Every finding on record at Concord Village Skilled Nursing & Rehabilitation

Based on observation, interview, medical record review, and review of facility policy, the facility failed to ensure oxygen was administered according to physician orders. This affected one resident (Resident #2) out of three residents reviewed for oxygen. The facility census was 70. Findings include: Review of the medical record for Resident #2 revealed an admitted [DATE] with diagnoses including pleural effusion, long term use of anticoagulants, atrial fibrillation, anemia, moderate protein-calorie malnutrition, hyperlipidemia, heart failure, essential (primary) hypertension, type two diabetes mellitus, osteoarthritis, cataract extraction status, stage four chronic kidney disease, and neuromuscular dysfunction of the bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had intact cognition. The MDS further revealed Resident #2 had a history of respiratory failure and was receiving oxygen therapy. Review of the care plan dated 04/19/24 revealed Resident #2 was at risk for respiratory distress related to congestive heart failure (CHF), pleural effusion, history of COVID-19, and respiratory failure. Interventions included administering oxygen as ordered. Review of the physician orders revealed an order dated 04/05/24 for oxygen to run at two liters per minute via nasal cannula (NC) continuously every shift for shortness of breath (SOB). Review of the progress notes revealed a respiratory therapy assessment dated [DATE]. Further review of the note revealed Resident #2 was on four liters of oxygen at the time of the assessment on 04/12/24 and the respiratory therapist recommendation was to place an order for oxygen weaning. Observation on 05/22/24 at 11:10 A.M. of Resident #2 revealed she was asleep with oxygen running via NC through an oxygen concentrator set at four liters. Interview on 05/22/24 at 12:15 P.M. with Resident #2 confirmed she was on four liters of oxygen. Another observation at this time revealed the oxygen setting on the oxygen concentrator was four liters per minute. Observation on 05/22/24 at 4:05 P.M. of Resident #2 in the activity room revealed her oxygen was running via NC from a portable oxygen tank set to four liters per minute. Interview on 05/22/24 at 4:15 P.M. with the Director of Nursing (DON) confirmed Resident #2's oxygen was running at four liters per minute. Further interview at 4:17 P.M. confirmed Resident #2's order was for the oxygen rate to be two liters per minute. Interview on 05/22/24 at 4:20 P.M. with Registered Nurse (RN) #301 confirmed Resident #2 had an order for oxygen to run at two liters per minute. Review of the policy titled Oxygen Administration revised 2010 revealed staff were to make sure the proper flow of oxygen was being delivered per administration orders. This deficiency represents non-compliance investigated under Complaint Number OH00153664.

Based on observation, interview, record review, and facility policy review, the facility failed to post oxygen in use signs per acceptable standards of nursing practice for Residents #10, #21, #22, #34, #47, #48 and #64. This affected seven residents (#10, #21, #22, #34, #47, #48 and #64) of 27 residents reviewed for respiratory care. The census was 67. Findings include: 1. Record review revealed Resident #10 was admitted on [DATE]. Diagnoses included pneumonia due to methicillin resistant staphylococcus aureus (MRSA), acute respiratory failure with hypoxia, and chronic bronchitis. The physician order dated 01/27/24 indicated oxygen continuous at 2 LPM (liters per minute) via nasal cannula. 2. Record review revealed Resident #21 was admitted on [DATE]. Diagnoses included unspecified bacterial pneumonia, pulmonary hypertension, acute respiratory failure with hypoxia, chronic atrial fibrillation, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). The physician order dated 01/30/24 indicated oxygen at 2 LPM as needed to maintain oxygen saturation above 92 percent every shift. 3. Record review revealed Resident #22 was admitted on [DATE]. Diagnoses included pneumonia, sleep apnea and asthma. The physician order dated 01/28/24 indicated oxygen at 2 LPM via nasal cannula every shift. 4. Record review revealed Resident #34 was admitted on [DATE]. Diagnoses included pneumonia due to MRSA, acute and chronic respiratory failure with hypercapnia and hypoxia, shortness of breath, and COPD. The physician order dated 01/16/24 indicated oxygen at 3 LPM via nasal cannula continuous every shift. 5. Record review revealed Resident #47 was admitted on [DATE]. Diagnoses included atrial fibrillation, chronic bronchitis, CHF, and COPD. The physician order dated 01/27/24 indicated oxygen at 3 LPM every shift. 6. Record review revealed Resident #48 was admitted on [DATE]. Diagnoses included bronchitis, CHF, acute pulmonary edema, and acute respiratory failure with hypoxia. The physician order dated 10/23/24 indicated oxygen at 2 LPM via nasal cannula as needed. 7. Record review revealed Resident #64 was admitted on [DATE]. Diagnoses included pneumonia, acute and chronic respiratory failure, heart failure, COPD, and obstructive sleep apnea. The physician order dated 01/19/24 indicated oxygen at 4 LPM via nasal cannula every shift. Observation on 01/30/23 at 8:50 A.M. revealed the following: - Resident #10 was in the room with a nasal cannula in place and the oxygen concentrator was turned on and set to 2 LPM. There was no oxygen in use safety sign posted on the entrance room door. - Resident #21 was in the room with a nasal cannula in place and the oxygen concentrator was turned on and set to 2 LPM. There was no oxygen in use safety sign posted on the entrance room door. - Resident #34 was in the room with a nasal cannula in place and the oxygen concentrator was turned on and set to 3 LPM. There was no oxygen in use safety sign posted on the entrance room door. - Resident #47 was in the room with a nasal cannula in place and the oxygen concentrator was turned on and set to 3 LPM. There was no oxygen in use safety sign posted on the entrance room door. - Resident #48 was in the room with an oxygen concentrator and nasal cannula setting on top of the concentrator which was not turned on. There was no oxygen in use safety sign posted on the entrance room door. - Resident #64 was in the room with a nasal cannula in place and the oxygen concentrator was turned on and set to 4 LPM. There was no oxygen in use safety sign posted on the entrance room door. Interview at the time of the observation with Registered Nurse #301 verified there were no oxygen in use safety signs posted on the entrance room doors for Residents #10, #21, #34, #47, #48 and #64. Observation on 01/30/24 at 8:53 A.M. revealed Resident #22 was in the room with a nasal cannula in place and the oxygen concentrator which was turned on and set to 2 LPM. There was no oxygen in use safety sign posted on the entrance room door. Interview at the time of the observation with State tested Nursing Assistant #377 verified there was no oxygen in use safety sign posted on the entrance room door for Resident #22. Interview on 01/30/24 at 9:01 A.M. with Director of Nursing (DON) confirmed oxygen in use safety signs were required to be posted at the entrance room doors for all residents with oxygen equipment. Interview on 01/30/24 at 9:16 A.M. with DON indicated after surveyor identification of the missing oxygen in use safety signs during the survey, additional signs were obtained and now applied to the entrance room doors for Residents #10, #21, #22, #34, #47, #48 and #64. Review of facility policy, Oxygen Administration, revised October 2010, revealed to place an oxygen in use sign on the outside of the room entrance door.

Based on interview, closed record review, and Centers for Medicare & Medicaid Services guidelines, the facility failed to ensure Resident #40's Minimum Data Set (MDS) assessment accurately documented the stage of a pressure ulcer injury. This affected one resident (Resident #40) of three residents reviewed for pressure ulcers. Findings include: Review of the closed medical record for Resident #40 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included surgical aftercare, dementia, diabetes mellitus, heart disease, and hypertension. Review of the surgical discharge summary dated 11/21/22, revealed Resident #40 was at risk for post-surgical infection due to gangrenous gallbladder and pressure injury. Orders for treatment included therapeutic services, wound treatment per physician order, gait training and activities of daily living (ADL). Review of Resident #40's transfer/discharge report faxed to the facility on [DATE] at 2:30 P.M., revealed the resident had an unstageable left ischium pressure ulcer at time of transfer to the facility. Review of the facility admission assessment dated [DATE], revealed the type of Resident #40's wound was a pressure ulcer, wound measurements were recorded as 12.0 cm (centimeters) long by 12.0 cm wide, by 0.1 cm deep, red non-blanchable. No additional information was available to indicate the stage of resident's pressure injury at the time of admission. Review of the physician orders dated 11/23/22 at 7:10 A.M., revealed pressure ulcer wound treatment to cleanse coccyx with normal saline solution, apply skin prep and allow to dry, apply foam dressing once daily as needed. Review of the entry Minimum Data Set (MDS) assessment, dated 11/24/22, revealed the resident had impaired cognition. Review of the discharge MDS assessment, dated 11/26/22 revealed Resident #40's pressure ulcer was documented as Stage I (non-blanchable erythema of intact skin) at the time of discharge. Interview on 03/27/23 at 5:20 P.M. with MDS Nurse #960 confirmed she had not reviewed orders for the staging of Resident #40's pressure injury and answered the MDS question using the documented admission assessment description of pressure injury red non-blanchable. MDS Nurse #960 confirmed the pressure ulcer was coded incorrectly on the MDS. Interview on 03/28/23 at 3:20 P.M. with Nurse Practitioner (NP) #950 revealed recommendations for wound assessments were to come from the transfer/discharge orders for the type and stage of a pressure injury. Interview on 03/27/23 at 4:20 P.M. with Director of Nursing (DON) verified she had not assessed Resident #40's pressure injury and confirmed the facility did not identify the stage of pressure injury at admission or discharge. Review of the Nursing Admission Completion/Audit Tool, revealed the facility was to perform a wound/skin care management assessment and to include orders relative to the residents condition/needs, for example wounds. The policy stated if appropriate orders are not included, you must inquire with the physician regarding missing orders. Review of the Centers for Medicare & Medicaid Services (CMS) guidelines for pressure injuries dated 11/2017, when assessing the pressure injury itself, it is important that documentation addresses type of injury (pressure-related versus non-pressure-related) because interventions may vary depending on the specific type of injury and to include pressure injury stage and a description of the pressure injury characteristics.

Based on interview and record review, the facility failed to ensure an antibiotic stewardship program was in place as required. This had the potential to affect all 61 residents who reside in the facility. Findings include: Review of the facility infection control program revealed monthly tracking of infections in a log type format. Categories tracked included resident name, body source (of infection), name of antibiotic ordered with start and end date, whether the infection was acquired in the community or from the hospital, dates of labs and results, dates of x-ray and results and date the infection resolved. Review of the tracking log revealed not all areas were completed for each resident/infection logged. Review of monthly infection control tracking revealed totals of numbers of nosocomial (acquired in the facility) infections, community acquired infections by unit, and types of infections, including categories such as wound infections, [MEDICAL CONDITION], pneumonia, [MEDICAL CONDITION], eye, ear or mouth infections, or urinary tract infections, as well as several other categories. Review of the facility policy for Antibiotic Stewardship, dated 11/19/17, revealed the facility would develop and maintain an antibiotic stewardship program to promote the appropriate use of antibiotics with a system of monitoring to improve resident outcomes and reduce antibiotic resistance. The policy indicated a core element was to track measures of antibiotic uses in the facility. The policy indicated a clinician, an Infection Preventionist, would be assigned to implement the program and the clinician would be responsible for ensure antibiotics were appropriately prescribed for the infection based on culture and sensitivity results, that doses were correct with correct directions, with appropriate durations and stop dates, and would use the services of the consulting pharmacist and the pharmacy website to access information regarding numbers and percentages of antibiotic use by drug class. An interview with the infection control nurse, Registered Nurse (RN) #300, on 01/23/20 at 12:36 P.M. revealed she had completed a course in (MONTH) 2019 and was certified as an Infection Preventionist. She stated she kept track of infections by monitoring them daily, looking for patterns and trends. She stated she checked labs and made sure the culture and sensitivity results were reported to physicians. She also indicated she kept track of all infections in the facility on the log. Review of the antibiotic stewardship program policy with RN #300 revealed she talked with physicians at times about the orders for antibiotics but did not confer with pharmacy. She indicated the facility utilized Centers for Disease Control (CDC) guidelines for it's infection control guidelines, but verified she had no other policies or protocols regarding the monitoring of antibiotics, written antibiotic use protocols or protocols to review clinical signs, symptoms and laboratory results to determine if an antibiotic is indicated. She also verified there was no process in place for periodic review of antibiotic use by prescribing practioners with a system of feedback reports for providers. RN #300 confirmed the information in the monthly tracking logs and the monthly tracking summary was the only information she compiled. She stated she had no written documentation of her monitoring activities regarding antibiotics, other than the information reviewed and verified there was no evidence of a program to ensure antibiotic stewardship.

Based on observation, interview and record review, the facility failed to provide the physician ordered pressure ulcer treatment and failed to complete the dressing change in a manner to prevent contamination for Resident #20. This affected one of two residents reviewed for pressure ulcers. The facility census was 61. Findings include: Record review for Resident #20 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was alert, oriented, cognitively intact, had no behaviors and required the extensive assistance of one staff member for bed mobility, toileting and hygiene and was totally dependent on staff for bathing. He was continent of bladder but incontinent of bowel. Review of Resident #20's nursing notes revealed he was found with an area of impaired skin to his right lateral (outer) foot on 11/30/19. Review of the skin assessment completed on 12/03/19 revealed the area was an unstageable pressure area that measured 2.0 centimeters (cm) by 1.3 cm. An unstageable pressure ulcer is an ulcer with slough (yellowish/tan/greenish non-viable tissue) or eschar (black/brown dead or dying tissue) covering the ulcer and in which the wound bed is not able to be visualized for proper staging. A treatment was ordered and the wound nurse was consulted. The physician order dated 12/03/19 was written for Medi-honey (a treatment that helps clean a wound by facilitating the removal of debris/dead tissue from the wound) to be applied after cleansing the wound, with a foam dressing. On 12/31/19, the dressing order was changed to [MEDICATION NAME] ointment to the wound twice daily for 14 days with a foam dressing as the resident's white blood cell count was increased slightly and a wound culture was positive for Staphylococcus Aureus, a bacterial infection. Review of a wound nurse note dated 01/14/20 revealed the wound treatment was changed to hydrogel with silver (a treatment that protects the wound bed and provides a moist environment with antimicrobial ingredients) and calcium alginate (an absorbent dressing that promotes healing and the formation of healthy, granulation tissue) and cover with a foam dressing every day. Review of the most recent wound nurse note available for review, dated 01/21/20, indicated the pressure ulcer was a full thickness ulcer measuring 2.5 centimeters (cm) long by 2.5 cm wide by 0.1 cm deep. Observation of the treatment with the wound nurse, Registered Nurse (RN) #300, and the Assistant Director of Nursing, and RN #301 assisting, was completed on 01/23/20 at 9:10 [NAME]M. RN #300 prepared supplies in the hall on the treatment cart, including putting a substance which she identified as Medi-honey in a small plastic cup. She also had a foam dressing and an opened package of calcium alginate. She stated they just tear a piece of the calcium alginate off to fit the pressure ulcer. Resident #20 was turned on his left side. RN #300 removed the old dressing, cleansed and measured the wound appropriately. She then washed her hands and applied new gloves. Resident #20 had relaxed onto his back during this time, so when RN #300 returned to the bedside, both nurses assisted him to turn again to his left side. His back was red and RN #300 indicated it was a fungal infection. She used her clean, gloved hands to assist him to roll back over, touching his back. As RN #301 held him to the side, RN #300 first applied the Medi-honey in the small cup with a cotton swab. She then obtained the package with the foam dressing from the night stand table and was observed to tear a piece of the calcium alginate from the opened package on the table and held it in her right gloved hand. She transferred the calcium alginate material to her left hand to open the foam dressing. Then she obtained a pen from her pocket and dated the foam dressing with the pen. She then held the calcium alginate in her right hand and applied it to the surface of the pressure ulcer. She applied the foam dressing over the calcium alginate. They then completed incontinence care and left the room. An interview with RN #300 on 01/23/20 at 9:44 [NAME]M. verified Resident #20 had a fungal infection on his back and she had touched Resident #20's back with her gloved hands after washing her hands and applying new gloves. She also verified she then touched the outside of the packages of the calcium alginate and the foam dressing, as well as her pen with her right hand, then used her right hand to apply the calcium alginate directly to the pressure ulcer wound bed. Interview with RN #300 on 01/23/20 at 10:28 [NAME]M. verified the Medi-honey was the previous dressing order and the physician order had changed on 01/14/20 to hydrogel silver and calcium alginate. She stated she had forgotten the dressing order had changed and had applied the wrong treatment to Resident #20's pressure ulcer. An interview with the Director of Nursing on 01/23/20 at 4:50 P.M. confirmed clean gloves should be used to apply a dressing directly to a wound and skin areas with any type of infection (fungal infection on Resident #20's back) should not be touched with the same gloves and then used on other areas of the body. Review of the facility policy on dressing changes, dated 12/17/13, revealed the nurse should verify the physician order for [REDACTED].

Based on observation, interview, and record review the facility failed to ensure fall interventions were in place for Residents #4 and #12 and failed to thoroughly investigate a fall for Resident #12. This affected two residents of four residents reviewed for falls. Findings include: 1. Record review of Resident #4 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the current physician orders revealed an active order dated 08/17/19 for Resident #4 to use a low bed and have floor mats to both sides of the bed while in bed. Staff were to check for and verify placement every shift. Review of the fall care plan initiated on 03/28/19 revealed Resident #4 was at risk of falls. Interventions revised on 08/18/19 included the implementation of a low bed with mats to the floor next to the bed. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 had impaired cognition, required extensive assistance of one staff for bed mobility, transfers, and toilet use, and had a fall with injury since admission, entry/re-entry or the prior assessment. Observation on 01/21/20 at 10:23 [NAME]M., revealed Resident #4 in bed, in a low position with a perimeter mattress. There were no floor mats on the floor on either side of the bed, however there were three floor mats leaning against the wall behind the wardrobe in an upright position. Observation on 01/23/20 at 07:38 [NAME]M. revealed Resident #4 in bed and the floor mats up against the wall behind the wardrobe in an upright position. Observation on 01/23/20 at 7:40 [NAME]M. with Registered Nurse (RN) #300 verified the floor mats were not on the floor next to Resident #4's bed. RN #300 verified Resident #4 had a physician order for [REDACTED]. Review of the facility policy titled, Fall Reporting, Investigation, and Documentation, dated 07/25/19, revealed appropriate interventions would be taken to prevent future falls. 2. Record review for Resident #12 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan for falls dated 07/08/19 revealed Resident #12 was at risk for falls due to decreased safety awareness. Interventions included for staff to keep frequently used items within her reach. An intervention for the bedside table to be placed on the window side of the bed when she was in her bed was dated 09/18/19. Review of the MDS assessment dated [DATE] revealed Resident #12 was cognitively impaired and she needed limited to extensive assist from staff for activities of daily living. This assessment indicated she had two falls with no injury since the last assessment. Review of the nursing notes dated 11/04/19 at 7:30 P.M. revealed Resident #12 was found on the floor. She stated she was trying to take her pants off and get into bed. She was assisted to bed by staff. The intervention was to reinforce use of her call light for assistance. Review of a nursing note dated 11/04/19 at 11:30 P.M. revealed at 11:15 P.M. that night, Resident #12 had been found in bed with several injuries. She had a large knot with a developing hematoma at the center top of her forehead, swollen with a developing bruising on the bridge of her nose, dried blood in her mouth, a small swollen area at the center of her bottom lip with a small split in the skin and a large skin tear observed on her right wrist area. The note said Resident #12 asked staff to, help me off the floor, although the note also indicated she was lying in her bed. The resident was sent to the hospital and returned according to a nursing note on 11/05/19 at 1:45 [NAME]M. There was no documentation to indicate Resident #12 received any stitches or any specific care. Review of the fall investigation for 11/04/19 at 11:15 P.M. revealed the resident was lying in bed on her left side facing the window and stated she fell and hit her head on the floor, trying to, shut the alarm off. Review of interventions to prevent future falls indicted the resident was to wear non-skid socks prior to attempting to transfer, as well as have staff obtain orthostatic blood pressures and place a mat to the floor by the bed. Review of the care plan revealed updated interventions dated 11/05/19 including dycem (a non-slip material) to her wheelchair seat and a low bed with floor mats. Review of her most recent quarterly MDS assessment dated [DATE] revealed Resident #12 was cognitively impaired, required the extensive assistance of one to two staff for her activities of daily living and had a history of [REDACTED]. An interview with the Director of Nursing (DON) on 01/21/20 at 2:20 P.M. verified the interventions indicated for the falls on 11/04/19. She verified the resident was found with injuries on 11/04/19 at 11:15 P.M. in bed, nearly four hours after her first fall. Another interview with the DON on 01/23/20 at 4:19 P.M. revealed the facility investigation had not concluded the resident had fallen out of bed or attempted to self-transfer to cause the injuries she sustained. She stated the facility thought an alarm sounded, which was most likely from the hall way, and Resident #12 thought it was going off in her room and she had obtained the injuries while in bed, when she hit her face, head and arm as she tried to turn off an alarm clock that she thought was on her night stand table. The DON stated the facility had concluded the resident would not have been able to get herself up from the floor if she had fallen and the injuries had to have come while she was in bed. The DON verified the investigation did not indicate this possible scenario and that the interventions indicated for the fall were related to the resident changing position and falling to the floor, including the non-skid socks, orthostatic blood pressures and low bed with mat to the floor. The DON verified Resident #12's record and investigation did not contain evidence that blood was found on any surface to verify the theory and did not contain interventions to address the scenario that the resident had caused the injury to herself while in bed.

Based on interview and record review, the facility failed to ensure interventions to address weight losses/gains were monitored and addressed promptly for Resident #48. This affected one of three residents reviewed for nutrition. Findings include: Review of the record revealed Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was sent to the hospital on [DATE] for shortness of breath and returned 12/13/19. She was sent to the hospital again for chest pain on 1[DATE] and returned on 12/26/19. Review of Resident #48's care plan dated 1[DATE] revealed she was at nutritional risk due to [MEDICAL CONDITIONS], diabetes, malnutrition,[MEDICAL CONDITION], anorexia and weight loss. Interventions included for staff to assist her with meals as needed, monitor intake of meals, provide alternatives as needed and monitor labs and weights. These interventions were all dated 1[DATE]. An additional intervention dated [DATE] indicated supplements were to be given as ordered. Review of her most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was moderately cognitively impaired and required extensive to limited assistance from staff for her activities of daily living. Review of the resident's current physician orders [REDACTED]. Review of weights revealed she weighed 148.2 pounds on [DATE] and 141.6 pounds on [DATE]. Review of the dietary section of the care conference held on 12/31/19 only listed Resident #48's diet orders which was a regular diet with thin liquids. There was no documentation reflecting her 6.6 pound weight loss in one month. An order on 12/31/19 revealed she was ordered Boost, a nutritional supplement, three times a day to be given with meals. Resident #48's weight on 01/01/20 was down to 137.2 pounds, revealing a loss of 4.4 pounds since 12/31/19. The resident was assessed by Registered Dietician (RD) #400 on 01/03/20 and a note indicated Boost supplement had been started. The RD note indicated Resident #48 reported having nausea, vomiting and diarrhea, but said it had been improving. The RD indicated the resident would have weekly weights and acknowledged the weight loss of 4.4 pounds. The note indicated meals and supplement intake would be monitored. On 01/07/20, Resident #48's weight had decreased by 13.4 pounds and she now weighted 123.8 pounds. The physician order [REDACTED].#48 was ordered [MEDICATION NAME], an appetite stimulant, to be given daily. A note by RD #400 on [DATE] revealed Resident #48 had a 12.6 % weight loss and the physician had started [MEDICATION NAME] for depression and as an appetite stimulant. The note also indicated staff were encouraged to push the supplement. The resident's weight on 01/14/20 was 121 pounds, a loss of 2.8 pounds in seven days. There were no documented notes regarding the decrease in weight noted on 01/14/20. No other weight had not been obtained as of the initial day of the survey, 01/21/20, and Resident #48 was to be weighted weekly. On 01/22/20, Resident #48 weight was 127.6, an increase of 6.6 pounds. Another weight was obtained on 0[DATE] and was 127.2 pounds. Review of the resident's meal intakes from [DATE] through 0[DATE] revealed she took [AGE]% for most meals. Meals marked 50% or less only numbered 18 and she took 41 meals at [AGE]% or greater. One meal was marked as refused and eight meals were not marked at all. Review of the resident's intake of the Boost revealed she took 100% of the supplement 15 times out of 24 opportunities between 01/01/20 and [DATE]. She took 50% or less of the supplement only 9 times. Additional review of the Boost intake documentation from 0[DATE] through 01/14/20 revealed the resident took 100% of the Boost only four times out of 24 opportunities. She was marked as refusing the supplement for the other opportunities. From [DATE] through 01/20/20, the supplement documentation revealed Resident #48 took the supplement 100% only six times out of 24 opportunities, with the other opportunities marked as refused. Review of a note dated 01/21/20 at 11:13 A.M., written by RD #400, revealed the resident did not like the Boost supplement because it tasted too sweet. The Boost supplement was discontinued and an order was given for a different nutritional supplement, a Magic cup, to be given twice a day with lunch and dinner. An interview with RD #400 on 01/22/20 at 3:46 P.M. confirmed the resident's weight had decreased when weighed on 01/07/20 and he indicated he encouraged staff to push the Boost supplement, as evidenced in his note on [DATE]. He verified Resident #48's weight had decreased again when weighed on 01/14/20 by 2.8 pounds. He verified there was no note in the record to address the continuing weight loss. He stated the team had discussed the weight loss in the nutrition risk meeting but verified there was no note in the chart to verify the weight loss was discussed and no new interventions were implemented. He further verified the resident had started refusing the Boost supplement more frequently after [DATE], when staff started to encourage or push the supplement. He verified there was no evidence in the record to reflect an investigation for the decrease with the intake of the Boost or that any alternate supplements were offered to Resident #48. This was not investigated until the note on 01/21/20, after the survey investigation began. He indicated they also implemented daily weights, starting on 0[DATE], due to the sudden weight gain on 01/22/20, which was significant due to the resident's history of [MEDICAL CONDITION].

Based on record review and staff interview the facility failed to ensure monthly physician orders [REDACTED].#7, #10, and #22. This affected three of 25 resident records reviewed for physician orders. The facility census was 61. 1. Review of the hard medical chart for Resident #7 revealed the monthly physician's orders [REDACTED]. On 01/23/20 at 10:29 [NAME]M., the Director of Nursing (DON) reviewed and verified this concern. 2. Review of the hard medical chart for Resident #10 revealed the monthly physician's orders [REDACTED]. On 01/23/20 at 10:29 [NAME]M., the DON reviewed and verified this concern. 3. Review of the hard medical chart for Resident #22 revealed the monthly physician's orders [REDACTED]. On 01/23/20 at 10:29 [NAME]M., the DON reviewed and verified this concern.

Based on observation, interview and record review, the facility failed to ensure on-going psychiatric services and coordination of care for Resident #20. This affected one of five residents reviewed for unnecessary medications. The facility census was 61. Findings include: Review of the record for Resident #20 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact, had no behaviors and required the extensive assistance of one staff member for bed mobility, toileting and hygiene and was totally dependent on staff for bathing. He was continent of bladder, but incontinent of bowel. Review of the resident's care plans revealed a care plan dated 11/30/18 for memory problems realted to cognition and psychiatric issues. Interventions included staff to reorient as needed and provide a calm environment. There were no other care plans related to anxiety, depression or psychiatric concerns. According to the medical record, Resident #20 had been followed by a consulting psychiatric service and was seen on 11/07/19. The note by the psychiatric nurse practioner indicted Resident #20's mood had been stable and he was not having agitation or irritability. The note indicated the [MEDICATION NAME], an anti-psychotic medication, would be discontinued. There was also an order [REDACTED]. The note indicated the nurse practitioner had attempted to contact Resident #20's daughter to discuss the medication changes but was unable to contact her. The nurse practicitioner indicated the medication changes were discuees with Physician Assistant (PA) #410. The staff were to monitor for changes and report if behavioral changes occurred. Review of the physician orders [REDACTED]. Review of the note written by PA #410 on 11/07/19 revealed Resident #20 was seen by the psychiatric nurse practioner on that day, and she indicated the resident's [MEDICATION NAME] had been discontinued with the [MEDICATION NAME] added. However, this note indicated the order for the [MEDICATION NAME] was a routine medication to be given twice a day, and not just as needed for 30 days. Review of the note dated [DATE], labeled, Termination note, indicated psychiatry services had been discontinued as the resident's insurance plan would not cover their services and previous service payments had gone unpaid. Review of a monthly medication review by the pharmacist dated 11/25/19 revealed Resident #20 had a physician order [REDACTED]. The pharmacist indicated the order was entered as a scheduled order without a stop date and it was to be given regularly and was not entered as an needed medication with a stop date. The monthly review by the pharmacist did not have any indication the concern was addressed or investigated by the physician or any other member of the facility staff. Review of a note on [DATE] at 4:49 P.M. revealed a care conference had been held. The note indicated the resident had a visit from psychiatric services. A nursing note on 12/26/19 at 3:24 P.M. revealed Resident #20 continued with confusion and the nurse practioner was notified. There was no prior mention of confusion in the nursing notes or medical record. The record also did not contain any other information or follow-up regarding the discontinuation of the [MEDICATION NAME], initiation of [MEDICATION NAME] or any behavior monitoring after the psychiatric note on 11/07/19. Review of the next note from PA #410 dated 12/26/19 revealed the resident had had a change in mental status and was seeing pictures on the walls and ceiling and next to his television that look like a brick city. The note indicted testing would be completed to rule out a source of infection as a possible reason for his change in mental status. If no other reason for the changes could be found, the note said they may need to consider restarting the [MEDICATION NAME] to improve his [MEDICAL CONDITION]. A note from PA #410 on [DATE] revealed staff had indicated the resident did not seem himself the last few days and a phone call was placed to the psychiatric nurse practitioner to update her to the patient condition, as they had seen the resident previously and his [MEDICATION NAME] had been discontinued sometime in November. The note indicated she was awaiting a call back, but would restart the resident on the [MEDICATION NAME] once a day with a psychiatric consult and requested them to follow-up on his [MEDICAL CONDITION]. A note from PA #410 on 12/30/19 indicated the resident's visual hallucinations had improved after restarting the [MEDICATION NAME] medication and that psychiatric services were to follow-up with the resident. The note indicated the resident indicated he was doing much better and nursing staff indicated his confusion had improved. The notes from PA #410 dated 12/26/19, [DATE], 12/30/19 and 12/31/19 all acknowledged the resident was taking the [MEDICATION NAME] medication routinely, twice a day. An interview with Resident #20 on 01/21/20 at 11:37 A.M. revealed him in bed. He denied concerns with care or with his current medications. He stated he did not leave his room or bed but that was his preference. An interview with the Director of Nursing on 0[DATE] at 5:10 P.M. confirmed the [MEDICATION NAME] medication was not given as written and verified this concern was identified by the pharmacist on 11/25/19 and it had not been addressed or clarified by the physician. She further verified the resident was still receiving the routine dose of the [MEDICATION NAME] twice a day, although the record did not contain a written physician order [REDACTED]. An interview with Social Service Designee (SSD) #405 on 0[DATE] at 5:30 P.M. revealed she knew the resident was not being seen by the psychiatric service but assumed it was because he was stable, doing well and no longer needed the services. She stated she did not know until 0[DATE], when the surveyor requested psychiatric nurse practioner notes, that the facility received a termination notice for psychiatric services for Resident #20 and that he had not been seen due to insurance concerns. An interview with the PA #410, by phone on 0[DATE] at 6:00 P.M., revealed she knew the resident's [MEDICATION NAME] had been discontinued as a gradual dose reduction attempt. She stated she assumed the [MEDICATION NAME] was ordered to help the resident if he had any symptoms of anxiety. She stated she did not routinely review handwritten orders in the chart, but did look at the printed orders or the orders in the computer, which should be current and accurate. She said she saw the order in the computer for the [MEDICATION NAME], but knowing the psychiatric service had followed the resident, just recopied the order as written into her progress notes. She said when the facility staff notified her on 12/26/19 about the change in mental status for Resident #20, she assumed the psychiatric service would manage that behavior and tried to contact them. She said when she finally reached the nurse practioner, she was told they were no longer following the resident. She stated she was unaware the resident had been dropped due to insurance concerns. An interview with the Director of Nursing (DON) on 0[DATE] at 6:45 P.M. confirmed the facility had been unaware of the termination of psychiatric services for Resident #20, as indicated in the notification on 11/22/20. She verified the resident had been given [MEDICATION NAME] routinely since 11/07/19, although the order was written for the medicaiton to be given only as neededfor 30 days, then should have been stopped. The DON verified the resident had a change in mental status on 12/26/19 with a need for the [MEDICATION NAME] to be restarted, but members of the interdisciplinary team had been unaware of the reason psychiatric services had been discontinued and did not assess the need for or provide for alternate, on-going monitoring of the resident's psychiatric condition.

Based on observation, interview and record review, the facility failed to ensure monthly pharmacy recommendation/irregularity reports were acted upon in a timely manner. This affected Resident #20, one of five residents were reviewed for unnecessary medications. The facility census was 61. Findings include: Record review for Resident #20 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors and required the extensive assistance of one staff member for bed mobility, toileting and hygiene and was totally dependent on staff for bathing. Review of a monthly review by the pharmacist dated 10/24/19 revealed Resident #20 had an active order for [MEDICATION NAME], a medication to treat high cholesterol. The pharmacist asked if it would be appropriate for a lipid panel and liver function testing (laboratory testing) to be drawn to monitor for side effects and efficacy of the medication. Review of the form revealed the physician signed it on 11/01/19 and agreed with the recommendation. Review of the record did not reveal the recommended testing had been completed. Review of the physician orders dated 11/07/19 revealed the resident's dose of [MEDICATION NAME] was discontinued for a gradual dose reduction (GDR) and [MEDICATION NAME] was ordered at a dose of 5 milligrams, up to twice a day, only as needed for 30 days then it was to be discontinued. Review of a monthly review by the pharmacist dated 11/25/19 revealed the resident had an order written [REDACTED]. The pharmacist indicated the order was entered as a scheduled order, not as needed and it had no stop date. Review of the resident's physician orders did not reveal an order after 11/07/19 for [MEDICATION NAME] as a routine medication however, Resident #20 was receiving the medication, according to the Medication Administration Record, [REDACTED]. The monthly review by the pharmacist did not have any indication the concern was addressed or investigated by the physician or any other member of the facility staff. An interview with the Director of Nursing (DON) on 01/23/20 at 5:10 P.M. confirmed the facility had not acted upon the recommendation of the pharmacist concerning the requested laboratory testing which was approved by the physician to obtain the testing. She indicated the laboratory testing was now ordered. The DON also verified the concern identified by the pharmacist regarding the dosing of [MEDICATION NAME] on 11/25/19 had not been addressed or clarified by the physician. She further verified the resident was still receiving the routine dose of the [MEDICATION NAME], although the record did not contain a written physician order for [REDACTED].>

Based on interview and record review the facility failed to ensure non-pharmacological interventions were attempted prior to the use of an as needed anti-anxiety medication for Resident #48 and failed to ensure Resident #20 was free from unnecessary medications. This affected two of five residents reviewed for unnecessary medications. The facility census was 61. Findings include: 1. Resident #48 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #48 had moderate cognitive impairment, scoring a 10 on the Brief Interview for Mental Status (BIMS), with scores of 10 to 12 indicating moderate cognitive impairment. Review of the electronic medical record revealed Resident #48 did not have a current care plan to address non-pharmacological interventions related to [MEDICAL CONDITION] drug use. Review of the physician orders [REDACTED]. Review of the (MONTH) 2020 Medication Administration Record [REDACTED].M., 01/02/20 at 9:00 [NAME]M., 01/04/20 at 12:21 [NAME]M., 01/07/20 at 10:02 [NAME]M., 01/07/20 at 9:12 P.M., 01/08/20 at 10:01 [NAME]M., 01/09/20 at 10:34 [NAME]M., 01/22/20 at 10:15 P.M., and 01/23/20 at 9:34 [NAME]M. Resident #48 received [MEDICATION NAME], 0.5 mg by mouth. There was no evidence any non-pharmacological interventions were not attempted prior to administering the as needed anti-anxiety medication. Review of Resident #48's progress notes from 01/01/20 through 01/23/20 revealed no evidence that any non-pharmacological interventions had been attempted prior to administering the as needed anti-anxiety medication, [MEDICATION NAME]. Interview on 01/23/20 at 1:00 P.M. with the Director of Nursing (DON) verified the above findings. 2. Review of the record for Resident #20 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact and had no behaviors. According to the medical record, Resident #20 had been followed by a consulting psychiatric service and was seen on 11/07/19. The note by the psychiatric nurse practioner indicted Resident #20's mood had been stable and he was not having agitation or irritability. The note indicated the [MEDICATION NAME], an anti-psychotic medication, would be discontinued. There was also an order [REDACTED]. The note indicated the nurse practioner had attempted to contact the Director of Nursing to discuss the medication changes but was unable to contact her. The nurse practitioner indicated the medication changes were discussed with Physician Assistant (PA) #410. The staff were to monitor for changes and report if behavioral changes occurred. Review of the physician orders [REDACTED]. Review of the note written by PA #410 on 11/07/19 revealed Resident #20 was seen by the psychiatric nurse practioner on that day, and she indicated the resident's [MEDICATION NAME] had been discontinued with the [MEDICATION NAME] added. However, this note indicated the order for the [MEDICATION NAME] was a routine medication to be given twice a day, and not just as needed for 30 days. Review of a monthly medication review by the pharmacist dated 11/25/19 revealed Resident #20 had a physician order [REDACTED]. The pharmacist indicated the order was entered as a scheduled order without a stop date and it was to be given regularly and was not entered as an needed medication with a stop date. The monthly review by the pharmacist did not have any indication the concern was addressed or investigated by the physician or any other member of the facility staff. The notes from PA #410 dated 12/26/19, 12/27/19, 12/30/19 and 12/31/19 all acknowledged the resident was taking the [MEDICATION NAME] medication routinely, twice a day. An interview with the DON on 01/23/20 at 5:10 P.M. confirmed the [MEDICATION NAME] medication was transcribed incorrectly and was not administered as per the original order. The DON verified the concern identified by the pharmacist on 11/25/19 had not been addressed or clarified by the physician. She further verified the resident was still receiving the routine dose of the [MEDICATION NAME] twice a day, which was started 11/07/19, although the record did not contain a written physician order [REDACTED]. An interview with the PA #410, by phone on 01/23/20 at 6:00 P.M., revealed she knew the resident's [MEDICATION NAME] had been discontinued as a gradual dose reduction attempt. She stated she assumed the [MEDICATION NAME] was ordered to help the resident if he had any symptoms of anxiety. She stated she did not routinely review handwritten orders in the chart, but did look at the printed orders or the orders in the computer, which should be current and accurate. She said she saw the order in the computer and just recopied the order as written into her progress notes.

Based on observation, interview, and medical record review the facility failed to administer medications with a medication administration error rate of less than five percent. This affected one (Resident #7) of six residents observed during medication administration in the facility. There were two medication errors in 38 opportunities resulting in a 5.26% error rate. The facility census was 61. Finding include: Review of the medical record for Resident #7 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record for Resident #7 revealed a physician order [REDACTED]. An additional physician order, dated 03/19/19, revealed Resident #7 was to receive [MEDICATION NAME] (vitamin D), 1000 units, one tablet daily. Registered Nurse (RN) #305 was observed on 01/23/20 at 8:33 [NAME]M. preparing medications to administer to Resident #7. RN #305 placed [MEDICATION NAME], 5000 mcg, one tablet, into the medication cup. RN #305 was observed at that time also placing one tablet of vitamin D, 400 units, into the medication cup. Observation of the bottle of vitamin D at that time revealed 1000 had been hand-written on the top of the bottle. The medication cup contained a total of 18 pills. Resident #7 was observed taking the medications in the medication cup into Resident #7. Registered Nurse #305 was interviewed on 01/23/20 at 10:40 [NAME]M. and verified the incorrect dose of [MEDICATION NAME] and vitamin D had been administered to Resident #7.

Based on observation, interview and record review, the facility failed to ensure the application of a treatment/cream was provided in a sanitary manner to minimize the spread of infection. This affected Resident #20, one of two residents, who were reviewed for wound/pressure ulcer care. The facility census was 61. Findings include: Record review for Resident #20 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors and required the extensive assistance of one staff member for bed mobility, toileting and hygiene and was totally dependent on staff for bathing. He was continent of bladder but incontinent of bowel. Review of his physician orders [REDACTED]. He also had an order on 12/17/19 for [MEDICATION NAME] powder, an antifungal powder, to be applied to his abdominal folds and groin every shift and as needed for redness. Review of his nursing notes revealed he was found with with an impaired skin area to his right lateral (outer) foot on 11/30/19. Observation of the treatment with the wound nurse, Registered Nurse (RN) #300, and the assistant director of nursing, who was assisted by RN #301, was completed on 01/23/20 at 9:10 [NAME]M. After entering the room and moving Resident #20 to his left side, RN #300 noted he had been incontinent of stool when she assisted to turn him to the side and indicated she would clean his perineal area after she completed the dressing change for his wound. RN #300 completed the dressing to his foot and then removed her gloves and washed her hands, and left the room, She returned with the anti-fungal cream for his back and a pad that would go under him after the incontinence care. She applied gloves, assisted the resident to roll over, and used a wash cloth to wash his back, which was reddened. She used a different wash cloth to wash his buttocks area of the fecal matter. She manipulated the washcloth several times to get a clean area to cleanse his buttocks. She then used the same contaminated gloves to open the tube of anti-fungal cream and applied it to his back. An interview with RN #300 on 01/23/20 at 9:44 [NAME]M. verified Resident #20 had a fungal infection/impaired skin on his back. She verified she applied gloves, rolled the resident over, touching the impaired skin area on his back, then cleaned his back and buttock area of stool, open the tube of anti-fungal cream and then applied the anti-fungal cream to his back using the same contaminated gloves. An interview with the Director of Nursing on 01/23/20 at 4:50 P.M. confirmed clean gloves should be used to apply a treatment and staff should not be touch other areas of the body with soiled gloves.

Based on observation and interview the facility did not ensure out-dated packaged food items were pulled from use properly in accordance with professional standards for food service. This had the potential to affect the 48 residents allowed bread on their diets. The facility census was 51. Findings Include: On 12/03/18 at 10:42 [NAME]M. seventeen loaves of bread dated 11/28/18 were found on the bread racks in the kitchen. On 12/03/18 at 10:42 [NAME]M. Certified Dietary Manager (CDM) #101 verified the bread should have been rotated and the outdated loaves returned to the bread company. Three residents (Resident #3, Resident #7, and Resident #36) were not allowed bread on there diets and would not have been affected.

Based on observation, record review, and interview, the facility failed to ensure expired medications were discarded from medication administration carts. This affected one of three medication carts, and had the potential to affect any of the 21 residents living on the 100 hall. The total census was 51. Findings include: Observation of medication storage areas with the Director of Nursing (DON) on 12/05/18 at 10:44 [NAME]M. revealed the following medications in the 100 hall cart to have an expiration date of 10/2018: Fiber-laxative supplements, calcium 500 milligrams (mg) with vitamin D-3 400 units per pill, vitamin D 400 units per pill, vitamin B-1 100 mg per pill, and calcium 200 mg per pill. These medications had stickers identifying them as being close to their expiration date, but were otherwise not distinguished or stored differently than the other resident medications. Interview with the DON on 12/05/18 at 11:20 [NAME]M. confirmed the observations. Review of the facility's Medication Storage Policy, dated 06/21/17, revealed outdated medications were to be immediately removed from stock and disposed of.

Based on interview and record review the facility failed to notify Resident #199's physician when her blood sugar was above 401 per her physician order. This affected one resident (Resident #199) out of 13 residents that received blood sugar monitoring. The facility census was 51. Findings included: Record review for Resident #199 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the physician order [REDACTED].#199 revealed she was to receive insulin [MEDICATION NAME] (anti-diabetic) solution subcutaneously before meals and at bedtime per sliding scale: if blood sugar 70 to 100 she was to receive no insulin, 101 to 150 she was to receive four units, 151-200 she was to receive six units, 201 to 250 she was to receive six units, 251 to 300 she was to receive seven units, 301 to 350 she was to receive seven units, 351 to 400 she was to receive eight units, and 401 and above she was to receive nine units and the nurse was to call the physician for further orders. Review of (MONTH) (YEAR) Medication Administration Record [REDACTED].M. her blood sugar was 587 and she received Lispo insulin solution nine units subcutaneously. On 12/01/18 at 11:30 [NAME]M. the MAR indicated [REDACTED]. Review of nursing notes dated 12/01/18 for Resident #199 revealed no documentation that the physician was notified on 12/01/18 at 7:30 [NAME]M. of Resident #199's blood sugar of 587 and 12/01/18 at 11:30 [NAME]M. of Resident #199's blood sugar of 422. Interview on 12/06/18 at 9:32 [NAME]M. with the Director of Nursing verified that on 12/01/18 the physician was not notified of Resident #199's blood sugar of 587 at 7:30 [NAME]M. and blood sugar of 422 at 11:30 [NAME]M. The Director of Nursing verified that Resident #199's physician order [REDACTED]. Review of facility policy titled, Change in Resident's Condition or Status, dated 11/19/09, revealed it is the policy to promptly notify the resident, their attending physician and representative of changes in the resident's medical status.

Based on interview and record review, the facility failed to thoroughly assess Resident #43 when she experienced a change in condition, failed to promptly notify the physician in order to obtain prompt care and treatment and failed to notify the resident's neurologist as ordered by the physcian. Actual harm occurred when Resident #43 experienced [MEDICAL CONDITION] episodes, each [MEDICATION NAME] 10-15 minutes over a period of 4 hours and the physician was not notified until approximately seven hours after the first episode. Resident #43 was later sent to the hospital and admitted with a [MEDICAL CONDITIONS], a stroke. This affected one of seven residents observed for changes in condition (Resident #'s 4, 6, 38, 42, 43 and 44). The facility census was 42. Findings include: Record review revealed Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She also had a history of [REDACTED]. The admission note indicated Resident #43 was slow to respond with [MEDICAL CONDITION] (partial loss of the ability to produce language although comprehension usually remains intact) and she had an immobilizer to her left leg. Record review revealed no concerns through 01/13/18. Resident #43 was cooperative, alert and oriented, and she was at times incontinent of bowel and bladder. A nursing note on 01/13/18 at 4:11 P.M. revealed the resident could at times be very anxious. Review of nursing notes through 02/07/18 did not reveal any other issues or concerns. Review of a nursing note written by Registered Nurse (RN) #500 dated 02/08/18 at 5:34 P.M. revealed Resident #43 exhibited evidence of focal type [MEDICAL CONDITION] activity, staring off to the left, (which) occurred several times during the course of the day. The note indicated the nurse spoke with the family, who spoke with the resident's neurologist and were advised to send the resident to the emergency room . Review of a nursing note written on 02/13/18 at 9:01 A.M., as a late entry for 02/08/18 at 8:10 A.M., revealed RN #501, the Director of Nursing (DON) went in the room to assess Resident #43 at the request of RN #500 and saw the resident staring off to one side. As she asked the resident if she was okay, she began to talk and said she was okay and smiled. The note indicated the DON told RN #500 to call and notify the physician. Review of a fax form entitled transmission log, dated 02/08/18 at 10:33 A.M. revealed the physician was faxed a note which indicted Resident #43 experienced a focal [MEDICAL CONDITION] which lasted about 10 minutes and was postictal (an altered state of consciousness after a [MEDICAL CONDITION] that lasts from about 5 minutes to 30 minutes or longer and is characterized by drowsiness, confusion, nausea, high blood pressure, headache or migraine and other disorienting symptoms) for approximately one hour. This fax indicated the resident was fine now and asked the physician for any new orders. A late entry nursing note written by RN #500 on 02/13/18 at 10:08 A.M. for 02/12/18 at 3:23 P.M. contained updated vital signs taken at 10:30 A.M. on 02/08/18 (stable) and indicated she had approached the resident around 8:00 A.M. on 02/08/18 to give her medications and noted the resident staring over to the left. The note indicated the DON was in to evaluate the resident and the physician was to be notified of the resident's condition, 'focal [MEDICAL CONDITION]'. The note indicated the resident's daughter was at the bedside around noon when she had another episode and she was checked multiple times between 12:00 P.M. and 2:00 P.M. The note indicated the physician called the facility at 3:00 P.M. and ordered blood work for the next morning and neurological checks. This note indicated the daughters were awaiting a phone call from the resident's neurologist and were advised of the physician orders. This note indicated the family returned to the facility around 5:00 P.M. with orders from the neurologist to send Resident #43 to the emergency room . An interview by phone with RN #500 on 02/13/18 at 12:40 P.M. revealed she checked the resident's vital signs around 7:30 A.M. and noted no concerns with the resident. She said she returned to give the resident her medication around 8:00 A.M. and noted the resident not responding as usual and staring off to the left side. She said she was concerned and left the room to find the DON. Upon return to the room with the DON, RN #500 said Resident #43 was still starring off and did not initially respond, but then smacked her lips together and started moving her hands, picking at things in the air. She then turned toward them and was able to verbally respond, stating she was okay when questioned. RN #500 said the DON said the incident looked like a focal [MEDICAL CONDITION] and told RN #500 to call and notify the resident's physician. RN #500 said she continued her medication pass, since the resident was stable. She said she saw the resident's daughter come soon after and explained the episode to her. She said at some point, probably around 9:00 A.M., the daughter came to get her and said the resident was having another episode. She said she entered the room and saw the resident as she had been previously, staring off and then with the same lip smacking and hand movements. She said she faxed the physician around 10:30 A.M. to notify him. She also stated she took the resident's vital signs around 10:30 A.M. as well, and they were stable. RN #500 stated she checked in on the resident several times, as several family members were visiting through the morning. She said when she discussed the concern with the family and stated the physician had been notified about the incidents and she was waiting to hear back. She said when she mentioned to the family that the physician may want the resident to be seen by a neurologist, the family members indicated the resident had seen a neurologist in the past and they would try to contact that physician. RN #500 said the resident had another episode around noon, although she could not be exactly sure of the time. She said she was not sure of how long the family was with the resident, but they did leave later in afternoon. She said she checked in on the resident but verified there were times the resident could have been alone in the room and may have had unwitnessed episodes of the same type. RN #500 verified she did not check the resident's vital signs after 10:30 A.M. and the resident had 3 episodes as described, once around 8:00 A.M., once around 9:00 A.M. and once around 12:00 P.M., all [MEDICATION NAME] 10-15 minutes. She did not hear back from the physician after she sent the fax around 10:30 A.M. until around 3:00 P.M. She stated the physician called the facility and she told him about the three incidents Resident #43 experienced. She said the physician ordered labwork for the resident for the next morning and to get a neurology consult. She stated she told the physician the resident had a neurologist and he said to notify that physician. RN #500 stated she had spoken with the family about the neurologist, so she waited to hear from them. She said around 5:00 P.M., the resident's daughter came in and said she had heard from the neurologist who stated the resident should be sent to the emergency room . She said the resident was sent to the hospital at 5:40 P.M. RN #500 verified Resident #43 had a change in condition, with at least three episodes of inability to respond, starring off in the distance, and unusual mouth and hand movements. She verified the resident had not eaten more than a few bites of her breakfast or lunch. She stated she was unsure of what the incidents really were, but stated she thought the resident may have had some type of [MEDICAL CONDITION], as she seemed to have a postictal period, with slight confusion and not acting herself. She stated the resident also told her she was very sleepy, but also stated she had slept really well. RN #500 verified she only faxed the physician after the resident had already had two episodes and did not attempt to call or page him to notify him of Resident #43's change in condition. She also verified she did not attempt to call the resident's neurologist, stating the family said they would call him. She also verified there was no formal assessment of the resident documented, including vital signs after 10:30 A.M. and no neurological assessment, such as the resident's hand grasps, pupil size or mental status other than the resident was alert. An interview with the resident's physician by phone on 02/13/18 at 3:15 P.M. revealed he was unaware of concerns with Resident #43 until 3:00 P.M. on 02/08/18. He stated he was not close to a fax machine and if the nursing staff needed to reach him, they had access to his phone number. He stated he called at 3:00 P.M. when he was made aware the facility was trying to reach him. He could not remember how he was made aware of this. He stated he was told by the nurse at the facility only that the resident had had some type of [MEDICAL CONDITION] but had no other effects and was doing fine. He stated he told the nurse to order lab work for the morning and a neurology consult. He said when the nurse indicated the resident had a neurologist who followed her care, he told her to contact that physician to inform him of the resident's condition. He stated he was unaware of any previous neurology concerns and she did not have any neurological diagnoses. He denied he was aware she had had three episodes of [MEDICAL CONDITION] activity. He said if he had known there had been three episodes, he would have ordered the resident be sent to the hospital for evaluation. He said the nurse should have called him instead of faxing so he could have responded sooner. He said he would have expected that the other episodes would have also been reported to him promptly and he could have ordered the resident be sent to the hospital. An interview with with the DON, RN #501, on 02/13/18 at 3:45 P.M. revealed the resident was admitted to the hospital with [REDACTED]. She stated the [DIAGNOSES REDACTED]. An interview with the Administrator and DON on 02/13/18 at 4:15 P.M. confirmed Resident #43 had at least three episodes of unresponsiveness with other unusual behaviors from about 8:00 A.M. until around 12:00 P.M. on 02/08/18. They confirmed facility staff did not contact the physician until 10:30 A.M. via fax and verified there was no other attempt to contact him. The physician later responded about 3:00 P.M. They verified the record for Resident #43 contained only vital signs taken at 10:30 A.M. and indications that she was alert, with no specific documentation of the resident's neurological status after the [MEDICAL CONDITION] activity described by nurses. They further verified the record did not contain evidence the facility attempted to contact the resident's neurologist after the order was given at 3:00 P.M., waiting instead for the resident's family to make the contact with the neurologist. They verified Resident #43's medical status changed and the staff did not ensure timely and accurate reporting of symptoms/change in condition to the physician, prompt response by the facility to physician orders [REDACTED]. This delayed treatment for [REDACTED]. This deficiency substantiates Complaint Number OH 197.

Based on interview and record review, the facility failed to ensure the physician was notified in a timely manner of Resident #43's change in condition and failed to promptly contact Resident #43's neurologist as ordered. This affected one of seven residents observed for changes in condition (Resident #'s 4, 6, 38, 42, 43 and 44). The facility census was 42. Findings include: Review of the facility policy on Change of Resident Condition or Status, dated 11/19/2009, revealed that the nurse would notify the resident's physician when a resident had a significant change, described as a decline in status that would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Record review revealed Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She also had a history of [REDACTED]. The admission note indicated Resident #43 was slow to respond with [MEDICAL CONDITION] (partial loss of the ability to produce language although comprehension usually remains intact) and she had an immobilizer to her left leg. Record review revealed no concerns through 01/13/18. Resident #43 was cooperative, alert and oriented, and she was at times incontinent of bowel and bladder. A nursing note on 01/13/18 at 4:11 P.M. revealed the resident could at times be very anxious. Review of nursing notes through 02/07/18 did not reveal any other issues or concerns. Review of a nursing note written by Registered Nurse (RN) #500 dated 02/08/18 at 5:34 P.M. revealed Resident #43 exhibited evidence of focal type [MEDICAL CONDITION] activity, staring off to the left, (which) occurred several times during the course of the day. The note indicated the nurse spoke with the family, who spoke with the resident's neurologist and were advised to send the resident to the emergency room . Review of a nursing note written on 02/13/18 at 9:01 A.M., as a late entry for 02/08/18 at 8:10 A.M., revealed RN #501, the Director of Nursing (DON) went in the room to assess Resident #43 at the request of RN #500 and saw the resident staring off to one side. As she asked the resident if she was okay, she began to talk and said she was okay and smiled. The note indicated the DON told RN #500 to call and notify the physician. Review of a fax form entitled transmission log, dated 02/08/18 at 10:33 A.M. revealed the physician was faxed a note which indicted Resident #43 experienced a focal [MEDICAL CONDITION] which lasted about 10 minutes and was postictal (an altered state of consciousness after a [MEDICAL CONDITION] that lasts from about 5 minutes to 30 minutes or longer and is characterized by drowsiness, confusion, nausea, high blood pressure, headache or migraine and other disorienting symptoms) for approximately one hour. This fax indicated the resident was fine now and asked the physician for any new orders. A late entry nursing note written by RN #500 on 02/13/18 at 10:08 A.M. for 02/12/18 at 3:23 P.M. contained updated vital signs taken at 10:30 A.M. on 02/08/18 (stable) and indicated she had approached the resident around 8:00 A.M. on 02/08/18 to give her medications and noted the resident staring over to the left. The note indicated the DON was in to evaluate the resident and the physician was to be notified of the resident's condition, 'focal [MEDICAL CONDITION]'. The note indicated the resident's daughter was at the bedside around noon when she had another episode and she was checked multiple times between 12:00 P.M. and 2:00 P.M. The note indicated the physician called the facility at 3:00 P.M. and ordered blood work for the next morning and neurological checks. This note indicated the daughters were awaiting a phone call from the resident's neurologist and were advised of the physician orders. This note indicated the family returned to the facility around 5:00 P.M. with orders from the neurologist to send Resident #43 to the emergency room . An interview by phone with RN #500 on 02/13/18 at 12:40 P.M. revealed she checked the resident's vital signs around 7:30 A.M. and noted no concerns with the resident. She said she returned to give the resident her medication around 8:00 A.M. and noted the resident not responding as usual and staring off to the left side. She said she was concerned and left the room to find the DON. Upon return to the room with the DON, RN #500 said Resident #43 was still starring off and did not initially respond, but then smacked her lips together and started moving her hands, picking at things in the air. She then turned toward them and was able to verbally respond, stating she was okay when questioned. RN #500 said the DON said the incident looked like a focal [MEDICAL CONDITION] and told RN #500 to call and notify the resident's physician. RN #500 said she continued her medication pass, since the resident was stable. She said she saw the resident's daughter come soon after and explained the episode to her. She said at some point, probably around 9:00 A.M., the daughter came to get her and said the resident was having another episode. She said she entered the room and saw the resident as she had been previously, staring off and then with the same lip smacking and hand movements. She said she faxed the physician around 10:30 A.M. to notify him. She also stated she took the resident's vital signs around 10:30 A.M. as well, and they were stable. RN #500 stated she checked in on the resident several times, as several family members were visiting through the morning. She said when she discussed the concern with the family and stated the physician had been notified about the incidents and she was waiting to hear back. She said when she mentioned to the family that the physician may want the resident to be seen by a neurologist, the family members indicated the resident had seen a neurologist in the past and they would try to contact that physician. RN #500 said the resident had another episode around noon, although she could not be exactly sure of the time. She said she was not sure of how long the family was with the resident, but they did leave later in afternoon. She said she checked in on the resident but verified there were times the resident could have been alone in the room and may have had unwitnessed episodes of the same type. RN #500 verified she did not check the resident's vital signs after 10:30 A.M. and the resident had 3 episodes as described, once around 8:00 A.M., once around 9:00 A.M. and once around 12:00 P.M., all [MEDICATION NAME] 10-15 minutes. She did not hear back from the physician after she sent the fax around 10:30 A.M. until around 3:00 P.M. She stated the physician called the facility and she told him about the three incidents Resident #43 experienced. She said the physician ordered lab work for the resident for the next morning and to get a neurology consult. She stated she told the physician the resident had a neurologist and he said to notify that physician. RN #500 stated she had spoken with the family about the neurologist, so she waited to hear from them. She said around 5:00 P.M., the resident's daughter came in and said she had heard from the neurologist who stated the resident should be sent to the emergency room . She said the resident was sent to the hospital at 5:40 P.M. RN #500 verified Resident #43 had a change in condition, with at least three episodes of inability to respond, starring off in the distance, and unusual mouth and hand movements. She verified the resident had not eaten more than a few bites of her breakfast or lunch. She stated she was unsure of what the incidents really were, but stated she thought the resident may have had some type of [MEDICAL CONDITION], as she seemed to have a postictal period, with slight confusion and not acting herself. RN #500 verified she only faxed the physician after the resident had already had two episodes and did not attempt to call or page him to notify him of Resident #43's change in condition. She also verified she did not attempt to call the resident's neurologist, stating the family said they would call him. Interview with Resident #43's physician by phone on 02/13/18 at 3:15 P.M. revealed he was unaware of concerns with Resident #43 until 3:00 P.M. on 02/08/18. He stated he was not close to a fax machine and if the nursing staff needed to reach him, they had access to his phone number. He stated he called the facility at 3:00 P.M. when he was made aware the facility was trying to reach him. He could not remember how he was made aware of this. He stated he was told by the nurse at the facility only that the resident had had some type of [MEDICAL CONDITION] but had no other effects and was doing fine. He stated he told the nurse to order lab work for the morning and ordered a neurology consult. He said when the nurse indicated the resident had a neurologist who followed her care, he told her to contact that physician to inform him of the resident's condition. He stated he was unaware of any previous neurology concerns and she did not have any neurological diagnoses. He denied he was aware she had had three episodes of [MEDICAL CONDITION] activity. He said if he had known there had been three episodes, he would have ordered the resident be sent to the hospital for evaluation. He said the nurse should have called him instead of sending a fax so he could have responded sooner. He said he would have expected that the other episodes would have also been reported to him promptly and he could have ordered the resident be sent to the hospital. An interview with with the DON, RN #501, on 02/13/18 at 3:45 P.M. revealed the resident was admitted to the hospital with [REDACTED]. She stated the [DIAGNOSES REDACTED]. An interview with the Administrator and DON on 02/13/18 at 4:15 P.M. confirmed Resident #43 had at least three episodes of unresponsiveness with other unusual behaviors from about 8:00 A.M. until around 12:00 P.M. on 02/08/18. They confirmed facility staff did not contact the physician until 10:30 A.M. via fax and verified there was no other attempt to contact him. The physician later responded about 3:00 P.M. They verified there was no evidence the facility attempted to contact the resident's neurologist after the order was given at 3:00 P.M., waiting instead for the resident's family to make the contact with the neurologist and notify the nursing home staff. They verified Resident #43's medical status changed and the staff did not ensure timely and accurate reporting of symptoms/change in condition to the physician and prompt notification to Resident #43's neurologist.

Based on record review, observation and interview, the facility failed to ensure foods were stored under the proper temperatures. This had the potential to affect all 28 residents in the facility, as there were no residents in the facility with a nothing by mouth physician order. Findings include: An interview on 11/01/17 at 10:50 A.M. with Consultant Registered Dietitian (RD) #100 revealed resident snacks from the kitchen and any food brought in for the residents by family was kept in the 200 wing pantry refrigerator. Consultant RD #100 explained that temperatures for that refrigerator were monitored by a computerized temperature log system overseen by the director of maintenance. An interview on 11/01/17 at 11:45 A.M. with Director of Maintenance #105 revealed the temperature for the 200 wing pantry refrigerator was reading 42.8 degrees Fahrenheit (F) and an alarm had notified him in the past if the temperature reached 44 degrees F or higher. Director of Maintenance #105 explained the temperature probe inside the refrigerator sent temperature readings to his computer tracking system. There was no internal or secondary thermometer inside the refrigerator. Review of the computerized temperature records of the 200 wing pantry refrigerator with Director of Maintenance #105 on 11/01/17 at 11:45 A.M. revealed temperatures recorded on 10/30/17 and 11/01/17 were consistently at 42.8 degrees F. An observation on 11/01/17 at 11:55 A.M. with Consultant RD #100 of the 200 Wing Pantry refrigerator revealed there was no internal thermometer nor secondary thermometer to monitor the temperatures. The maintenance director placed a dial thermometer inside the refrigerator as a secondary method to monitor the temperature. Consultant RD verified that there had not been a secondary internal thermometer to monitor the internal temperature of the refrigerator. An observation on 11/01/17 at 12:00 P.M. with the Director of Nursing (DON) of the 200 wing pantry refrigerator revealed there were 21 individual packs of pudding, eight individual yogurts and 11 half pints of milk all stamped with the instruction to keep refrigerated. The DON verified that those products were to be stored under refrigeration and were in the refrigerator as snacks for the residents. An interview on 11/01/17 at approximately 4:15 P.M. with the administrator verified refrigerator temperatures in the facility should be between 36 and 41 degrees F and prior to the survey findings there had not been an internal thermometer inside the 200 wing pantry refrigerator. Information provided by the facility revealed there were no residents in the facility with a nothing by mouth physician order.