Every finding on record at Continental Manor Nurs and Rehabilitation Center

Based on record review, resident and staff interview, hospital records review, facility policy review, and fall investigation review, the facility failed to provide appropriate gait belt assistance and care planned two persons assist during a wheelchair to chair transfer. This resulted in harm when Resident #28 sustained a fall with a laceration, and a dislocated toe that required a hospital visit and 11 stitches. This affected one (Resident #28) of four Residents reviewed for accident hazards. The facility census was 48. Findings include: Record review of Resident #28 revealed an admitted [DATE] with pertinent diagnoses of: amyotrophic lateral sclerosis, spinal stenosis lumbar region, chronic obstructive pulmonary disease, type two diabetes mellitus with diabetic neuropathy, weakness, acute kidney failure, umbilical hernia, major depressive disorder, lack of coordination, unilateral primary osteoarthritis left knee, low back pain, tremor, retention of urine, hypertension, anxiety disorder, and malignant neoplasm of the kidney. Review of the 12/05/21 plan of care revealed Resident #28 is at risk for falls related to decreased mobility, poor balance, poor safety awareness, use of psychoactive medications,refusing the use of alarms with removing alarm from self . The chair alarms were discontinued due to placing resident at higher risk due to his increased restlessness and maneuvering self to remove his own alarms. The goal was for Resident #28 to be free from fall related injury with a target date of 08/31/24. Care planned interventions included two persons assist with all transfers since 09/22/22, and follow facility fall protocol. Record review of the 07/09/24 quarterly Minimum Data Set (MDS) assessment revealed Resident #28 was cognitively intact and used a wheelchair to aid in mobility. Resident #28 required substantial to maximal assist for upper and lower body dressing and transfer from bed/chair to chair transfer. Review of Progress Notes dated 07/22/24 at 7:07 A.M. revealed a late entry for 07/19/24 at 11:45 A.M. this resident was lowered to floor by State tested Nurse Aide (STNA) #74 during transfer. Resident was lowered to floor to sitting position then head lowered to floor not hitting his head. Resident was laying on the floor on his back in front of recliner, bilateral lower extremities extended toward the door, fully dressed in street clothes with non-skid socks on and arms at sides. Room was well lit, no obstacles or clutter on floor. Resident was alert and oriented x 4. Denied hitting his head and pain. STNA #74 was not using gait belt for transfer. Resident stated that his foot got caught under the chair as he was pivoting during transfer from wheelchair to recliner. Vital signs, head to toe assessment, range of motion (ROM), skin, pain assessments completed. His vital signs, pain, ROM assessments found within normal limits. Right great toe noted to be misshapen and large laceration from inside right great toe underneath to outside of right great toe noted. Draining moderate amount of bright red blood. Resident was assisted from floor to recliner with Hoyer lift and four person assist. Physician aware and new order received to send to emergency room (ER) for eval. 911 was notified and Resident #28 was transferred to local hospital emergency room per stretcher accompanied by two attendants. Resident to be a two person assist with transfers, staff education completed on the use of gait belts with transfers, and corrective action for STNA for not using gait belt. Resident's family notified of incident and transfer to ER. Resident later return from ER per stretcher accompanied by two attendants with new orders for ortho boot to right foot for three weeks, non-weight bearing status to right foot, monitor right great toe and sutures for signs and symptoms of infection. Review of hospital records dated 07/19/24 revealed the proximal inter phalangeal is dislocated with medial deviation of the distal phalange. The Physician applied mild traction and reduced it without sedation. Wound repair of three-centimeter subcutaneous laceration to right foot. Skin closed with 11 simple sutures. The diagnosis was laceration without foreign body of right great toe without damage to nail. Review of the 07/19/24 Witness Statement revealed State tested Nurse Aide (STNA) #74 revealed she was transferring Resident #28 from wheelchair to recliner without a gait belt. She held his pant and locked arms with him while he stood, he then pivoted to the right and stopped right before turning completely. She slowly lowered him to a seating position on the floor and then slowly lowered his head to the ground in a lying position. Review of the 07/22/24 post fall investigation report for the fall on 07/19/24 revealed Resident #28 had a fall on 07/19/24 at 11:45 A.M. and the contributing factors was STNA was not using a gait belt. Injuries were a dislocated right great toe, and a laceration. Interview with Resident #28 on 08/12/24 at 10:00 A.M. revealed he had a fall three or four weeks ago and he hurt his toe. He stated he needs two people for transfers, and they only used one person. He got 11 stitches in his right big toe. Interview with Director of Nursing (DON) on 08/15/24 at 8:42 A.M. verified STNA #74 did not use a gait belt and transferred Resident #28 by herself. The floor was dry, room light was on evaluated for injuries no complaints of pain did not hit his head. DON stated they got the Hoyer lift to transfer after the fall then we noticed blood on his sock, and we realized he needed treatment and called 911. Resident has an ALS diagnosis that makes him high risk for falls we try to promote the least number of transfers with him. The facility policy is to use gait belts with all transfers, and she verified the plan of care stated he was a two person assist with transfer. The DON stated the care plan should have been adjusted and he is a one or two person assist for transfers. Interview with STNA #97 on 08/15/24 at 8:51 A.M. Resident #28 has been a two person transfer for longer than six months. She stated have never transferred him with one person in the last six months. Review of the 02/2023 Facility Use of Gait Belt Policy revealed it is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety. Failure to use gait belt properly may result in termination.

Based on staff interview, and record review the facility failed to ensure residents were informed of their rights to pay for therapy services or decline to pay for those services when Resident #50 and #106 were not given skilled nurse facility advanced beneficiary notice of non-coverage (SNF ABN) form 10055 upon being cut from services and still staying in the building. This affected two (Resident #50 and #106) of three Residents reviewed for beneficiary notices. The facility census was 48. Findings include: 1. Record review of Resident #50 revealed an admitted [DATE] and he still resides in the building. The resident had pertinent diagnoses of: chronic obstructive pulmonary disease, type two diabetes mellitus, heart failure, atrial fibrillation and hyperlipdemia. Review of the Notice of Medicare Non-coverage form 10123 dated 07/09/24 revealed Resident #50 was being discharged for m services on 07/11/24 and he was still residing in the building. Review of the medical record on 08/13/24 revealed there was no skilled nurse facility advanced beneficiary notice of non-coverage (SNF ABN) form 10055 provided Resident #50 when he was cut from skilled services. Interview with The Administrator on 08/13/24 at 2:59 P.M. verified there was no skilled nurse facility advanced beneficiary notice of non-coverage (SNF ABN) form 10055 provided to Resident #50 when he was cut from skilled services and he stayed in the building. 2. Record review of Resident #106 revealed an admitted [DATE] and a discharge to another facility on 06/11/24. The resident had pertinent diagnoses of: arthropathy, myocardial infarction, hypertension, and atrial fibrillation. Review of the Notice of Medicare Non-coverage form 10123 dated 05/23/24 revealed Resident #106 was being discharged for m services on 05/26/24 and he was still going to be residing in the building. Review of the medical record on 08/13/24 revealed there was no skilled nurse facility advanced beneficiary notice of non-coverage (SNF ABN) form 10055 provided to Resident #106 when he was cut from skilled services. Interview with The Administrator on 08/13/24 at 2:59 P.M. verified there was no skilled nurse facility advanced beneficiary notice of non-coverage (SNF ABN) form 10055 provided to Resident #106 when he was cut from skilled services and he stayed in the building.

Based on staff interview and record review the facility failed to resubmit a Preadmission Screening and Resident Review (PASARR) or discharge the Resident after 90 days per the level two screening determination. This affected one (Resident #15) of one reviewed for PASARR. The facility census was 48. Findings include: Record review of Resident #15 revealed an admitted [DATE] with pertinent diagnoses of: cerebral infarction, hemiplegia and hemiparesis, toxic effect of other metals, bipolar disorder,acute kidney failure, muscle weakness, cognitive communication deficit, obstructive and reflux uropathy, dysphagia, adult failure to thrive, and schizoaffective disorder. Review of the 06/30/24 quarterly Minimum Data Set (MDS) assessment revealed the resident is severely cognitively impaired, he uses a wheelchair to aid in mobility, and is always incontinent of bladder and frequently incontinent of bowel. Review of the 10/17/23 Notice of PASRR determination and right to a state hearing revealed Resident #15 required the level of services provided by a nursing facility and they may continue to reside in the nursing facility for 90 day from the determination. The nursing facility inconjunction with the local entities shall initiate and continue discharge planning activities throughout the period of time specified on this notice. Interview with Licensed Social Worker (LSW) #66 on 08/15/24 ay 9:50 A.M. verified Resident #15 was only approved to be in the facility 90 days and no one sent in the updated PASARR we assumed the local was doing it and it was suppose to be us doing it. LSW #66 verified Resident #15 is still in the facility.

Based on observation, staff interview, record review, and policy review, the facility failed to ensure medication error rates were not greater than 5% when they did not prime an insulin pen before administration and gave the wrong amount of tablets for cranberry. This affected two (Resident #1 and #29) of four residents observed for medication administration. There was two errors out of 26 opportunities for a medication error rate of 7.69%. The facility census was 48. Findings include: 1. Record review of Resident #1 revealed an admitted [DATE] with pertinent diagnoses of: type two diabetes mellitus, anemia, hypothyroidism, hyperlipdemia, hypertension, and chronic kidney disease stage three. Review of the 06/16/24 modification of quarterly Minimum Data Set (MDS) revealed the resident was moderately cognitively impaired and used a wheelchair to aid in mobility and was frequently incontinent of bladder and occasionally incontinent of bowel. Review of a Physician Order dated 05/07/24 revealed Cranberry 930 milligrams (mgs) give one capsule by mouth one time a day for urinary tract infection prevention. Observation on 08/14/24 at 9:08 A.M. revealed Licensed Practical Nurse (LPN) #84 administered medications to Resident #1 including one tab of Cranberry 450 mgs. Interview with LPN #84 on 08/14/24 at 9:36 A.M. verified she only gave 450 mgs of cranberry and the order is for 930 mgs. 2. Record review of Resident #29 revealed an admitted [DATE] with pertinent diagnoses of: cerebral infarction, asthma, type two diabetes mellitus with diabetic neuropathy, and congestive heart failure. Review of the 05/10/24 significant change Minimum Data Set (MDS) revealed the resident was cognitively intact and used a wheelchair to aid in mobility and is occasionally incontinent of bowel and bladder. Review of a Physician Order dated 04/24/24 revealed an Novolog FlexPen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Aspart) Inject as per sliding scale: if 140 - 179 = 2U; 180 - 219 = 4U; 220 - 259 = 6U; 260 - 299 = 8U; 300 - 339 = 10U; 340 - 379 = 12U; 380 - 419 = 14U; 420 - 500 = 20U >501 call physician, subcutaneously before meals and at bedtime related to type two diabetes mellitus. Review of a Physician Order dated 04/24/24 revealed to Novolog FlexPen Subcutaneous Solution Pen-injector 100 unit/ml/ML (Insulin Aspart) Inject 15 units subcutaneously three times a day related to type two diabetes mellitus. Observation on 08/15/24 at 11:25 A.M. revealed Licensed Practical Nurse (LPN) #290 took Resident #29 blood sugar level and it was 319 milligrams per deciliter (mg/dl). This required 15 units scheduled dose of Novolog insulin and 10 additional units for sliding scale coverage. LPN #290 dialed the Novolog pen to 25 units she did not prime the insulin pen prior to administration to the Resident. Interview with LPN #290 on 08/15/24 at 11:35 A.M. verified she did not prime the insulin pen before injecting Resident #29. Review of a undated facility policy title insulin administration with use of insulin pen and needle revealed to prime the pen by removing the air from the needle and cartridge. Select two units when turning the dose knob. Hold the pen with the needle pointing up, then gently tap the cartridge holder to collect the air bubbles at the top. Press the push-button until it stops. You should see a O in the dose window. You should see insulin at the needle tip. If you do not see insulin, repeat the priming steps but not more than 6 times. If there is still no insulin, do not use the pen. Turn the dose selector, be careful not to press the push-button. Insert the needle into the resident's and press the push-button all the way in for at least six seconds. Keep pressing until the needle has been pulled out from the skin. This will make sure that you have received the full dose. Use a new needle each time you give an an injection. Always remove and discard the needle into a sharps container after each injection.

Based on observation, staff interview, record review, and policy review, the facility failed to ensure residents are free of significant medication errors when they did not prime an insulin pen before administering insulin to a resident. This affected one (Resident #29) of four residents observed for medication administration. The facility census was 48. Findings include: Record review of Resident #29 revealed an admitted [DATE] with pertinent diagnoses of: cerebral infarction, asthma, type two diabetes mellitus with diabetic neuropathy, and congestive heart failure. Review of the 05/10/24 significant change Minimum Data Set (MDS) revealed the resident was cognitively intact, used a wheelchair to aid in mobility, and is occasionally incontinent of bowel and bladder. Review of a Physician Order dated 04/24/24 revealed an Novolog FlexPen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Aspart) Inject as per sliding scale: if 140 - 179 = 2U; 180 - 219 = 4U; 220 - 259 = 6U; 260 - 299 = 8U; 300 - 339 = 10U; 340 - 379 = 12U; 380 - 419 = 14U; 420 - 500 = 20U >501 call physician, subcutaneously before meals and at bedtime related to type two diabetes mellitus. Review of a Physician Order dated 04/24/24 revealed to Novolog FlexPen Subcutaneous Solution Pen-injector 100 unit/ml/ML (Insulin Aspart) Inject 15 units subcutaneously three times a day related to type two diabetes mellitus. Observation on 08/15/24 at 11:25 A.M. revealed Licensed Practical Nurse (LPN) #290 took Resident #29 blood sugar level and it was 319 milligrams per deciliter (mg/dl). This required 15 units scheduled dose of Novolog insulin and 10 additional units for sliding scale coverage. LPN #290 dialed the Novolog pen to 25 units she did not prime the insulin pen prior to administration to the Resident. Interview with LPN #290 on 08/15/24 at 11:35 A.M. verified she did not prime the insulin pen before injecting Resident #29. Review of a undated facility policy title insulin administration with use of insulin pen and needle revealed to prime the pen by removing the air from the needle and cartridge. Select two units when turning the dose knob. Hold the pen with the needle pointing up, then gently tap the cartridge holder to collect the air bubbles at the top. Press the push-button until it stops. You should see a O in the dose window. You should see insulin at the needle tip. If you do not see insulin, repeat the priming steps but not more than 6 times. If there is still no insulin, do not use the pen. Turn the dose selector, be careful not to press the push-button. Insert the needle into the resident's and press the push-button all the way in for at least six seconds. Keep pressing until the needle has been pulled out from the skin. This will make sure that you have received the full dose. Use a new needle each time you give an an injection. Always remove and discard the needle into a sharps container after each injection.

Based on record review, review of facility infection control surveillance records, staff interviews, review of facility policies and procedures, review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to document and track employee reported illness as part of their infection control and prevention program. This affected 17 (#01, #02, #06, #12, #19, #41, #42, #44, #09, #13, #23, #34 #37, #08, #17, #26 and #25) residents but had the potential to affect all residents at the facility. The facility census was 46. Findings include: Review of the facility's infection control and surveillance logs with Infection Preventionist (IP) Nurse #150 revealed the facility experienced a gastroenteritis illness (GI) including symptoms of nausea, vomiting and/or diarrhea (loose stools) from 03/13/24 through 03/16/23. The facility's infection control and surveillance logs documented 17 residents who were affected by the GI illness. On 03/13/24, Residents' (#01, #02, #06, #12, #19, #41, #42, and #44), on 04/14/24, Residents' (#09, #13, #23, #34 and #37), on 03/15/24 Residents' (#08, #17, and #26), and on 03/16/24, Resident #25 had symptoms of a GI illness. Interview with IP Nurse #150 at the same verified she was tasked with being the facility's Infection Preventionist over the infection control and prevention program. IP Nurse #150 verified the facility had a GI virus outbreak that affected 17 residents from 03/13/24 to 03/16/24. IP Nurse #150 was questioned on whether any staff members were affected by the recent GI virus outbreak and IP #150 indicated she would have to call human resources because she did not track employee call offs and/or illnesses. IP Nurse #150 consulted with the Human Resource (HR) Manager #184 and learned a total of ten employees were affected by the GI virus outbreak from 03/13/24 through 03/16/24. The infection control and surveillance logs revealed no documented evidence of any staff members being identified with the GI illness or employees calling off for illness. Review of a facility document titled Staff GI Virus revealed the following 10 employees were affected by the GI Virus: On 03/13/24, Maintenance Director #181 called off with similar GI illness symptoms. On 03/14/24, Registered Nurse #151 and State tested Nursing Assistant (STNA) #162 called off with similar GI symptoms. On 03/15/24, the Administrator called off for similar symptoms and the Admissions/Marketing #160 left work near the end of her workday with similar GI symptoms. On 03/16/24, RN #67 and #167 called for similar GI symptoms. On 03/18/24, STNA #73, Housekeepers' #175 and #185 called off for similar GI symptoms. Review of an untitled facility document revealed five additional employees called off with illnesses from 03/11/24 through 03/18/24. On 03/12/24, housekeeper #198 called off due to being ill and on 03/16/24, STNA #60 called off due to being ill. Housekeeper #198 and STNA #60 were not listed on the infection control and prevention surveillance logs. Interview with IP Nurse #150 and the Director of Nursing (DON) on 03/19/24 at 1:53 P.M. verified the facility does not record, track, and follow up on employee call offs related to illness as part of their infection control and prevention program. IP #150 reported she was not aware she was required to track employee related illness as part of their infection control and prevention program. IP Nurse #150 and DON verified the ten employees identified as being part of the GI outbreak were not recorded on the facility's infection control and surveillance logs. IP Nurse #150 and DON reported any employee call-offs were directed to the Human Resource Manager. During reconciliation of the infection control surveillance logs and employee call-off documentation with IP #150 and DON on 04/01/24 at 12:40 P.M., revealed on 03/18/24, STNA #73, Housekeeper #175 and Housekeeper #185 called off for similar GI symptoms. IP #150 stated she was not aware that the employees had called off related to GI illness on 03/18/24 and after the date the facility determined the GI illness outbreak had ended. Review of a document titled Train - Training Plan Proof of Completion revealed IP Nurse #150 started the Nursing Home Infection Preventionist Training Course on 11/06/22 and completed the course on 03/19/24 and after the surveyor asked for verification of the Infection Preventionist certificate. Review of the facility policy titled, Infection Control Policy and Procedure, dated 2022, revealed the facility will designate an Infection Preventionist (IP) nurse who is responsible for the facilities infection control program. The IP will establish a program to prevent, identify, investigate, and control the infections of residents, staff (includes employees, consultants, contractors, volunteers, students in the nurse aide program, or academic institutions), and visitors. This included ongoing surveillance to identify possible communicable diseases or infections before they can spread to others in the facility. Review of the facility policy titled, Additional Infection Control Policies and Procedures, dated 2022, revealed the facility will have written occupational health policies that address reporting of staff illness and following work restrictions per nationally standards and guidelines and monitoring/evaluating for clusters or outbreaks of illness among staff. Further review of the policy revealed the facility surveillance system shall include a data collection tool and use of the nationally recognized surveillance criteria such as the Centers for Disease Control (CDC) and National Healthcare Network Safety Network (NHSN) Long Term Care Criteria to define infections.

Based on observation, record review, and interview, the facility failed to document and assess bruising of unknown origin. This affected one (Resident #21) of two residents reviewed for skin conditions. The facility census was 51. Findings include: Review of the medical record for Resident #21 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly comprehensive assessment dated [DATE] revealed Resident #21 had severe cognitive deficits and no skin issues. Review of physician orders [REDACTED]. Review of weekly skin assessments dated 04/04/19 and 04/11/19 revealed skin was warm and dry and no areas noted. Review of the care plan revealed Resident #21 was at risk for skin breakdown related to decreased mobility, decreased strength, incontinence, resistance to care and refusal to be repositioned in bed. Observation and interview was conducted on 04/09/19 at 8:55 A.M. and on 04/11/19 at 9:41 A.M. with Resident #21. He had dark purplish red bruising to the top of both hands. He stated he did not know what happened and denied any staff abuse. During interview was on 04/11/19 at 9:41 A.M., the Director of Nursing verified the bruising to the resident's hands. She stated the origin of the bruising had not been investigated and should have been identified on the weekly skin assessment dated [DATE].

Based on record review and staff interview, the facility failed to issue the correct liability notices, when Medicare Part A Services were terminated to two residents. This affected two (Residents #12 and #36) of three reviewed for liability notices. The facility census was 51. Findings include: 1. Review of Resident #12's medical record revealed a readmission date of [DATE] with a Medicare Part A skilled services episode start date of 02/10/19 and a last covered date of 03/28/19. On 03/28/19, Resident #12 was at her maximum potential for therapy services and was discharged from Medicare Part A services and remained in the facility. Review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review revealed Resident #12 did not receive a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when she was discharged from Medicare Part A Services as she was noted to have not received non-covered services and went back to private pay but remained in the facility. 2. Review of Resident #36's medical record revealed an admission date of [DATE] with a Medicare Part A skilled services episode start date of 11/29/18 and a last covered date of 01/18/19. Further review of the medical record revealed Resident #36 was at her maximum potential for therapy services and was discharged from Medicare Part A services on 01/18/19 and remained in the facility. Review of the SNF Beneficiary Protection Notification Review revealed Resident #36 did not receive a SNF ABN when she was discharged from Medicare Part A Services as she was noted to have remained in the facility under Medicaid. During interview on 04/11/19 at 2:43 P.M., Business Office Manager #61 stated she was unaware the regulation required residents who were discharged from Part A services and remained in the facility were to have received the SNF ABN notice.

Based on medical record review, hospital documentation, staff interview, and review of facility admission checklist, the facility failed to ensure admission physician orders [REDACTED].#52) resulting in a significant medication error. This resulted in actual harm when Resident #52 did not receive her medication to treat her [MEDICAL CONDITION] for four days which resulted in the resident developing [MEDICAL CONDITION] with rapid ventricular response which resulted in a hospitalization and admission to the intensive care unit. This affected one (Resident #52) of three residents reviewed for medication reconciliation. The facility census was 50. Findings include: Review of the medical record for Resident #52 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE], readmitted to facility on 01/22/19, and discharged home on[DATE]. Review of the admission Minimum Data Set (MDS) assessment, dated 01/29/19, revealed Resident #52 was cognitively intact. Review of Resident #52's hospital Discharge to Extended Care Physician order [REDACTED].M., revealed a primary admitting [DIAGNOSES REDACTED]. Review of Resident #52's hospital Drug Summary Continuity of Care form, dated 01/10/19 at 10:00 A.M., revealed discharge medications included Cardiazem, dilitiazem [MEDICATION NAME], 240 milligrams (mg) extended release capsule daily. This medication is a calcium channel blocker/blood pressure medication which is also used to control [MEDICAL CONDITION]. Review of the resident's admission physician orders, dated 01/10/19, revealed the dilitiazem [MEDICATION NAME] 240 mg extended release capsule daily was not on the order sheet. Review of the Medication Administration Record [REDACTED]. Review of a progress note dated 01/15/19 at 4:10 A.M. revealed Resident #52 was complaining of shortness of breath when sitting up at bedside. The resident's pulse ranged from 88 to 110 beats per minute, was thready, and was irregular. The resident had respirations of 44 per minute (normal respiration rate is 12-20 per minute) and a pulse oxygen rate of 91% on two liters of oxygen via nasal cannula. The physician was notified and Resident #52 was sent by ambulance to the hospital. Review of a progress note dated 01/15/19 at 4:10 A.M. revealed Resident #52 was admitted to the hospital with [REDACTED]. Review of the hospital Chief Complaint documentation dated 01/15/19 at 9:00 A.M. revealed Resident #52 was found to be in chronic [MEDICAL CONDITION] with her heart rate markedly elevated. The note documented the resident had not been getting her [MEDICATION NAME] (dilitiazem [MEDICATION NAME]) in the nursing home for some reason. The resident was given intravenous [MEDICATION NAME] to control her heart rate. She had some mild congestive failure related to the elevated heart rate. Resident #52's heart rate was 170 beats per minute and irregular, respirations were 36 per minute, and the resident was in moderate respiratory distress. The physician's impression documented Resident #52 was suffering from [MEDICAL CONDITION] with rapid response and [MEDICAL CONDITION] secondary to the [MEDICAL CONDITION]. The treatment plan included admission to the intensive care unit (ICU). Review of the hospital Cardiology Consultation History and Physical documentation, dated 01/15/19 at 5:55 P.M., revealed the Resident #52 was in [MEDICAL CONDITION] due to missing medications and to restart the dilitiazem extended release every day by mouth and to taper the intravenous dilitiazem medication as tolerated. Review of a progress note dated 01/22/19 at 9:17 P.M. revealed the Resident #52 arrived back to the facility from the hospital. Interview with the Director of Nursing (DON) on 03/27/19 at 10:43 A.M. verified the staff did not transcribe Resident #52's [MEDICATION NAME] order from the hospital discharge medications. The resident missed four doses of the [MEDICATION NAME] and was sent to the hospital in a state of [MEDICAL CONDITION] with rapid ventricular response and placed in the intensive care unit. The DON stated a new charge nurse transcribed the orders upon admission and she missed the medication. The DON stated she disciplined staff involved and did training with staff. The DON verified she did not train all nursing staff and was not monitoring the new admissions checklist. Review of a facility Admission Readmission Checklist dated 12/06/18 revealed the admitting shift is responsible for admission orders [REDACTED]. The admission orders [REDACTED]. This deficiency substantiates Complaint Number OH 192.

Based on personnel file review, policy review and staff interview, the facility failed to ensure two employees had a [MEDICATION NAME](TB)test in their personnel file. This affected two of nine employee personnel records reviewed during the annual survey. This had the potential to affect all 41 residents residing in the facility. Findings include: 1. Review of personnel file for State tested Nursing Aide(STNA)#74 revealed a hire date of 11/17/17 and the file it was silent for a TB test for the past year. 2. Review of personnel file for STNA #79 revealed she was hired on 02/15/18 and the file was silent to a step two of the TB test. Interview with Payroll Director #60 on 03/15/18 at 12:25 P.M. revealed STNA #74 received her TB test with another Payroll Director who no longer worked at the facility and she stated there have been multiple attempts to get the test from an urgent care facility, but was unable to obtain it. She stated a new TB test was done on STNA #79 on that day, 03/15/18. She further stated she noticed STNA #79's step 2 wasn't done in a timely manner so the TB test was started all over that day, 03/15/18. Review of facility's TB Control Plan, dated 05/08/17, revealed all personnel who were in contact with the residents shall be screened for TB on hire before working with the residents.

Based on record review, resident council meeting, resident and staff interviews, the facility failed to ensure the residents knew who the State Long-Term Care Ombudsman and purpose they serve. This had the potential to affect all residents except 15 residents who were identified by the facility to have severely impaired cognition (Resident #4, #12, #13, #14, #15, #18, #23, #27, #28, #31, #33, #34, #38, #42, and #96). The facility census was 41. Findings include: 1. Medical record review for Resident #2 revealed her comprehensive Minimum Data Set (MDS) assessment, dated 12/06/17, revealed she was moderately cognitively impaired. 2. Medical record review for Resident #6's revealed comprehensive MDS assessment, dated 12/15/17, revealed she was cognitively intact. 3. Medical record review for Resident #10 revealed her comprehensive MDS assessment, dated 01/08/18, revealed she was cognitively intact. 4. Medical record review for Resident #24 revealed her comprehensive MDS assessment, dated 01/18/18, revealed she was moderately cognitively impaired. 5. Medical record review for Resident #39 revealed her comprehensive MDS assessment, dated 02/02/18, revealed she was cognitively intact. Review of the facility's list of residents with severe cognitive impairments revealed Resident #4, #12, #13, #14, #15, #18, #23, #27, #28, #31, #33, #34, #38, #42, and #96 had severe cognitive impairments. Observation and resident interview of a resident council meeting, on 03/14/18 at 11:25 A.M., revealed there were five residents (#2, #6, #10, #24, and #39) in attendance. Activities Director #23 was also in attendance and invited by the Resident #6 who was the resident council president. Interview with these five residents revealed they did not know about the State Long-Term Care Ombudsman office and the purpose they serve. Even though Resident #2 and #24 had impaired cognition, they were able to answer resident council interview questions appropriately. Review of resident council minutes from 01/23/17 through 02/28/18 revealed there was no discussion concerning the State Long-Term Care Ombudsman's program information and contact information. Interview on 03/14/18 at 12:53 P.M. with Activities Director #23 verified she did not discuss the State Long-Term Care Ombudsman in resident council meetings at any of the meetings since 01/23/17. She stated she should have and it would need to be discussed more than just once. Interview with the Director of Nursing on 03/14/18 at 2:00 P.M. verified she didn't know who the Ombudsman representative was for the facility.

Based on medical record review, observation, and interview, the facility failed to ensure a call light was within reach for Resident #22. This affected one (#22) of 24 reviewed for call lights during the annual survey. The facility census was 41. Findings include: Medical record review for Resident #22 revealed he was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of his comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he was moderately cognitively impaired and required limited assistance from staff for bed mobility, required extensive assistance from staff for transfers and was always continent for bowel and bladder. Review of the resident's care plan with target date of 04/30/18 revealed Resident #22 was a fall risk and an intervention was to be sure the call light was within reach. Observation on 03/13/18 at 9:30 A.M. revealed Resident #22 was sitting in his recliner and his call light was lying in the floor out of reach to the resident. Another observation on 03/14/18 at 9:07 A.M. revealed Resident #22 was sitting in his recliner and his call light was lying over the bed out of reach to the resident. Interview on 03/13/18 at 9:40 A.M. with Licensed Practical Nurse #49 verified the call light for Resident #22 was lying on the floor and should have been within reach of the the resident.

Based on medical record review and staff interview, the facility failed to ensure Resident #45 was provided written notice regarding the facility's bed hold policy when he was sent to the hospital. This affected one(#45)of two residents reviewed for bed hold notices. The facility census was 41. Findings include: Medical record review revealed Resident #45 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Review of his comprehensive Minimum Data Set (MDS) assessment, dated 02/26/18, revealed he was cognitively intact. His medical [DIAGNOSES REDACTED]. Review of progress note dated 03/01/18 revealed Resident #45 was having left sided chest pain at 12:15 P.M. and was documented he was sent out to the hospital at 12:30 P.M. review of the resident's medical record revealed [REDACTED]. Interview with the Administrator on 03/15/18 at 1:45 P.M. verified the facility did not provide the resident with the facility's bed hold policy. The Administrator stated he was under the impression if a resident was on Medicaid services and went to the hospital, they would be provided with bed hold information and stated Resident #45 was private pay at the time of hospitalization .

Based on record review and staff interviews, the facility failed to accurately complete comprehensive assessment for Resident #38. This affected one (#38) of 30 sampled residents. Findings include: Record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A urinalysis lab report dated 01/13/18 with the final version dated 01/19/18 revealed a positive culture report for [MEDICAL CONDITION] (MRSA) that had been treated with [MEDICATION NAME] (antibiotic) capsule 100 milligrams (mg.) one capsule by mouth every 12 hours for seven days with a start date on 01/16/18. Review of the resident's significant change Minimum Data Set (MDS) assessment, dated 01/30/18, revealed the resident was cognitively impaired. The MDS assessment was silent for the [DIAGNOSES REDACTED]. On 03/15/18 at 10:20 A.M., an interview with Registered Nurse (RN) #27 verified the resident's significant change assessment was inaccurate and did not capture the resident had [MEDICAL CONDITION] diagnosis. The RN verified [MEDICAL CONDITION] infection should have been marked on this MDS assessment.

Based on observation, record review and staff interview, the facility failed to ensure Resident #39's food preferences were followed. This affected one (#39) of forty one residents reviewed for dining. The facility census was 41. Findings include: Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's physician orders [REDACTED]. Review of Resident #39's dietary meal ticket revealed the resident disliked included green peas. Observation on 03/14/18 at 05:16 P.M. revealed Resident #39 was seated at a table in the dining room eating a sandwich and there were also green peas on her dinner plate that appeared untouched. An interview was conducted on 03/14/18 at 5:21 P.M. with the Director of Food Service and she confirmed that Resident #39's dietary meal ticket listed her dislikes included peas. The Director of Food Service stated that if any one of the dislike items came up on the menu they would automatically give Resident #39 a substitute. She stated Resident #39 could have green beans as a substitute. Further interview on 03/14/18 at 5:28 P.M. with the Director of Food Service verified Resident #39 had a green peas on her dinner plate. Another interview on 03/15/18 at 10:43 A. M. with the Director of Food Service reported Resident #39 was mistakenly given green peas because they were out of green beans.

Based on observation, staff interview, and policy review, the facility failed to ensure cooking equipment was maintained in a sanitary manner. This had the potential to affect 45 of 45 residents who receive food from the kitchen. The facility identified two (Resident #45 and #47) resident who currently receive nothing by mouth. The facility census was 47. Findings include: Observation on 01/03/17 at 8:58 A.M. during initial tour of the kitchen revealed there was a build up of dirt on the hood filters above the stove in the cooking area. Interview on 01/03/17 at 8:58 A.M. with Dietary Manager (DM) #170 confirmed the build up of dirt on the hood filters above the stove in the cooking area of the kitchen. Interview on 01/04/17 at 1:06 P.M. with DM #170 verified the hood filters were not cleaned weekly as per the facility cleaning policy. Review of facility policy titled Hoods/Filter revised 08/08 revealed filters were to be cleaned at least weekly.

Based on medical record review and staff interview, the facility failed to develop a plan of care for a resident who declined in urinary continence. This affected one ( Resident #11) of three residents reviewed for urinary incontinence. The facility census was 47 residents. Findings include: Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] with the admitting [DIAGNOSES REDACTED]. Review of Resident #11's admission Minimum Data Set (MDS) assessment dated [DATE] and her quarterly MDS dated [DATE] both documented she understood others, made herself understood, and was moderately impaired for daily decision making skills. She had signs of [MEDICAL CONDITION] such as fluctuating inattention. She did not have signs of [MEDICAL CONDITION], negative behaviors, or reject care. She needed extensive one staff assistance with toileting. She was not on a toileting program. MDS [DIAGNOSES REDACTED]. The 11/04/16 MDS documented the resident was always continent of bladder and the 11/26/16 MDS documented she was occasionally incontinent of bladder. Review of Resident #11's medical record revealed the resident did not have a plan of care for incontinence. Interview on 01/04/17 at 1:45 P.M. with Registered Nurse (RN) #153, stated Resident #11 currently was occasionally incontinent. Interview on 01/04/17 at 4:50 P.M. with RN #153 verified the resident did not have a care plan to address urinary incontinence.

Based on observation, staff interview and facilities policy review, the facility failed to ensure infection control practices were followed for residents with Foley catheters. This affected one Resident (Resident #21) of three residents assessed for activities of daily living. The facility census was 47. Findings include: Medical record review of Resident #21 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of indwelling catheter care plan revealed that on 12/01/16 the resident returned from the hospital with indwelling catheter in place related to worsened necrotic pressure ulcer to sacrum. Observation on 01/05/16 at 9:04 A.M. revealed Resident #21 was resting in bed with bed in low position. The residents's foley catheter bag was not in a privacy bag and was resting on the floor. Interview on 01/05/17 at 9:05 A.M. with Registered Nurse (RN) #154 verified Resident #21's catheter was touching the floor. Review of facilities policy for Urinary Catheter Care dated 10/18/16 revealed the catheter tubing and drainage bag are to be kept off the floor.

Based on medical record review and staff interview, the facility failed to put into place interventions for a resident who had declined in urinary incontinence from always continent to occasionally incontinent. This affected one (Resident #11) of three residents reviewed for urinary incontinence. The facility census was 47. Findings include: Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] with the admitting [DIAGNOSES REDACTED]. Review of Resident #11's admission Minimum Data Set (MDS) assessment dated [DATE] and her quarterly MDS dated [DATE] both documented she understood others, made herself understood, and was moderately impaired for daily decision making skills. She had signs of [MEDICAL CONDITION] such as fluctuating inattention. She did not have signs of [MEDICAL CONDITION], negative behaviors, or reject care. She needed extensive one staff assistance with toileting. She was not on a toileting program. MDS [DIAGNOSES REDACTED]. The 11/04/16 MDS documented the resident was always continent of bladder and the 11/26/16 MDS documented she was occasionally incontinent of bladder. Review of Resident # 11's medical record revealed the resident did not have a plan of care or interventions in place for a decline in incontinence. Interview on 01/04/17 at 1:45 P.M. with Registered Nurse (RN) #153 revealed Resident #11 was currently occasionally incontinent. Interview on 01/04/17 at 4:50 P.M. with RN #153 verified that the resident was assessed as always continent of bladder on the admission assessment on 11/04/16 and declined to occasionally incontinent on 11/26/16. RN #153 could not give a reason for the decline and verified there was no care plan in place for the decline in incontinence. Interview on 01/04/16 at 5:42 P.M. with RN #153 stated Resident #11's decline in urinary continence was noted on 11/16/16 and they did a urine dip to rule out a urinary infection. RN #153 stated the dip had a trace of protein but she did not have a urinary infection. RN #153 stated an intervention was that the resident started therapy on 11/17/16. When questions about the reason for therapy, RN #153 stated it was to help with transfers and activities of daily living and verified it was not about the decline in urinary continence. Interview with Nurse Aid (NA) #113 on 01/05/17 at 9:30 A.M. denied Resident #11 was on a toileting program. She verified there were no interventions put in to place since the resident was admitted related to toileting or incontinence.

Based on observation and staff interview, the facility failed to dispose of trash in closed and contained trash receptacles. This had the potential to affect all 47 of 47 residents residing in the facility. Findings include: Observation on 01/03/17 at 8:58 A.M. during the initial tour of the outdoor area revealed two out of three dumpsters were noted with broken non-closing upper lids and one dumpster out of three with an opened side door. Interview on 01/03/17 at 8:58 A.M. with Dietary Manager (DM) #170 confirmed two dumpsters had broken lids and one dumpster had the side door left open. Follow up observation on 01/05/17 at 10:13 A.M. of the outside dumpsters revealed that two of the three dumpsters continued to have broken upper lids that did not close on top of dumpster and one of the three dumpsters with continued with the side door left opened. Follow up interview with DM #170 on 01/05/17 10:15 A.M. verified two of the three dumpsters did not have upper lids that close and one of the dumpsters side door was left opened. In addition, DM #170 stated the facility presently had no policy for trash disposal or receptacles.

Based on review of medical records, review of hospital records, interviews with facility staff, the attending physician, medical assistant and laboratory technologist, review of laboratory results and the Nursing Drug Handbook, 36th Edition, the facility failed to ensure a resident on oral anticoagulant therapy ([MEDICATION NAME]) who was having signs and symptoms of increased bleeding was monitored. This failure to monitor anticoagulant therapy resulted in Immediate Jeopardy and actual harm to Resident #30 when she was found to have a critically high [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) greater than 100 seconds (PT) and greater than 13.8 (INR) and blood in her urine and nares (nose). This affected one (#30) of 11 residents reviewed who received anticoagulant (blood thinning) medication. The facility census was 53. On 04/22/16 at 2:20 P.M., the Administrator, Director of Nursing (DON), and Licensed Practical Nurse (LPN) #22 were notified Immediate Jeopardy began on 02/28/16 when the facility failed to timely notify the physician Resident #30 was having signs and symptoms of bleeding. The resident continued to receive [MEDICATION NAME] 3 milligrams (mg) until the resident was sent out to the emergency room (ER) on 02/29/16 at 11:50 P.M. for treatment of [REDACTED]. Review of laboratory results dated [DATE] revealed Resident #30 had a critically high PT of greater than 100 seconds (normal reference range of 11.7 - 14.2 seconds) and an INR of greater than 13.8 (normal therapeutic range of 2.0 to 3.0). The resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. The resident was hospitalized for [REDACTED]. The Immediate Jeopardy was removed on 02/29/16 when the facility audited the medical records of all current residents receiving [MEDICATION NAME] anticoagulant therapy to ensure each had current physician and laboratory orders for anticoagulant therapy monitoring, and to ensure the PT/INR levels were within acceptable therapeutic ranges, and the facility implemented the following corrective actions: · On 02/29/16 at 11:50 P.M., Resident #30 was sent to the ER for treatment of [REDACTED]. · Since 02/29/16, review of the medical records of all current residents receiving anticoagulant therapy revealed the residents were monitored appropriately and stable overall. The audits demonstrated on-going monitoring of all residents ' anticoagulant regimen and laboratory results, with evidence of timely adjustment when indicated. · On 04/21/16 at 2:00 P.M., Registered Nurse (RN) #33 audited the medical records of all current residents receiving [MEDICATION NAME] to ensure each had a current care plan in place. · On 04/21/16, the DON (or designee) began new audits of all residents on anticoagulant therapy, every day for seven days, then weekly for four weeks to include charting of signs and symptoms of bleeding. · On 04/21/16 and 04/22/16, the DON and LPN #22 began in-services to all full time and part time nurses addressing [MEDICATION NAME] administration, the signs and symptoms of bleeding, documentation of the assessment of signs and symptoms of bleeding, abnormal laboratory results and immediate communication with the physician. · On 04/26/16, the DON (or designee) began new audits of correct procedures for facsimile form completion every day for seven, then weekly for four weeks. · Audits will be referred to the Quality Assurance Committee for on-going recommendations. · On 04/29/16 between 4:20 P.M. and 4:35 P.M., LPN #21, #22, #29 and RN #30 were interviewed regarding the in-service they received addressing signs and symptoms of bleeding, documentation of assessment of signs and symptoms of bleeding to be completed each shift, notification of abnormal laboratory results and the need to immediately contact the physician. All staff interviewed was able to correctly articulate the information given in the in-service. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: Review of the medical record for Resident #30 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the plan of care for anticoagulant medication therapy, dated 11/25/13, revealed interventions to complete laboratory tests as ordered by the physician and to report any abnormal laboratory results to the medical doctor. Interventions also included to monitor/document and report to the medical doctor as needed signs and symptoms of anticoagulant complications identified as blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, lethargy, shortness of breath, and sudden changes in mental status. Review of the physician's order [REDACTED]. Review of the 02/2016 Medication Administration Record [REDACTED].M. including 02/28/16 and 02/29/16. Review of the nurse ' s progress note completed by LPN #15 on 02/28/16 (Sunday) at 5:43 A.M. revealed the resident was noted with a dark discoloration in her attends (incontinence brief) and an occasional nonproductive cough with decreased breath sounds. A facsimile was sent to the attending physician. Review of the facsimile dated 02/28/16 at 5:47 A.M. revealed Resident #30 was noted with a small amount of blood and a dark discoloration in her attends. LPN #15 requested to obtain a urinalysis with a culture and sensitivity laboratory test. The area for related medications and laboratory results was left blank. Physician #45 answered the facsimile on 02/29/16 at 8:31 P.M. (approximately 39 hours later) with an approval to complete the laboratory test. Review of the nurse ' s progress note documented by LPN #15 on 02/29/16 at 3:46 A.M. revealed the resident continued with dark discoloration in attends, bloody in appearance, and a laboratory request was written to draw a PT/INR today instead of on 03/01/16. The original order was to draw PT/INR every month and the last PT/INR was drawn on 02/02/16. Review of the laboratory results dated [DATE] at 6:00 A.M. revealed the blood quantity was not sufficient to test for PT/INR. A redraw was completed on 02/29/16 at 2:40 P.M. and the problem was noted as the result for the PT/INR was outside the defined limits of the assay. A STAT (immediate) laboratory redraw to the hospital was ordered by the laboratory. Review of the laboratory results obtained from a local hospital ' s laboratory department dated 02/29/16 at 6:57 P.M. revealed a PT greater than 100 seconds and an INR greater than 13.8. Review of the progress note dated 03/01/16 at 12:00 A.M. revealed at 11:15 P.M. a critical laboratory value was called in from the laboratory company from a local hospital ' s laboratory department and revealed the PT was greater than 100 seconds and the INR was greater than 13.8. The resident was very lethargic and difficult to arouse. Physician #45 was notified and an order was received to send the resident to the ER for treatment and evaluation. Nine-one-one (911) was called and the squad arrived at the facility at 11:50 P.M on 02/29/16. Review of the hospital records dated 03/04/16 revealed Resident #30 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. The resident required a blood transfusion of six units of fresh frozen plasma, one unit of packed red blood cells, and was hospitalized for [REDACTED]. Interview with the DON on 04/21/16 at 3:20 P.M. revealed her expectation would be for the nurse to notify the physician if a resident on [MEDICATION NAME] was showing signs and symptoms of bleeding. The DON also stated if the physician did not respond back timely to a facsimile concern, then a telephone call should be made. The DON stated it is expected for the nurse to list related medications on the facsimile sheet. The DON verified LPN #15 had failed to list the resident was on [MEDICATION NAME] on the facsimile. The DON also stated the medical director could be contacted if a nurse could not get a hold of the attending physician. Interview with LPN #19 on 04/22/16 at 8:30 A.M. revealed she worked on 02/29/16 and took care of Resident #30. She stated she did not remember if it was reported to her the resident had signs and symptoms of bleeding. She denied the resident had any bleeding on her shift. LPN #19 stated she received a telephone call from the laboratory company the PT/INR results were outside of the defined assay and they were going to come and redraw the laboratory test. LPN #15 stated she did not know what the laboratory result meant and she did not notify the physician. She stated she did medicate the resident with the [MEDICATION NAME] as scheduled on 02/29/16. Telephone interview with attending Physician #45 on 04/22/16 at 9:35 A.M. revealed she normally orders PT/INR to be drawn every month unless the resident is on medications that cause interactions or if the resident is on an antibiotic. Physician #45 stated she would expect the medications to be listed on the facsimile sheet especially when being notified at 5:40 A.M. She further stated if she was notified Resident #30 was on [MEDICATION NAME] she would have ordered a STAT PT/INR. She also stated if a resident who is on [MEDICATION NAME] has blood coming out of an orifice, the staff should call immediately. Physician #45 stated sometimes she will not send facsimiles back for 24 hours. Interview with Laboratory Technologist #46 on 04/22/16 at 9:50 A.M. revealed when a laboratory result is reported as being outside the defined limits of the assay it means the laboratory machines could not detect the high count so it has to be sent to the hospital. She stated the laboratory instruments can only test a PT of up to 150 seconds. Therefore, if the PT was outside the defined limits of the assay that meant it was greater than 150 seconds. Interview with Medical Assistant #47 on 04/22/16 at 10:50 A.M. revealed there is no one in the office to answer facsimiles on Sundays. She stated the facsimiles go into a computer system and in order for Physician #45 to see them on the weekend she would have to log into the system from home. Interview with LPN #15 on 04/22/16 at 11:07 A.M. revealed she was told by a State tested Nurse Aide (STNA) on 02/28/16, Resident #30 had a dark discoloration in her attends. LPN #15 could not remember which STNA had told her. LPN #15 stated she completed an assessment and took Resident #30 ' s vitals. She stated she notified Physician #45 by facsimile. She verified it was on a Sunday and the physician would not have received the facsimile until Monday. LPN #15 was aware the resident was on [MEDICATION NAME] and she believes she reported it to the oncoming nurse, but could not remember what nurse she reported to. LPN #15 stated on 02/29/16 there was blood in Resident #30 ' s attends again and the resident was scheduled to have a PT/INR completed on 03/01/16. LPN #15 stated she moved the PT/INR up a day to 02/29/16. LPN #15 stated she did not notify the physician about changing the laboratory test day or the blood in Resident #30 ' s attends on 02/29/16. Interview with Resident #30 on 04/22/16 at 12:42 P.M. revealed she does not know how long she has been in the facility and does not remember any instances of bleeding or being sent out to the hospital. Interview with STNA #17 on 04/22/16 at 2:30 P.M. revealed Resident #30 had a lot of blood in her attends and she notified LPN #15 on 02/28/16. She stated the resident had been bleeding for three days before she was sent out to the hospital. Interview with STNA #24 on 04/22/16 at 2:50 P.M. revealed Resident #30 had blood in her attends on 02/29/16 at 6:30 A.M. when she checked the resident. She stated she told the nurse, and the nurse said to just keep an eye on it. STNA #24 stated she had never seen bloody red pink discharge coming from a resident before and knew it was blood on her incontinence brief. Review of the Nursing Drug Handbook, 36th edition, identifies [MEDICATION NAME] as an anticoagulant and used as treatment of [REDACTED]. The medication should be used with caution and the most serious risk of therapy is hemorrhage. The dosage is adjusted according to the INR results and the elderly tend to require lower dosages to produce a therapeutic level of anticoagulation. Under black box warning it indicates to regularly inspect patient for bleeding gums, bruises on arms or legs, petechiae (red or purple spots on the skin), nosebleeds, melena (dark and sticky stools), tarry stool, hematuria and hematemesis (blood in vomit). This deficiency substantiates Complaint Number OH 890.

Based on observations, record review, and staff interview, the facility failed to ensure one of two residents (Resident #28) reviewed for falls received adequate supervision and assistive devices to prevent falls. This resulted in harm for Resident #28 when she fell from her wheelchair and experienced severe facial trauma, including a right orbital fracture. The facility identified at least 19 residents who were at high risk of falls. The facility census was 65. Findings include: Observations were conducted in the facility during the morning of 01/09/14. At approximately 9:30 A.M., Resident #28 was observed sitting in a wheelchair in the front lobby of the facility. She was observed to have massive bruising and swelling across her entire face. Upon questioning of staff, State tested Nursing Assistant #1 (STNA #1) stated Resident #28 had experienced a fall on the previous Sunday. Review of the medical record for Resident #28 revealed she was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The plan of care for Resident #28 indicated she was at high risk for falls. Further review of the medical record for Resident #28 revealed on 01/05/14 at 1:10 P.M., the nurse was called to the 200 hall by a state tested nursing assistant. Resident #28 had been sitting in her wheelchair on the 200 hall, but was now observed lying in the middle of the hall with her wheelchair behind her. She was lying on her right side face down facing the floor and blood was noted under her head. A laceration was noted to the resident's right cheek below her eye. The right side of her nose was swollen, deformed and bruising rapidly. Blood was noted to her right nares. Review of the fall investigation for Resident #28's fall on 01/05/14 revealed the sensor pad alarm on her wheelchair was alarming. It was noted that the resident had fallen to the floor from her wheelchair. She was observed lying on her side, wearing eyeglasses, shoes, and was fully dressed. The fall investigation indicated injury was noted to the right side of her face (nose, around eye, cheek). The investigation indicated the resident was sent to the hospital emergency room for evaluation and was diagnosed with [REDACTED]. Review of the physician's orders [REDACTED].#28's fall, in addition to the alarming sensor pad, was a wedge cushion. The fall investigation did not indicate there were any other fall interventions in place other than the alarming sensor pad at the time of Resident #28's fall. An interview with the Director of Nursing (DON) on 01/09/14 at 2:30 P.M. confirmed she was in the facility at the time of Resident #28's fall on 01/05/14 and she stated she did not believe the wedge cushion was in place at the time of her fall and she confirmed the fall investigation did not indicate the wedge cushion was in place. Further review of the fall investigation for Resident #28 revealed a new intervention that was ordered by the physician on 01/05/14 when she returned to the facility from the emergency room was an alarming self releasing seat belt (when available). Observation of Resident #28 on 01/09/14 at 12:15 P.M. with the DON and Licensed Practical Nurse #2 (LPN #2) revealed Resident #28 did not have a self releasing seat belt in place and did not have a wedge cushion in place. The DON confirmed the resident should have had a wedge cushion in place. The DON also stated the facility had attempted to apply the self releasing alarming seatbelt to Resident #28 after she returned to the facility on [DATE], but found that the alarm box was not functioning on the seatbelt. She stated a new self releasing seat belt had been ordered, but had not yet arrived. The DON confirmed that Resident #28 had the same interventions in place today as she had on 01/05/14 when she fell from her wheelchair and experienced severe facial trauma, including a right orbital fracture. The DON stated the facility did have other "sister" facilities within their organization from which they could obtain supplies if absolutely necessary, but had not obtained the self releasing alarming seatbelt for Resident #28. Further review of the fall investigations for Resident #28 revealed the resident had experienced at least eight falls since their last annual survey in April, 2013. A fall investigation of 09/09/13 revealed at that time, the physician ordered the wedge cushion. However, the resident had another fall on 09/23/13 and there was no evidence that the wedge cushion was in place at the time of that fall either. Additionally, the fall investigation of 09/23/13 stated "continue current interventions to prevent serious injuries from falls". Further review of the plan of care for Resident #28 revealed no evidence that a wedge cushion had been ordered by the physician nor that the wedge cushion should be in place to prevent further falls. The plan of care also indicated the resident used a "chair/bed electronic alarm". However, the plan of care did not indicate what type of electronic alarm was ordered for use with Resident #28. An interview with Licensed Practical Nurse #1 (LPN #1) on 01/09/14 at 2:00 P.M. confirmed the wedge cushion ordered by the physician for Resident #28 to help prevent falls was not addressed on the resident's plan of care. Further, LPN #1 confirmed the plan of care only identified the use of "electronic alarm" and did not specify what type of electronic alarm had been ordered for Resident #28 to prevent falls. An interview was conducted with State tested Nursing Assistant #1 (STNA #1), State tested Nursing Assistant #2 (STNA #2) and LPN #2 on 01/09/14 at 12:10 P.M. They stated the nursing assistants utilized a "STNA flow sheet" that outlined any fall interventions that should be in place for the residents to which they were assigned. Upon reviewing the STNA flow sheet for the 200 hall, there was no evidence that Resident #28 should have a wedge cushion in place. LPN #2 confirmed at that time that the flow sheet did not instruct the STNA's to use a wedge cushion and she confirmed that Resident #28 did not have a wedge cushion in place at the time of the observation. This is an incidental citation found during the investigation of Complaint Number OH 154.