic conjunctivitis, and presence of intraocular lens.Review of the MDS assessment dated [DATE] revealed Resident #39 had intact cognition and was dependent on staff for ADLs. Review of Resident #19's current physician orders revealed an order for Simbrinza (an eye drop medication to reduce pressure) ophthalmic suspension 1-0.2 percent (%) (Brinzolamide-Brimonidine Tartarte). Observation on 03/18/26 at 10:53 A.M of the medication cart with RN #96 revealed Resident #39's Brinzolamide-Brimonidine Tartrate had no open date.Interview on 03/18/26 at 10:55 A.M. RN #96 verified Resident #39's Brinzolamide-Brimonidine should have an open date and the medication should have been discarded due to not having an open date.Interview on 03/19 at 10:45 A.M. the Director of Nursing (DON) verified Resident #07 and Resident #19's insulins should have been discarded due to expiration and Resident #39's medication should have had an open date.Review of the facility diabetic information titled Stability of Common Insulins in Vials and Pens, updated November revealed Novolog (aspart), Humalog (lispro), and Lantus (glargine) should be discarded in 28 days after being opened.Review of the facility policy titled, Storage of Medications dated April 2019 revealed outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, medical record review, staff interview, and facility policy review, the facility failed to administered medications to residents as ordered. The medication administration observation identified four medication errors out of 39 medications administered for a medication error rate of 10.26 percent. This affected three (#19, #26, and #27) of four residents reviewed for medication administration. The facility census was 70. Findings include: 1. Review of medical records for Resident #19 revealed an admitted d 02/04/23. Diagnoses included multiple sclerosis, peripheral vascular disease, age related cataract bilateral, dry eye syndrome of bilateral lacrimal glands, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was assessed as moderately cognitively impaired. Review of a physician order dated 07/25/24 revealed Resident #19 was ordered Refresh Liquigel Ophthalmic Gel one (1) percent (%) eye drops to instill one drop in both eyes two times a day for dry eyes. 2. Review of medical records for Resident #26 revealed an admitted [DATE]. Diagnoses included acute kidney failure, heart failure, elevation of levels of liver transaminase levels, and cardiac pacemaker. Review of the MDS assessment dated [DATE] revealed Resident #26 was assessed as cognitively intact. Review of a physician order dated 07/14/24 revealed Resident #26 was ordered the combination medication for treatment of hepatitis C, sofosbuvir and velpatasvir 400-100 milligrams (mg) by mouth once daily. 3. Review of medical records for Resident #27 revealed an admitted d of 10/03/21. Diagnoses included epilepsy, agoraphobia with panic disorder, type two diabetes, schizophrenia, and dementia. Review of the MDS assessment dated [DATE] revealed Resident #27 was assessed as cognitively intact. Review of a physician order dated 08/23/22 revealed Resident #27 was ordered Biotene [NAME] Mouth Liquid to give two tablespoons by mouth two times a day for dry mouth for swish and spit. Review of a physician order dated 05/23/24 revealed Resident #27 was ordered the antipsychotic medication Zyprexa five (5) mg by mouth one time a day. Observation on 08/13/24 from 9:14 A.M. through 10:14 A.M. with Registered Nurse (RN) #304 revealed the nurse administered medications to Resident #19, Resident #26, and Resident #27. Observations during medication administration revealed Resident #19 did not receive Refresh 1% eye drops, Resident #26 did not receive sofosbuvir and velpatasvir 400-100 mg, and Resident #27 did not receive her Zyprexa 5 mg and Biotene mouth wash for dry mouth as ordered. Interview on 08/13/24 at 11:49 A.M. with RN #304 confirmed Resident #27 did not receive her Zyprexa 5 mg one tablet with the morning medication pass. RN #304 stated he was sure he gave that medication, and RN #304 looked in the medication cart, and verified Zyprexa 10 mg was in the medication cart, not Zyprexa 5 mg. RN #304 verified he signed off in Resident #27's medication administration record (MAR) as the medication was given. RN #304 also verified Resident #27 did not receive Biotene swish and spit medication because the pharmacy had not delivered it yet. RN #304 also verified he did not administer Refresh tears liquid gel eye drops to Resident #19. RN #304 checked in the medication cart and no Refresh liquid gel eye drops were in the medication cart for Resident #19. RN #304 verified that Resident #26 did not receive the sofosbuvir and velpatasvir 400-100 mg tablet because the pharmacy had the medication on back order. Interview on 08/13/24 at 3:08 P.M. with the Director of Nursing (DON) stated he forgot to get clarification for Resident #26's sofosbuvir and velpatasvir 400-100 mg tablet usage in asking the physician to clarify the diagnosis for the medication ordered by the hospital. The DON stated he reached out to Resident #26's primary care provider today to get the physician's name who ordered medication from the hospital. The DON stated Resident #26 was admitted to the facility on [DATE], and did not have her medication, since pharmacy notified him on 07/30/24 in an email that stated the physician did not put the correct diagnosis on the medication when ordered. The DON stated the pharmacy would not pay for medication. Review of the undated facility policy titled, Administering Medication, revealed the medication must be administered in accordance with the orders, including any required time frame. This deficiency represents non-compliance investigated under Complaint Number OH00155905.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure dependent residents were assisted with repositioning to prevent skin impairment. This affected three (#46, #53, #72) of three residents reviewed for repositioning. The census was 74. Findings included 1. Review of Resident #46's medical record revealed an admitted [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, obstructive uropathy, diabetes, cerebrovascular attack, tracheostomy, gastrostomy, and ventilator dependent. Review of the care plan for Resident #46 dated 01/02/24 revealed the resident was at risk for skin impairment related to immobility. Interventions included to assist to turn and reposition at frequent intervals to provide pressure relief and to offload the hips and sacrum to promote skin integrity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was rarely or never understood. The resident's was assessed as dependent for toileting and for transfers. Observation of Resident #46 on 05/14/24 at 9:40 A.M., 11:45 A.M., 1:05 P.M., and 2:14 P.M. revealed the resident was laying on his back in bed with his position unchanged. 2. Review of Resident #53's medical record revealed an admitted [DATE]. Diagnoses included hypoxic ischemic encephalopathy, aphasic, respiratory failure, tracheostomy, gastrostomy, and ventilator dependent. Review of the quarterly MDS assessment dated [DATE] revealed Resident #53 was rarely or never understood. The resident was dependent for toileting and bed mobility. Review of the care plan dated 03/19/24 for Resident #53 revealed the resident was at risk to develop skin conditions related to fragile skin. Interventions were to encourage and assist to turn every two hours. Observation of Resident #53 on 05/14/24 at 9:38 A.M., 11:47 A.M., 1:04 P.M., and 2:14 P.M. revealed the resident was sitting upright in a geriatric chair with his head leaning over to the left side of the chair. The resident's position was unchanged throughout the observations. 3. Review of Resident #72's medical record revealed an admitted [DATE]. Diagnoses included respiratory failure with hypoxia or hypercapnia, obstructive uropathy, pneumonia, diabetes, and seizure disorder. Review of an admission MDS assessment dated [DATE] for Resident #72 revealed the resident was rarely or never understood. The resident was dependent on toileting and bed mobility. Review of the care plan for Resident #72 dated 04/11/24 revealed the resident was at risk for skin impairment related to immobility. Interventions were to encourage and assist to turn and reposition every two hours and as needed. Observation of Resident #72 on 05/14/24 at 9:43 A.M., 11:48 A.M., 1:05 P.M., and 2:15 P.M. revealed the resident was lying on her back in the bed with her position unchanged. Interview with the State tested Nurse Aide (STNA) #75 on 05/14/24 at 2:21 P.M. stated she shared the hall with STNA #76 and they worked together to complete their jobs. STNA #75 verified she had not had a chance to turn and reposition Resident #46, Resident #53, and Resident #72 on 05/14/24. STNA #75 stated Resident #53 was in his chair when she arrived at 7:00 A.M. and normally they did not lay the resident down until after lunch. Review of the policy titled, Repositioning, dated 05/01/13, revealed the purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed- or chair-bound residents, to prevent skin breakdown, promote circulation and provide pressure relief for residents. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. This deficiency represents non-compliance investigated under Complaint Number OH00153613.

Based on observation, medical record review, staff interview, the facility failed to complete an accurate skin assessment. This affected one (#72) of three residents reviewed for skin assessments. The census was 74. Findings included: Medical record review for Resident #72 revealed an admitted [DATE]. Diagnoses included respiratory failure with hypoxia or hypercapnia, obstructive uropathy, pneumonia, diabetes, and seizure disorder. Review of the admission Minimum Data Set (MDS) assessment for Resident #72 revealed the resident was rarely/never understood. The resident was dependent on toileting and bed mobility, was assessed with an indwelling catheter, was always incontinent for bowel, and was dependent on a tracheostomy and a ventilator. Review of a skin assessment dated [DATE] at 11:40 A.M. for Resident #72 documented by Licensed Practical Nurse (LPN) #77 revealed there was not documentation in the skin assessment grid for any new areas of skin impairment. Review of Resident #72's physician orders and progress notes dated 05/14/24 revealed no reports of new skin issues. Observation of Resident #72's skin with State tested Nurse Aide (STNA) #75 and STNA #76 on 05/14/24 at 2:30 P.M. revealed under the resident's left armpit was and area of bright red excoriation and the resident's feet were dry and scaly from the bottom up half way on each foot. Interview with LPN #77 on 05/14/24 at 3:25 P.M. stated she documented a skin assessment for Resident #72 on 05/14/24 at 11:40 A.M. and documented the assessment as completed. LPN #77 stated there was only some redness on the Resident #72's bottom and under her right armpit and did not find anything else. Observation of Resident #72's skin during the interview on 05/14/24 at 3:25 P.M. with LPN #77 revealed she knew about the excoriation under the resident's left armpit, but did not write a note in the skin assessment or in the progress notes about the findings and stated she did not know about the resident's feet being scaly and dry.

Based on observation, staff interview, and policy review, the facility failed to ensure foods were stored in a manner to protect against the potential spread of food-borne illness. This had the potential to affect all 59 residents who received food from the kitchen. The facility identified 13 residents who were NPO (nothing by mouth) and did not receive food from the kitchen. The facility census was 72. Findings include: Observation on 04/18/24 at 1:16 P.M., revealed the refrigerator on the facility's C-hall contained 10 unlabeled containers, each containing unidentified substances. None of the containers were labeled nor dated. Additionally, there was a sandwich, which was loosely wrapped in a plastic sandwich bag, unsealed, unlabeled, and undated. Further observation revealed the refrigerator did not contain a thermometer, nor was any type of temperature log. Interview at the same time of the observation, with Registered Nurse (RN) #375 verified the 10 containers were unlabeled and undated and all foods in the refrigerator should be labeled and dated. RN #375 stated she thought five of the containers were ambrosia, however, she was unsure of the contents of the other containers. RN #375 verified the sandwich was not sealed, labeled, nor dated and stated the sandwiches are normally all kept in a large Ziploc back together which would be labeled and dated. RN #375 further verified the refrigerator did not have a thermometer and there was no temperature log. RN #375 stated refrigerator temperatures should be checked and recorded on each shift. Review of the policy titled, Food Receiving and Storage, dated October 2017, revealed all foods stored in the refrigerator will be covered, labeled, and dated with a use by date. Refrigerators must have working thermometers and be monitored for temperature according to state-specific guidelines.

Based on medical record review, staff interview, and policy review, the facility failed to ensure the physician was notified of a change in condition. This affected one (#22) of five residents reviewed for nutrition. The facility census was 72. Findings include: Review of the medical record of Resident #22 revealed an admitted [DATE]. The resident transferred to the hospital on 01/31/24 and readmitted to the facility on [DATE]. Diagnoses included end-stage renal disease, chronic diastolic heart failure, fluid overload, pulmonary embolism, chronic obstructive pulmonary disease, chronic respiratory failure, and obstructive sleep apnea. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident required setup assistance with eating, partial/moderate assistance with personal hygiene, sitting to lying, and rolling from side to side in bed, substantial/maximal assistance for lying to sitting on side of bed, and was dependent on staff for toileting, sit to stand, Review of physician orders revealed an order dated 02/08/24 for the resident to be weighed daily and to report an increase or decrease of three pounds. Review of the medication administration record revealed on 02/08/24, the resident weighed 245.3 pounds and on 02/09/24, the resident weighed 266.8 pounds. Review of a Dietary/Nutrition Progress note dated 02/11/24, revealed a reweigh would be requested. Further of the medical record revealed no progress notes addressing the change in Resident #22's weight. Interview on 04/18/24 at 1:04 P.M., the Director of Nursing (DON) verified there was no documentation in Resident #22's medical record regarding the 21 pound change in weight or the physician being notified. Review of the policy titled, Change in a Resident's Condition or Status, dated May 2017, revealed the nurse will notify the resident's attending physician or physician on-call when there is specific instruction to notify the physician of changes in the resident's condition.

Based on medical record review, review of the Resident Assessment Instrument (RAI) User Manual, review of the facility's Minimum Data Set (MDS) Completion and Submission Timeframe's policy and procedure, and staff interview, the facility failed to ensure MDS discharge assessment was completed within 14 days of discharge. This affected one (#60) of one resident reviewed for MDS discharge assessments. The facility census was 72. Findings include: Review of the medical record for Resident #60 revealed an admitted [DATE], with diagnoses of schizoaffective disorder, anxiety disorder, polysubstance abuse, and nicotine addiction. Resident #60 was discharged on [DATE]. Review of the MDS assessment dated [DATE] revealed Resident #60 is cognitively intact. The resident is independent for ambulation, transfers, dressing, and toileting, requires set up assistance for eating, oral and personal hygiene, and supervision with bathing. Review of the MDS discharge assessment for Resident #60 revealed a completion date of 04/17/24. Resident #60 was discharged on [DATE]. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual revealed the discharge assessment is to be completed no later than 14 days after discharge. Review of the facility's undated MDS Completion and Submission Timeframe's policy and procedure revealed the discharge assessment, return not anticipated, is to be completed no later than 14 calendar days after discharge date . Interview on 04/18/24 at 9:37 A.M., with MDS Coordinator #324 confirmed Resident #60 discharged on [DATE] and MDS discharge assessment was not completed until 04/17/24. MDS Coordinator #324 confirmed the timeline for completion of the MDS discharge assessment is 14 days from date of discharge.

Based on medical record review, review of the Resident Assessment Instrument (RAI) User Manual, review of the facility's Minimum Data Set (MDS) Completion and Submission Timeframe's policy and procedure, and staff interviews, the facility failed to ensure MDS assessments were transmitted within 14 days of completion date. This affected three (#25, # 50, and #59) of three residents reviewed for MDS assessment submissions. The facility census was 72. Findings include: 1. Review of the medical record for Resident #25 revealed an admitted [DATE], with diagnoses of Alzheimer's disease, bi-polar disorder, schizoaffective disorder, anxiety disorder, and alcohol abuse. Review of the MDS assessment dated [DATE] revealed Resident #25 is cognitively intact. Resident #25 is independent for mobility with no devices, transfers, toileting, dressing, requires set up assistance for eating and oral hygiene, and supervision for showering and personal hygiene. Review of MDS assessments for Resident #25 revealed a MDS quarterly assessment dated [DATE] was completed on 03/28/24 and transmitted on 04/14/24. 2. Review of the medical record for Resident #50 revealed an admitted [DATE], with diagnoses of cerebrovascular accident with right sided hemiplegia, alcohol abuse, chronic pain syndrome, seizure disorder, coronary artery disease, congestive obstructive pulmonary disease, and diabetes mellitus type II with neuropathy. Review of the MDS assessment dated [DATE] revealed Resident #50 is cognitively intact. The resident is not ambulatory and uses a wheelchair for mobility, requires partial assistance for toileting, bathing, personal hygiene, dressing, and moderate assistance for transfers. Review of MDS assessments for Resident #50 revealed a MDS quarterly assessment dated [DATE] was completed on 03/26/24 and transmitted on 04/14/24. 3. Review of the medical record for Resident #59 revealed an admitted [DATE], with diagnoses of Wernicke's encephalopathy, depression, post-traumatic stress disorder (PTSD), anxiety disorder, and alcohol abuse. Review of the MDS assessment dated [DATE] revealed Resident #59 is cognitively intact. The resident is independent for mobility with no devices, transfers, dressing, requires supervision for bathing and personal hygiene, and set up assistance for eating, oral hygiene, and toileting. Review of MDS assessments for Resident #59 revealed a MDS quarterly assessment dated [DATE] was completed on 01/26/24 and transmitted on 02/12/24. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual revealed the MDS quarterly assessment is to be transmitted within 14 days after completion. Review of the undated facility's MDS Completion and Submission Timeframe's policy and procedure revealed the MDS quarterly assessment is to be transmitted within 14 calendar days after completion. Interview on 04/16/24 at 2:52 P.M., with the Administrator and MDS Coordinator #324 confirmed the MDS quarterly assessment for Resident #25 dated 03/14/24 was completed 03/28/24 and transmitted 04/14/24; confirmed the MDS quarterly assessment for Resident #50 dated 03/12/24 was completed 03/26/24 and transmitted 04/14/24; and confirmed the MDS quarterly assessment for Resident #59 dated 01/12/24 was completed on 01/26/24 and transmitted 02/12/24. The Administrator and MDS Coordinator #324 confirmed the transmission date to submit these MDS quarterly assessments for Residents #25, #50, and #59 exceeded the 14-day timeline.

Based on medical record review and staff interviews, the facility failed to notify the state mental health authority of a significant change in condition for residents with mental disorders. This affected two (#9 and #49) of five residents reviewed for Pre-Admission Screening and Resident Review, (PASARR) admission process. The total facility census was 72. Findings include: 1. Review of Resident #49's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #49 include dementia, encephalopathy, major depressive disorder and anxiety disorder. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and was dependent on staff for self-care and mobility. Review of Resident #49's physician orders revealed the resident had orders for hospice service beginning on 07/27/23. Record review of Resident #49 revealed no Pre-admission Screening and Resident Review, (PASARR) within 14 days of a significant change in condition on 07/27/23. 2. Review of Resident #9's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #9 include dementia, major depressive disorder, edema, bipolar disorder, schizoaffective disorder, hypertension, tachycardia, pacemaker, and heart failure. Review of the MDS comprehensive assessment dated [DATE] revealed the Resident #9 had moderately impaired cognition and required supervision with self-care, was dependent on care for toileting and bathing, and total dependent for care with mobility. Review of Resident #9's physician orders revealed the resident had orders for hospice services beginning on 12/29/23 and beginning on 03/23/24. Review of Resident #9's medical record revealed no Pre-admission Screening and Resident Review, (PASARR) within 14 days of a significant change in condition on 12/29/23 and on 03/23/24. Interview on 04/18/24 at 1:26 P.M., with Business Office Manager (BOM) #371 and Social Service Designee (SD) #375 verified Resident #49 and Resident #9 had a significant change in condition when accepting hospice services. BOM #371 stated the facility should have completed a revised PASARR and reported the significant change to the state mental health board within 14 days of the change to hospice services.

Based on observation, staff interview, medical record review,and policy review, the facility failed to ensure the plan of care reflected the fluid restriction as ordered by the physician. The affected one (#61) of one resident reviewed for fluid restriction. The total facility census was 72. Findings include: Review of Resident #61's medical record revealed the resident was admitted to the facility on [DATE] . Diagnoses for Resident #61 include acute respiratory failure with hypoxia, dementia, chronic gastric ulcer, malnutrition, dependence on oxygen, and heart failure. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE], revealed the resident had impaired cognition and required moderate assistance with mobility and supervision assistance with feeding self. Review of physician orders dated 01/30/24 revealed orders for No Added Salt diet, nutritional supplement two times a day. Orders also included a fluid restriction 2000 cubic centimeters (cc) per day and document every shift. Review of Resident #61's Plan of Care on 04/16/24 revealed no fluid restriction or division of the fluid between department throughout a 24-hour period. Review of Resident #61's Plan of Care revealed a fluid restriction of 2000 cc with 360 cc breakfast, 360 cc at lunch, 360 cc at dinner and 920 cc for nursing was added to the Plan of Care on 04/17/24 by MDS Coordinator #324. Observation on 04/16/24 of the lunch meal and 04/17/24 breakfast meal, revealed Resident #61's meal ticket at breakfast and at lunch revealed no fluid restriction documented on the meal ticket. Observation of the breakfast meal of 04/17/24, revealed the resident had large containers of fluid greater than 480 cc and 240 cc of dark fluid at bedside, 480 cc fluid on the meal tray and 240 cc of supplement. Interview on 04/17/24 at 8:57 A.M., with State tested Nurse Assistant (STNA) #340 stated Resident #61 had no fluid restrictions and consumed a lot of soda and water. There was no knowledge Resident #61 had an order for fluid restrictions or the amount permitted for the nursing department. Interview on 04/17/24 at 9:12 A.M., with STNA #339 verified Resident #61 had no fluid restriction on her meal ticket and no fluid restriction listed in the plan of care for fluid restriction. STNA #339 verified there was no plan of care to indicate Resident #61 was on a fluid restriction. Interview on 04/17/24 at 12:45 P.M., with Dietary Manger (DM) #311 verified there had been no notification to the dietary department Resident #61 was on a fluid restriction. DM #311 verified the Dietary Department should have been notified of the fluid restriction and the fluid amounts allotted to the dietary and nursing departments. Interview on 04/17/24 at 12:55 P.M., with the MDS Coordinator #324 verified the STNAs and the dietary staff did not know of Resident #6's a fluid restriction order because the Plan of Care had not included the fluid restriction order and intervention. The MDS Coordinator #324 verified the fluid restriction, and the division of the fluids should have been included in the Plan of Care and on the dietary meal ticket to coordinate the fluid division between departments. Interview on 04/18/24 at 6:41 A.M., with night shift STNA #384 verified a fluid restriction intervention was added to Plan of Care for STNAs on 04/17/24. Prior to 04/17/24, STNA #384 was unaware Resident #61 had an order for a fluid restriction and the amount allotted for the nursing department. Review of the policy, titled, Encouraging and Restricting Fluids, dated October 2010, revealed when a resident is on restricted fluid remove fluids from the room. Review the resident care plan and the daily assignment sheet to assess for any special needs of the resident.

Based on observations, medical record review, resident interview, and staff interview, the facility failed to ensure physician orders were followed for assistive devices to prevent further contracture. This affected one (#52) of two residents reviewed for limited range of motion. The facility census was 72. Findings include: Review of the medical record of Resident #52 revealed an admitted [DATE]. The resident transferred to the hospital on 03/15/24 and returned to the facility on [DATE]. Diagnoses included encephalopathy, anxiety, hypothyroidism, depression, chronic obstructive pulmonary disease, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had moderately impaired cognition. The resident was assessed as having impaired range of motion to all extremities. The resident was dependent on staff for all activities of daily living. Observation and interview on 04/15/24 at 10:05 A.M., revealed both of Resident #52's hands were contracted. Resident #52 stated she was supposed to have wash cloths put in her hands but staff were not doing it consistently. Review of physician orders revealed an order dated 04/02/24 to apply bilateral towel rolls in palm for seven hours daily, on at 11:00 A.M. and off at 6:00 P.M. Observation on 04/16/24 at 1:20 P.M., revealed Resident #52 did not have wash cloths in either hand. Observation on 04/16/24 at 3:50 P.M., revealed Resident #52 did not have wash cloths in either hand. Interview on 04/16/24 at 3:51 P.M., with, Registered Nurse (RN) #304 verified Resident #52 did not have wash cloths in her hands as per the order. RN #304 stated he was not aware they were not in her hands and thought the aids had put them in. RN #304 verified the wash cloths should be worn daily between 11:00 A.M. and 6:00 P.M.

Based on medical record review, staff interview, review of the Resident Assessment Instrument (RAI), and policy review, the facility failed to ensure a resident's significant weight loss was addressed in an accurate and timely manner. This affected one (#42) of three residents reviewed for weight loss. The facility also failed to ensure weights were completed per the physician's order. This affected two (#09 and #22) of five residents reviewed for nutrition. The facility census was 72. Findings include: 1. Review of the medical record of Resident #42 revealed an admitted [DATE]. Diagnoses included huntington's disease, mood disorder due to known physiological condition with depressive features, schizophrenia, and schizoaffective disorders. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had intact cognition. The resident exhibited delusions during the assessment period. Review of the medical record revealed, on 10/08/23, Resident #42 weighed 160.2 pounds. On 11/21/23, the resident weighed 157 pounds. On 01/02/24, the resident weighed 155.2 pounds. On 02/14/24, the resident weighed 152.8 pounds. On 03/04/24, the resident weighed 148.2 pounds. On 04/01/24, the resident weighed 144.2 pounds. Review of the care plan dated 03/02/24 revealed Resident #42 had a nutritional problem due to diagnoses of Huntington's Disease, schizophrenia, mood disorder. The resident received boost twice per day and remeron. On 03/02/24, the Resident #42's weight was described as stable. Review of current physician orders revealed an order dated 11/22/23 for Boost (oral supplement) twice daily with breakfast and supper. Review of meal intakes for the past 30 days revealed the resident consumed 75-100% of most meals. Review of a diet progress note dated 03/02/24 revealed Diet Technician Registered (DTR) #501 indicated Resident #42 received a regular diet with meal intakes of 75-100% at most meals and Boost twice a day. The resident weighed 152.8 pounds. The resident received Mirtazapine (remeron), which may promote appetite. No new recommendations were made at that time. Further review of the medical record revealed no indication of Resident #42's 4.6 pound weight loss from 03/04/24 being addressed and an additional four pound loss on 04/01/24 being addressed. Interview on 04/18/24 at 1:56 P.M., Diet Technician Registered (DTR) #501 stated, in a perfect world, weights would be addressed within a week, however, she worked at several buildings and had not been able to review weights obtained 18 days prior to the interview. DTR #501 stated Resident #42's weight loss was technically 9.9%, however the weight loss trend warranted being looked at. Review of DTR's method of calculating percent weight loss was taking the exact weight from 6 months prior (160.2 pounds), subtracting the exact current weight (144.2 pounds), dividing by the exact weight from 6 months prior (160.2 pounds), and multiplying by 100. DTR #501 verified Resident #42 had been on the same diet and supplement order since November 2023 and had lost 13 pounds since the last time any changes to his regimen were made. DTR #501 further verified she had not addressed the 4.6 pound loss from 03/04/24 nor the additional 4 pound loss from 04/01/24. Review of the Resident Assessment Instrument (RAI), section K, revealed the method for determining significant weight loss was to use mathematical rounding (ie if the weight is X.1 to X.4 pounds, round down to the nearest whole pound). For example, a weight of 152.4 pounds would be rounded to 152 pounds. Further review of Resident #42's weight loss, revealed the resident had a 10% weight loss (160 minus 144, divided by 160, multiply by 100) during the last 6 months. Interview on 04/18/24 at 2:19 P.M., the Director of Nursing (DON) stated the expectation would be for weights to be reviewed and addressed by the Registered Dietitian or DTR within seven days. The DON stated DTR #501 typically came to the facility on ce a week. Review of the policy titled, Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol, dated September 2012, revealed a 10% weight loss in a six month period is severe and the physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Monitoring is also required for residents whose nutritional status is stable, including observing for and reporting significant weight loss. 2. Review of the medical record of Resident #22 revealed an admitted [DATE]. Diagnoses included end-stage renal disease, chronic diastolic heart failure, fluid overload, pulmonary embolism, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had moderately impaired cognition. Review of physician orders revealed a current order, dated 03/04/24 for weekly weights and to notify the physician if greater than 5 pound weight gain and additional orders dated 02/08/24 to 02/26/24 for daily weights-report an increase or decrease of three pounds. Review of the medical record revealed the following weights: 04/06/24-235 pounds, 03/04/24- 247.5 pounds, 02/09/24- 266.8 pounds, 02/08/24- 245.3 pounds, and 02/07/24- 245.3 pounds. Review of progress notes and the medication administration record revealed the resident refused to be weighed on 02/10/24, 02/11/24, 02/13/24, 02/14/24, 02/15/24, 02/20/24, 02/21/24 02/22/24. Review of the medical record revealed no documentation of any weight or refusal to be weighed on 02/12/24, 02/16/24, 02/17/24, 02/18/24, 02/19/24, 02/23/24, 02/24/24, 02/25/24, 02/26/24, 03/11/24, 03/18/24, 03/25/24, 04/01/24, 04/08/24, and 04/15/24. Interview on 04/18/24 at 10:30 A.M., Registered Dietitian (RD) #503 verified Resident #22's daily weights were not documented in February 2024 and weekly weights were not documented in March 2024 and April 2024. RD #503 stated weights completed are entered into the electronic medical record. Review of the policy titled, Weight Assessment and Intervention, dated March 2022, revealed weights are obtained at intervals established by the interdisciplinary team and recorded in the individual's medical record 44083 3. Review of Resident #9's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #9 include dementia, edema, hypertension, tachycardia, pacemaker, and heart failure. Review of the MDS comprehensive assessment dated [DATE] revealed the Resident #9 had moderately impaired cognition and required supervision with self-care, was dependent on care for toileting and bathing, and total dependent for care with mobility. Review of Resident #9 Plan of Care, dated 09/09/22, revealed the resident had edema to bilateral extremities with expected weight fluctuations. Review of physician orders revealed Resident #9 had orders for hospice service for two hospice periods, beginning on 12/29/23 and then again on 03/23/24. Resident #9 had a physician order, dated 02/25/24, to weigh the resident every morning related to congestive heart failure. The resident received Furosemide tablet 40 milligrams (mg) one time a day related to heart failure and Digoxin tablet 125 micro grams (mcg) one time a day related to atrial fibrillation. Review of Resident #9's weight record from 02/25/24 through 04/15/24 revealed missing weights on dates of 04/01/24, 04/02/24, 04/03/24, 04/04/24, 04/07/24, 04/08/24, 04/09/24, 04/10/24, 4/14/24, 04/15/24, 03/02/24, 03/03/24, 03/05/24, 3/07/24, 03/08/24, 03/09/24, 03/10/24, 03/11/24, 03/12/24, 03/13/24, 03/14/24, 03/15/24, 03/16/24,03/17/24, 03/08/24, 03/18/24, 03/19/24, 03/20/24, 03/21/24, 03/22/24,03/23/24, 03/24/24, 03/25/24, 03/26/24, 03/28/24, 03/29/24,03/30/24, 03/31/24, 02/26/24 and 02/29/24. Interview on 04/18/24 at 10:34 A.M., with RD #503 verified Resident #9 had a physician order for daily weight every morning to monitor congestive heart failure. RD #503 verified Resident #9's daily weights were not documented in the weight record log. RD #503 stated she had not been informed if Resident #9 had refused to be weighed daily and daily weights should be documented in the electronic medical record.

Based on observation, record review, and staff interview, the facility failed to ensure the oxygen tubing was changed and dated as ordered by the physician. This affected for two (#19 and #61) of two residents reviewed for oxygen administration orders. The total facility census was 72. Findings include: 1. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #19 include dementia, Down syndrome, chronic respiratory failure, and pseudobulbar affect. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE], revealed the resident had severely impaired cognition and required supervision of self-care and maximal assistance for mobility. Review of physician orders revealed Resident #19 was to receive oxygen two to four liters to keep oxygen saturation above 88 percent and oxygen tubing changed, label and date every Wednesday. Observation on 04/15/24 at 8:30 A.M., revealed Resident #19 oxygen tubing was not dated. Interview on 04/15/24 at 8:32 A.M., with Licensed Practical Nurse (LPN) #356 and State tested Nurse Aide(STNA) #330 verified Resident #19 oxygen tubing was not dated. 2. Review of Resident #61's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #61 include acute respiratory failure with hypoxia, dementia, chronic gastric ulcer, malnutrition, dependence on oxygen, and heart failure. Review of Resident #61's MDS comprehensive assessment dated [DATE], revealed the resident had impaired cognition and required moderate assistance with mobility and supervision assistance with feeding self. The resident was assessed to be short of breath with exertion, sitting at rest and when lying flat. The resident required continuous oxygen therapy. Review of physician orders dated 01/30/24 revealed Resident #61 was to receive continuous oxygen at three liters to keep saturation above 92 percent and to change oxygen tubing every Tuesday. Observation on 04/15/24 at 8:31 A.M., revealed Resident #61 oxygen tubing was not dated. Interview on 04/15/24 at 8:32 A.M., with LPN #356 and STNA #330 verified Resident #61 oxygen tubing was not dated. Interview on 04/17/24 at 2:17 P.M., with the Director of Nursing, (DON), verified Resident #19 and Resident #61 had physician orders for oxygen tubing to be changed weekly. The DON stated a contract company is to change and date to the oxygen tubing weekly and may have forgotten to date the tubing.

Based on observation and staff interview, the facility failed to provide full visual privacy for resident. This affected for two (#48 and #61) of three residents reviewed for physical environment. The total facility census was 72. Findings include: 1. Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #48 include acute respiratory failure, schizoaffective disorder, bipolar disorder, anxiety disorder, and depressive disorder. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE], revealed the resident had intact cognition and was dependent on staff for self-care and mobility. Observation on 04/15/24 at 8:32 A.M., revealed Resident #48 had no privacy curtain which prohibited full privacy around the entire bed. Resident #48 had a roommate. Interview on 04/15/24 at 8:32 A.M., with Licensed Practical Nurse (LPN) #356 and State tested Nurse Assistant(STNA) #330 verified Resident #48 had no privacy curtain and full privacy could not maintained while providing care. 2. Review of Resident #61's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #61 include acute respiratory failure with hypoxia, dementia, chronic gastric ulcer, malnutrition, dependence on oxygen, and heart failure. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had impaired cognition and required moderate assistance with mobility and supervision assistance with feeding self. Observation on 04/15/24 at 8:32 A.M., revealed Resident #61 had an privacy curtain ceiling track railing which was coming lose from the ceiling and had no privacy curtain. This prevented full visual privacy around Resident #61's bed. Resident #61 had a roommate. Interview on 04/15/24 at 8:32 A.M., with Licensed Practical Nurse (LPN) #356 and State tested Nurse Aide (STNA) #330 verified Resident #61's privacy curtain track was coming lose from the ceiling and had no privacy curtain. Full privacy could not maintain while providing care. Interview on 04/18/24 at 7:18 A.M., Housekeeping Director #401 verified double occupied resident rooms of Residents #48 and #61 had no privacy curtains on 04/15/24, which could not provide privacy for Residents #48 and #61.

Based on record review and staff interview, the facility failed to post nurse staffing information that included the total number worked daily of Registered Nurses, Licensed Practical Nurses, and State tested Nurse Aides. This had the potential to affect all 72 residents in the building. The census was 72. Findings include: Observation on 04/17/24, revealed the Nursing Staffing posting did not include the number of Registered Nurses (RN), Licensed Practical Nurses (LPN), and State tested Nurse Aides (STNA) that were working. Review of the daily staffing posting from 03/01/24 to 04/17/24 revealed all the nursing staff postings sheets were missing the number of Registered Nurses (RN), Licensed Practical Nurses (LPN), and State tested Nurse Aides (STNA) that worked. Interview on 04/18/24 at 12:43 P.M., with the Administrator verified the staffing posting did not show the number of working RN, LPN, or STNA.

Based on staff interview, medical record review, and review of pharmacy board website, the facility failed to administer parenteral fluids per professional standards when they allowed a company who was not licensed in Ohio by the State Pharmacy Board to administer dangerous intravenous (IV) fluid medications to residents. This affected three (Resident #46, #48 and #65) of three reviewed for pharmacy services. The facility identified 13 former residents, (Residents #70,#71,#72,#73,#74,#75,#76,#77,#78,#79,#80,#81 and #82) and 32 residents who currently reside in the facility, (Residents #65,#2,#3,#5,#7,#10,#11,#48,#12,#15,#17,#18,#19,#21,#23,#26,#46, #28,#30,#31,#33,#38,#41,#42,#45,#51,#55,#57,#60,#62,#63,and #64) who received intravenous fluids through the unlicensed company. The facility census was 65. Findings include: 1. Record review of Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #46 include pressure ulcer, diabetes, and surgical amputation. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #46's physician orders revealed orders dated 05/16/23, 06/08/23, 07/07/23, and 08/15/23 for IV Company #700 hydration therapy for infection infusion at 250 milliliter per hour (ml/hr). Review of Resident #65 physician orders dated 04/14/23 and 09/6/23 for IV Company #700 hydration therapy for infection infusion at 500 ml/hr. 2. Record review of Resident #48 revealed the resident was admitted to the facility on [DATE] . Diagnoses for Resident #48 include pressure ulcer, paraplegia and schizophrenia. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #48's physician orders revealed orders dated 05/16/23, 06/08/23, 07/07/23, and 08/15/23 for IV Company #700 hydration therapy for infection infusion at 250 ml/hr. Review of Resident #65 physician order dated 04/14/23 for IV Company #700 hydration therapy for infection infusion at 500 ml/hr. 3. Record review of Resident #65 revealed the resident was admitted to the facility on [DATE] . Diagnoses for Resident #65 include dementia, paranoid schizophrenia, and Parkinson Disease. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition. Review of Resident #65's physician orders revealed orders dated 05/16/23, 06/08/23, 07/08/23, and 08/15/23 for IV Company #700 hydration therapy for cognitive infusion at 250 milliliter per hour (ml/hr). Review of Resident #65 physician orders dated 04/14/23 and 09/6/23 for IV Company #700 hydration therapy for cognitive infusion at 500 ml/hr. Review of the Ohio State Pharmacy Board website on 12/01/23 revealed IV Company #700 company did not have a valid license to dispense dangerous drugs in Ohio. Interview with Assistant Director of Nursing, (ADON) #200 on 12/01/23 at 10:25 AM. revealed she found out from corporate they were going to try this IV program to enhance quality of life for residents with weight loss, wounds, or hydration issues. There were different types of nutritional IV bags for skin and hydration. ADON #200 stated she completed the resident IV assessment, and contacted the facility physicians, who wrote an order for IV Company #700 services. IV Company #700's nurse administered the IV fluids, which consisted of vitamins, supplements, and hydration. The last infusion month was September 2023 and ADON #200 was unsure why the corporate stopped services. IV Company #700's nurse brought all supplies, ran the IV administration, completed documentation and took all supplies when they left. Interview with Director of Nursing, (DON) on 12/01/23 at 10:30 A.M. verified IV Company #700 did not have a Ohio State Pharmacy Board license to dispense dangerous drugs in Ohio and the facility was unaware of that at the time of IV administrations from April 2023 to September 2023. A phone interview with Ohio State Pharmacy Board Worker #300 on 12/01/23 at 9:15 A.M. revealed IV Company #700 was not licensed in Ohio to dispense dangerous medications such as intravenous (IV) fluids. Review of past noncompliance documentation revealed the facility had education on 11/21/23 titled TDDD Licensure Education undated. There was a sign in sheet, with no presenter listed, signatures of the facility managers and the Medical Director, via phone. The education material did not include a designated facility staff person or position to ensure new drug companies held a valid license with the Ohio State Board of Pharmacy and to ensure license renewals were current. Interview on 12/01/23 at 3:15 P.M. the Regional Nurse #400 and the DON verified the education presented to the facility mangers on 11/21/23 titled, TDDD Licensure Education, did not indicate who was responsible to ensure the drug companies held a current and valid license with the Ohio State Board of Pharmacy. This deficiency represents non-compliance investigated under Complaint Number OH00148183.

Based on staff interview, medical record review, and review of pharmacy board website, the facility failed to provide pharmaceuticals services that assure the accurate acquiring, receiving, and dispensing of drugs when they allowed a company who was not licensed in Ohio by the State Pharmacy Board to administer dangerous intravenous (IV) fluid medications. This affected three (Resident #46, #48 and #65) of three reviewed for pharmacy services. The facility identified 13 former residents, (Residents #70,#71,#72,#73,#74,#75,#76,#77,#78,#79,#80,#81 and #82) and 32 residents who currently reside in the facility, (Residents #65,#2,#3,#5,#7,#10,#11,#48,#12,#46,#15,#17,#18,#19,#21,#23,#26,#28,#30,#31,#33,#38,#41,#42,#45,#51,#55,#57,#60,#62,#63,and #64) who received intravenous fluids through the unlicensed company. The facility census was 65. Findings include: 1. Record review of Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #46 include pressure ulcer, diabetes, and surgical amputation. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #46's physician orders revealed orders dated 05/16/23, 06/08/23, 07/07/23, and 08/15/23 for IV Company #700 hydration therapy for infection infusion at 250 milliliter per hour (ml/hr). Review of Resident #65 physician orders dated 04/14/23 and 09/6/23 for IV Company #700 hydration therapy for infection infusion at 500 ml/hr. 2. Record review of Resident #48 revealed the resident was admitted to the facility on [DATE] . Diagnoses for Resident #48 include pressure ulcer, paraplegia and schizophrenia. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #48's physician orders revealed orders dated 05/16/23, 06/08/23, 07/07/23, and 08/15/23 for IV Company #700 hydration therapy for infection infusion at 250 ml/hr. Review of Resident #65 physician order dated 04/14/23 for IV Company #700 hydration therapy for infection infusion at 500 ml/hr. 3. Record review of Resident #65 revealed the resident was admitted to the facility on [DATE] . Diagnoses for Resident #65 include dementia, paranoid schizophrenia, and Parkinson Disease. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition. Review of Resident #65's physician orders revealed orders dated 05/16/23, 06/08/23, 07/08/23, and 08/15/23 for IV Company #700 hydration therapy for cognitive infusion at 250 milliliter per hour (ml/hr). Review of Resident #65 physician orders dated 04/14/23 and 09/6/23 for IV Company #700 hydration therapy for cognitive infusion at 500 ml/hr. Review of the Ohio State Pharmacy Board website on 12/01/23 revealed IV Company #700 company did not have a valid license to dispense dangerous drugs in Ohio. Interview with Assistant Director of Nursing, (ADON) #200 on 12/01/23 at 10:25 AM. revealed she found out from corporate they were going to try this IV program to enhance quality of life for residents with weight loss, wounds, or hydration issues. There were different types of nutritional IV bags for skin and hydration. ADON #200 stated she completed the resident IV assessment, and contacted the facility physicians, who wrote an order for IV Company #700 services. IV Company #700's nurse administered the IV fluids, which consisted of vitamins, supplements, and hydration. The last infusion month was September 2023 and ADON #200 was unsure why the corporate stopped services. IV Company #700's nurse brought all supplies, ran the IV administration, completed documentation and took all supplies when they left. Interview with Director of Nursing, (DON) on 12/01/23 at 10:30 A.M. verified IV Company #700 did not have a Ohio State Pharmacy Board license to dispense dangerous drugs in Ohio and the facility was unaware of that at the time of IV administrations from April 2023 to September 2023. A phone interview with Ohio State Pharmacy Board Worker #300 on 12/01/23 at 9:15 A.M. revealed IV Company #700 was not licensed in Ohio to dispense dangerous medications such as intravenous (IV) fluids. Review of past noncompliance documentation revealed the facility had education on 11/21/23 titled TDDD Licensure Education undated. There was a sign in sheet, with no presenter listed, signatures of the facility managers and the Medical Director, via phone. The education material did not include a designated facility staff person or position to ensure new drug companies held a valid license with the Ohio State Board of Pharmacy and to ensure license renewals were current. Interview on 12/01/23 at 3:15 P.M. the Regional Nurse #400 and the DON verified the education presented to the facility mangers on 11/21/23 titled, TDDD Licensure Education, did not indicate who was responsible to ensure the drug companies held a current and valid license with the Ohio State Board of Pharmacy This deficiency represents non-compliance investigated under Complaint Number OH00148183.

Based on staff interview, medical record review, and pharmacy board website review, the facility failed to ensure an outside Intravenous (IV) company (IV Company #700) had a proper license to provide services to residents. This affected three (Resident #46, #48 and #65) of three reviewed for pharmacy services. The facility identified 13 former residents, (Residents #70,#71,#72,#73,#74,#75,#76,#77,#78,#79,#80,#81 and #82) and 32 residents who currently reside in the facility, (Residents #65,#2,#3,#5,#7,#10,#11,#48,#46, #12,#15,#17,#18,#19,#21,#23,#26,#28,#30,#31,#33,#38,#41,#42,#45,#51,#55,#57,#60,#62,#63,and #64) who received intravenous fluids through the unlicensed company. The facility census was 65. Findings include: 1. Record review of Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #46 include pressure ulcer, diabetes, and surgical amputation. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #46's physician orders revealed orders dated 05/16/23, 06/08/23, 07/07/23, and 08/15/23 for IV Company #700 hydration therapy for infection infusion at 250 milliliter per hour (ml/hr). Review of Resident #65 physician orders dated 04/14/23 and 09/6/23 for IV Company #700 hydration therapy for infection infusion at 500 ml/hr. 2. Record review of Resident #48 revealed the resident was admitted to the facility on [DATE] . Diagnoses for Resident #48 include pressure ulcer, paraplegia and schizophrenia. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #48's physician orders revealed orders dated 05/16/23, 06/08/23, 07/07/23, and 08/15/23 for IV Company #700 hydration therapy for infection infusion at 250 ml/hr. Review of Resident #65 physician order dated 04/14/23 for IV Company #700 hydration therapy for infection infusion at 500 ml/hr. 3. Record review of Resident #65 revealed the resident was admitted to the facility on [DATE] . Diagnoses for Resident #65 include dementia, paranoid schizophrenia, and Parkinson Disease. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition. Review of Resident #65's physician orders revealed orders dated 05/16/23, 06/08/23, 07/08/23, and 08/15/23 for IV Company #700 hydration therapy for cognitive infusion at 250 ml/hr. Review of Resident #65 physician orders dated 04/14/23 and 09/6/23 for IV Company #700 hydration therapy for cognitive infusion at 500 ml/hr. Review of the Ohio State Pharmacy Board website on 12/01/23 revealed IV Company #700 company did not have a valid license to dispense dangerous drugs in Ohio. Interview with Assistant Director of Nursing, (ADON) #200 on 12/01/23 at 10:25 AM. revealed she found out from corporate they were going to try this IV program to enhance quality of life for residents with weight loss, wounds, or hydration issues. There were different types of nutritional IV bags for skin and hydration. ADON #200 stated she complemented resident the IV assessment, and contacted the facility physicians, who wrote an order for IV Company #700 services. IV Company #700's nurse administered the IV fluids, which consisted of vitamins, supplements, and hydration. The last infusion month was September 2023 and ADON #200 was unsure why the corporate stopped services. IV Company #700's nurse brought all supplies, ran the IV administration, completed documentation and took all supplies when they left. Interview with Director of Nursing, (DON) on 12/01/23 at 10:30 A.M. verified IV Company #700 did not have a Ohio State Pharmacy Board license to dispense dangerous drugs in Ohio and the facility was unaware of that at the time of IV administrations from April 2023 to September 2023. A phone interview with Ohio State Pharmacy Board Worker #300 on 12/01/23 at 9:15 A.M. revealed IV Company #700 was not licensed in Ohio to dispense dangerous medications such as intravenous (IV) fluids. Review of past noncompliance documentation revealed the facility had education on 11/21/23 titled TDDD Licensure Education undated. There was a sign in sheet, with no presenter listed, signatures of the facility managers and the Medical Director, via phone. The education material did not include a designated facility staff person or position to ensure new drug companies held a valid license with the Ohio State Board of Pharmacy and to ensure license renewals were current. Interview on 12/01/23 at 3:15 P.M. the Regional Nurse #400 and the DON verified the education presented to the facility mangers on 11/21/23 titled, TDDD Licensure Education, did not indicate who was responsible to ensure the drug companies held a current and valid license with the Ohio State Board of Pharmacy This deficiency represents non-compliance investigated under Complaint Number OH00148183.

Based on record review, observation, policy review, and staff interview, the facility failed to prepare puree foods as planned in the facility's spreadsheet and recipes. This had the potential to affect all nine residents (Residents #1, #7, #9, #20, #23, #26, #27, #56, and #59) receiving pureed food from the kitchen. The facility census was 72. Findings include: Review of the facility's lunch menu spreadsheet dated 06/27/23 revealed the puree meal consisted of cheesy ham and egg scramble with a number 10 scoop size (three-eights cup), wheat toast with a number 16 scoop size (one-fourth cup), cereal, juice, and milk. Review of the facility's recipe for Cheesy Ham and Egg Scramble revealed for puree consistency required four quarts of liquid eggs, two pounds of ham and two pounds of shredded cheese to be mixed together, cooked, and then pureed with milk, to obtain a puree consistency. Observation on 06/27/23 at 7:14 A.M. revealed Dietary Cook (DC) #92 preparing pureed eggs, ham and cheese in a blender for the breakfast meal. There was no recipe or spreadsheet visible on the counter. DC #92 added cheese, unmeasured, to the cooked eggs and ham into the blender. DC #92 added slices of bread into the egg mixture. DC #92 completed the puree process. During meal service, DC #92 used a number eight scoop size (four-ninths cup) for the puree mixture to serve the puree egg mixture. Interview on 06/27/23 at 7:26 A.M. with DC #92 verified she should have followed a recipe for the amount of cheese and ham added to the mixture. DC #92 verified she did not prepare the bread puree separate from the egg puree mixture, as listed on the spreadsheet. DC #92 stated she added the bread to the egg puree mixture because it makes a better consistency. DC #92 verified the bread should have been prepared separately from the egg mixture to obtain the correct food portion and should have used a number 10 scoop size for the eggs and a number 16 scoop size for the puree bread. Interview on 06/27/23 at 10:00 A.M. with Dietary Manager (DM) #85 verified DC #92 should not have pureed the eggs and bread together per the facility's recipe and the spreadsheet. DM #85 verified DC #92 utilized the wrong scoop size for the egg and bread mixture and did not follow the spreadsheet. DM #85 verified DC #92 had access to the recipe and spreadsheet to accurately prepare the puree foods. Review of the resident's physician orders revealed Residents #1, #7, #9, #20, #23, #26, #27, #56, and #59 had diet orders for puree food consistency. Review of the facility policy titled Menu Planning, dated May 2021, revealed diets must be planned in accordance with the diet manual and meet nutritional needs of resident. Diets are modified as medically necessary following the same plan.