Every finding on record at Continuing Healthcare of Toledo

Based on medical record review, staff and resident interviews, review of incidents and accident policy, review of hospital documentation, and review of emergency medical services (EMS) reports, the facility failed to provide assessments, care planning, and monitoring for two residents (#2 and #3) identified with a substance abuse history and failed to investigate incidents when two residents were discovered to have experienced an overdose. This resulted in Immediate Jeopardy and serious life-threatening harm, injuries, and/or negative health outcomes when Resident #2 and Resident #3 were able to obtain and consume drugs they did not have prescriptions for resulting in Resident #2 having three episodes of being found unresponsive within a 32-hour timeframe requiring the administration of Narcan (medication to reverse opioid overdose), transfer to the emergency department (ED), and a resulting hospital admission. Furthermore, Resident #3 was discovered unresponsive with no pulse, required cardiopulmonary resuscitation (CPR), Narcan administration, and transfer to the ED where the resident was intubated and placed on mechanical ventilation prior to hospital admission. This affected two (#2 and #3) of five (#1, #2, #3, #9, #16) residents reviewed for substance use disorder. The facility identified a total of 16 residents with history of substance use disorder in a facility census of 64. On [DATE] at 3:04 P.M., the Administrator and Director of Nursing (DON) were notified the Immediate Jeopardy began on [DATE] at 2:36 P.M. when Licensed Practical Nurse (LPN) #303 was called into Resident #2's room due to the resident having low blood pressure, not responding to a sternal rub, and her pupils were pinpointed. The staff administered two doses of Narcan and EMS was contacted. Resident #2 tested positive for benzodiazepines, which were not prescribed for her. On [DATE] at 11:30 A.M., Resident #2 was found unresponsive, was transported by EMS to the ED, was administered Narcan, and returned to the facility. Again on [DATE] at 10:24 P.M., Resident #2 was found unresponsive. The resident was administered Narcan, was transported by EMS to the ED, and was admitted to the hospital. Resident #2 again tested positive for benzodiazepines. Eight days later, on [DATE], Resident #3 was discovered unresponsive without a pulse or respirations. CPR was performed, Narcan was administered, and EMS transported the resident to the ED. The resident was intubated, placed on mechanical ventilation and admitted to the hospital. After Resident #3 left the facility, a small baggie containing a white powder was discovered in Resident #3's room. Following these instances with Resident #2 and Resident #3, the facility did not complete any type of investigation into how the residents obtained the substances ingested during their overdoses, did not complete any care planning for the residents' substance use disorder, and did not provide any increase in supervision/monitoring levels for either resident. The Immediate Jeopardy was removed on [DATE], when the facility implemented the following corrective actions: On [DATE], Resident #2 was discharged from the facility. On [DATE], the DON, Assistant Director of Nursing (ADON) #600, Licensed Social Worker (LSW) #800, and Administrator reviewed all resident medical records to identify any substance use disorder. Sixteen residents were identified. On [DATE], LSW #800, Minimum Data Set (MDS) Coordinator/Licensed Practical Nurse (LPN) #300, the Administrator, and ADON #600 completed social history assessments for the sixteen identified residents with substance use disorder. On [DATE], the facility drafted and implemented a new policy titled Illegal Drug Possession and Use by Residents Policy. The policy identifies illegal drugs, directs staff to an immediate response if drug use or possession is suspected, directs staff not to destroy or dispose of suspected evidence, what to do if a visitor is suspected of bringing in drugs, instructs the facility to conduct an investigation, and report any suspected criminal activity to the local law enforcement. The policy addresses resident care following stabilization, prevention of illegal drug possession and use, and documentation of any incidents. On [DATE] at 1:53 P.M., the DON and ADON #600 completed education to all staff related to substance use disorder. Information covered included: disorder explanation, how to identify potential sources, monitoring resident signs and symptoms, response to suspected substance, and implementation of the new policy Illegal Drug Possession and Use by Residents Policy. On [DATE], the Administrator educated the DON regarding discarding potential evidence or illegal contraband discovered in the facility. On [DATE], the facility began a new protocol on admission of new residents. The interdisciplinary team (IDT), which includes the DON, ADON #600, MDS Coordinator/LPN #300, Administrator, and social services, will review the social and medical history of residents and ensure appropriate interventions and screens are in place with staff education if substance use disorder is identified. Additionally, a social history assessment will be complete by social services upon admission within the first 24 to 48 hours, at readmission, and as needed. On [DATE], the IDT will begin monitoring the findings of the social and medical histories during their weekly risk meeting to ensure appropriate follow up. On [DATE], the facility implemented the baseline care plan will also include interventions/monitoring for substance use disorder history. The DON will monitor this for all new admission on an ongoing basis. On [DATE], the facility's Quality Assurance Performance Improvement (QAPI) met and implemented a QAPI monitoring tool used following every resident admission and readmission to monitor residents identified with substance use disorder have updated care plans, intervention/monitoring, a behavior contract as needed, and an order in place for monitoring. This will be reviewed daily by the Administrator and DON during clinical morning meeting. The Administrator is responsible to ensure the QAPI monitoring tool is completed following each admission/readmission. On [DATE], the Administrator and DON will complete, and review investigations are completed following any incidents involving resident use or possession of an illegal substance. This includes notifying any law enforcement. The Administrator will be responsible for monitoring the investigations are completed. All monitoring listed will be reviewed during facility QAPI reviews to ensure compliance. On [DATE], interview with LPN #302, Certified Nurse Aide (CNA) #203 and CNA #204 verified they had received education on [DATE] related to residents identified with polysubstance abuse and a new facility illegal drug possession policy. Although the Immediate Jeopardy was removed on [DATE], the deficiency remained 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: 1) Review of the medical record revealed Resident #2 admitted to the facility on [DATE]. Diagnoses included cervical disc displacement, quadriplegia, central cord syndrome, altered mental status, conversion disorder with seizures, psychoactive substance abuse, major depression, and hypertension. Review of the hospital community referral documentation dated [DATE] noted a hospital admission on [DATE] due to concerns for episode of unresponsiveness, potentially secondary to cerebral vascular event versus seizure like activity. The resident was found to have magnetic resonance imaging (MRI) findings suggestive of toxic metabolic encephalopathy as well as drug screen positive for cocaine. Hospital diagnoses included polysubstance abuse dating from [DATE]. Laboratory blood testing on [DATE] noted Resident #2 tested positive for the use of fentanyl. Review of the nursing admission assessment dated [DATE] revealed Resident #2 was admitted to the facility from the hospital due to being found unresponsive. The assessment documented Resident #2 was assessed with intact cognition, used drugs regularly, had a withdrawn mood, and required staff assistance with activities of daily living. Review of the MDS assessment dated [DATE] revealed Resident #2 had no upper or lower extremity range of motion deficit, was independent with eating, required assistance by staff for mobility and used a manual wheelchair. Review of a clinical nursing note dated [DATE] at 2:36 P.M. revealed LPN #303 was called into the room due to Resident #2 having a low blood pressure, Resident #2 was not responding to a sternum rub and her pupils were pinpointed. The Nurse Practitioner (NP), LPN #303 and two other nurses were at bedside during this time. LPN #303 called emergency transport (911) and then administered Narcan to Resident #2 twice, five minutes apart. Once EMS arrived, Resident #2's vital signs were stable, but the resident was still not responding to any stimuli. After about two to three minutes, EMS gave the resident another sternum rub and Resident #2 woke up. EMS decided not to transport Resident #2 due to being back at baseline. LPN #303 and another nurse obtained a urine sample to run a toxicology screen and obtained vital signs every two hours for 24 hours. Review of the EMS Run Report dated [DATE] at 2:44 P.M. revealed Resident #2 was assessed and returned to baseline. Resident #2 remained in the facility. Review of the laboratory (lab) urine drug screen results dated [DATE] at 3:03 P.M. revealed Resident #2's urine tested positive for benzodiazepines and cannabinoids. Resident #2's record revealed no physician orders for benzodiazepine medications or cannabinoids. Review of the physician orders on [DATE] at 4:00 P.M. revealed an order for the administration of Narcan Nasal Liquid four milligrams (mg)/milliliter (ml). One application alternating nostrils as needed for opioid overdose. Review of the clinical nursing note dated [DATE] at 11:31 A.M. documented LPN #303 entered Resident #2's room to take vital signs and noticed the resident was drooling and not responding to verbal stimuli. The resident's blood pressure (BP) was 87/65, heart rate was 206 beats per minute, and oxygen (O2) level was at 96 % on room air. The resident's pupils were dilated and non-reactive to light. LPN #303 and the ADON #600 were present in room. ADON #600 called the NP who gave a verbal order to send the resident to the hospital. LPN#303 called 911, the EMS arrived and the resident was transported to the local hospital ED. Review of the EMS Run Report dated [DATE] at 11:45 A.M. revealed Resident #2 was slumped over in the chair and lethargic. Facility staff reported the resident had a similar episode the prior day. The resident had pinpoint pupils, responded verbally occasionally, but would nod back off. The resident was moved to the ambulance and received Narcan 4 mg nasally. Approximately five minutes later the resident was considerably more alert, and her pupil's were now normal size. The resident's care was transferred to the hospital ED staff. Review of hospital ED documentation dated [DATE] noted Resident #2 arrived at 12:11 P.M. and was evaluated for altered mental status. Resident #2 reportedly awakened with a dose of Narcan from EMS technicians. The resident denied ingesting any substances. The nursing home reported the resident had an episode of unresponsiveness where she awakened with Narcan. Review of laboratory urine toxicology revealed a positive result for Cannabinoid. At 3:44 P.M. hospital progress notes revealed a suspect unintentional overdose, resident with history of polysubstance abuse. Resident to discharge back to nursing home and follow-up with neurology and psychiatry on an outpatient basis. Review of the clinical nursing notes on [DATE] at 5:09 P.M. revealed Resident #2 returned from the local hospital. No new orders were given. The resident was given intravenous (IV) fluids in the ED. The resident had returned to normal baseline. Review of EMS Run Report dated [DATE] at 10:00 P.M. revealed Resident #2 was found sitting in her wheelchair with an altered level of consciousness and constricted pupils. The resident was alert to verbal stimulation but unable to appropriately answer questions. The resident was known to have a history of narcotic abuse and reportedly overdosed both yesterday and earlier this morning while at the nursing facility. EMS administered Narcan 4 mg intranasally, resulting in improvement in level of consciousness. The resident was transported to the local hospital. Review of the clinical nursing notes dated [DATE] at 10:24 P.M. documented LPN #304 was alerted by Certified Nurse Aide (CNA) that while moving Resident #2 from the nurse's station to her room and bed the resident was stiff as a board. LPN #304 entered the room to find Resident #2 unresponsive, drooling, had weak hand grasps, and her pupils were pinpoint and non-reactive to light. Nine-one-one (911) was called at 10:24 P.M. and arrived at 10:30 P.M. EMS gave the resident Narcan twice, causing the resident to have slight movement again. The resident continued to be unresponsive to name being called. EMS transferred the resident to the local hospital. Review of EMS Run Report dated [DATE] at 2:20 A.M. documented the hospital called the facility and spoke with the nurse regarding Resident #2's appropriateness and baseline. The hospital staff reported the resident's urine was positive for cannabinoid and benzodiazepine. Review of the hospital history and physical dated [DATE] at 5:42 A.M. revealed Resident #2 presented to the ED with chief complaint of drug overdose. Urine drug screen in the ED and laboratory toxicology screen showed positive for benzodiazepine and cannabinoids. A computed tomography (CT) scan of the chest showed multiple pulmonary emboli (PE), including saddle embolus and emboli in the main and segmental branches. The resident was admitted to the hospital, administered blood thinners and vascular surgery was consulted. Review of the medical record revealed there was no care plan for the resident's substance use disorder. The record revealed no new interventions or increased monitoring/supervision was implemented following the incidents of overdose. The facility had not completed any investigation into Resident #2's ingestion of benzodiazepine medications. Interview on [DATE] at 2:55 P.M. the DON verified Resident #2 had a history of illegal drug use prior to being admitted to the facility; however, no plan of care or interventions had been implemented to prevent or monitor for illegal drug use while she was a resident at the facility. The DON verified no investigation had been documented following Resident #2's overdoses requiring Narcan administration to return to baseline. The DON stated on [DATE] the DON and ADON #600 searched Resident #2's room and found no illegal contraband or drugs. The local police were not contacted regarding the resident use of illegal drugs or related overdoses. Resident #2 remains in the hospital due to unrelated issues. The DON confirmed Resident #2 did not have a physician order for a benzodiazepine medication. Interview on [DATE] at 3:05 P.M., MDS Coordinator/LPN #300 verified Resident #2's medical record, including the plan of care, did not contain substance abuse prevention, monitoring or treatment interventions to prevent further occurrences. 2) Review of the medical record revealed Resident #3 admitted to the facility on [DATE]. Diagnoses included type 2 diabetes mellitus, open wound left upper arm, arthrodesis, altered mental status, convulsions, and psychoactive substance abuse with intoxication. Review of hospital community referral dated [DATE] revealed Resident #3 reported social history of drug use including heroin and marijuana. Review of the MDS assessment dated [DATE] revealed Resident #3 had intact cognition, range of motion impairment to bilateral upper extremities, and was dependent on staff for the provision of activities of daily living. Review of the physician orders revealed an order dated [DATE] at 12:00 P.M. for the administration of Narcan Nasal Liquid 4 mg/0.1 ml one spray alternating nostrils every three minutes as needed for opioid overdose. Review of the clinical nursing notes dated [DATE] at 6:59 P.M. revealed at approximately 6:15 P.M Registered Nurse (RN) #400 was notified by the CNA Resident #3 was unresponsive. RN #400 immediately responded with an additional nurse, Nurse #1. The resident was unresponsive, apneic, and pulseless. CPR was initiated immediately and the facility emergency/code response was activated. The CNA was instructed to call 911. Nurse #1 administered Narcan 4 mg intranasally at 6:16 P.M. per emergency protocol. Resident #3 was lowered safely to the floor to facilitate continued CPR. A second dose of Narcan 4 mg intranasally was administered at 6:18 P.M. due to continued unresponsiveness. At approximately 6:19 P.M. there was a return of spontaneous circulation (ROSC), and the resident had a palpable pulse. EMS arrived at approximately 6:21 P.M. and assumed care of the resident. On [DATE] at 7:00 P.M., RN #400 and another staff found a small, opened baggie containing a white substance on Resident #3's tray table. Review of EMS run report dated [DATE] at 6:22 P.M. documented upon arrival Resident #3 was assessed as unresponsive. EMS took over care and inserted an advanced airway. EMS placed an Intraosseous (IO) needle (needle that goes directly into the bone marrow for fluid delivery) to left distal femur and the resident now had agonal respirations. The resident was administered Narcan 2mg via the IO needle. The resident's respiratory effort improved a few minutes later, the airway was removed, and the resident was placed on 10 liters of oxygen per minute via a non-rebreather mask and transported to the hospital. Review of the hospital adult intensive care unit history and physical admission note dated [DATE] at 6:54 P.M. documented Resident #3 presented to the ED after a suspected overdose. She was found at the nursing facility without a pulse, not breathing, and was receiving CPR. She also received Narcan and woke up. Upon arrival she was confused and there was concern about her ability to protect her airway, so she was intubated emergently in the ED. The note documented Resident #3 reported current drug use of heroin. Review of the clinical nursing notes dated [DATE] at 3:13 P.M. documented Resident #3 returned to the facility. The note documented the resident stated I don't know what happened to me. All I remember is waking up in the hospital. Resident #3 admitted to using an illicit street drug prior to hospitalization but stated she did not remember who supplied it or what substance it was. Resident verbalized she has used illicit drugs in the past and stated, I should have talked to someone instead of taking the drugs when I felt the urge to use again. Per facility order, the resident was placed on a no-visitation restriction due to concerns unauthorized substances had previously been brought to the resident by visitors. Resident was informed of the restrictions and verbalized understanding. Review of the physician progress notes dated [DATE] at 8:44 A.M. documented Resident #3 was hospitalized on [DATE] for unresponsiveness and respiratory failure secondary to fentanyl overdose. She required intubation and mechanical ventilation, with Narcan administered emergently at the facility prior to transfer to the hospital. The resident has no acute withdrawal symptoms noted. She denies interest in formal addiction treatment but agreed to ongoing psychiatric and talk therapy follow-up. Review of the medical record revealed there was no care plan for the resident's substance use disorder. The record revealed no new interventions or increased monitoring/supervision was implemented following the incident of overdose. The facility had not completed any investigation into Resident #3's overdose. Interview on [DATE] at 7:39 A.M., LPN #301, identified to be assigned to Resident #3, was unaware of any resident utilizing illegal drugs or experiencing a drug overdose. LPN #301 was unable to provide any interventions utilized to prevent resident related illegal drug consumption. Interview on [DATE] at 1:10 P.M., CNA #200 and on [DATE] at 6:08 A.M. with CNA #201, who were assigned to Resident #3, both were unaware of any residents consuming illegal drugs or with a history of overdose. Interview on [DATE] at 2:55 P.M., the DON verified no plan of care was implemented to address Resident #3's history of illegal drug use. The DON could not provide any investigation related to the resident's drug overdoses or preventive measures implemented to prevent further illegal drug overdoses. The DON stated when the bag of white substance was discovered in Resident #3's room, the substance was wasted by the DON in a controlled substance waste kit. Law enforcement was not notified regarding Resident #3's drug overdoses and the unidentified substance in the resident's room. Interview on [DATE] at 3:05 P.M., MDS Coordinator/LPN #300 verified Resident #3's medical record did not contain a plan of care to address history of substance abuse or interventions to prevent further occurrences. Interview on [DATE] at 6:01 A.M., LPN #302, who was sometimes assigned to Resident #3, was aware Resident #3 experienced a drug overdose; however, LPN #302 was unaware of any resident specific interventions to prevent further occurrences. LPN #302 verified no care plan with interventions was in place to prevent illegal drug use and confirmed there was no information indicating Resident #3 was not to have visitors or was to have monitored visitation. Interview on [DATE] at 8:21 A.M., Resident #3 stated on [DATE] she contacted a person in the community to obtain fentanyl and subsequently consumed the substance. Resident #3 stated prior to residing in the facility she had previously consumed fentanyl. Review of the facility policy titled Incidents and Accidents, with a date of 2025, revealed it is the policy of the facility for staff to utilize point click care management report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. Conducting root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement (QAPI) to avoid further occurrences. Alert risk management and/or administration of occurrences that could result in claims or further reporting requirements. Meeting regulatory requirements for analysis and reporting of incidents and accidents. Licensed staff will utilize point click care risk management to report incidents/accidents and assist with completion of any investigative information to identify root causes. If necessary, law enforcement may be contacted for specific events. The nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information. Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions. If an incident/accident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the Director of Nursing and/or Administrator. This deficiency represents non-compliance investigated under Master Complaint Number 3084200.

Based on medical record review, and staff interview, the facility failed to develop a comprehensive plan of care to address a resident's substance use disorder. This affected one (#3) of five residents reviewed for care plan development. The facility identified 16 residents with a history of substance use disorder in a facility census of 64. Findings include:Review of the medical record revealed Resident #3 admitted to the facility on [DATE]. Diagnoses included type 2 diabetes mellitus, open wound left upper arm, arthrodesis, altered mental status, convulsions, and psychoactive substance abuse with intoxication. Review of hospital community referral dated 07/12/25 revealed Resident #3 reported social history of drug use including heroin and marijuana. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had intact cognition, range of motion impairment to bilateral upper extremities, and was dependent on staff for the provision of activities of daily living. Review of the medical record lacked a plan of care to address Resident #3's history of substance use. Interview on 07/20/26 at 3:05 P.M. MDS Coordinator Licensed Practical Nurse #300 verified Resident #3's medical record did not contain a plan of care to address history of substance abuse or interventions to prevent further occurrences. This deficiency represents non-compliance investigated under Master Complaint Number 3084200.

Based on medical record review and staff interview, the facility failed to ensure develop a baseline care plan at admission to address substance use disorder. This affected one (#2) out of five residents reviewed for resident care plan development. The facility identified 16 residents with a history of substance use disorder in a facility census of 64. Findings include:Review of the medical record revealed Resident #2 admitted to the facility on [DATE]. Diagnoses included cervical disc displacement, quadriplegia, central cord syndrome, altered mental status, conversion disorder with seizures, psychoactive substance abuse, major depression, and hypertension. Review of the hospital community referral documentation dated 06/12/26 noted a hospital admission on [DATE] due to concerns for episode of unresponsiveness, potentially secondary to cerebral vascular event versus seizure like activity. The resident was found to have a drug screen positive for cocaine. Hospital diagnoses included polysubstance abuse dating from 12/07/25. Laboratory blood testing on 06/06/26 noted Resident #2 tested positive for the use of fentanyl. Review of the nursing admission assessment dated [DATE] revealed Resident #2 was admitted to the facility from the hospital due to being found unresponsive. The assessment documented Resident #2 was assessed with intact cognition and used drugs regularly. Review of the record revealed no baseline care plan was developed to identify Resident #2's substance use prevention, monitoring or treatment interventions to prevent further occurrences of substance abuse. Interview on 07/20/26 at 3:05 P.M. the Minimum Data Set (MDS) Coordinator Licensed Practical Nurse (LPN) #300 verified Resident #2's medical record had no plan of care related to her substance abuse. This deficiency represents non-compliance investigated under Master Complaint Number 3084200.

Based on medical record reviews, observations, staff interviews, and review of facility policy, the facility failed to ensure respiratory equipment was maintained and stored in a sanitary manner. This affected two (Residents #54 and #58) of two residents reviewed for respiratory equipment. The facility census was 60.Findings include:1. Review of the medical record for Resident #54 revealed she was admitted on [DATE] with diagnoses including acute kidney failure, asthma, cataracts, difficulty walking, obesity, unspecified psychosis, depression, fatty liver, symptomatic epilepsy, cognitive communication deficit, heart failure, stage three chronic kidney disease, hypertension, gastrointestinal hemorrhage, and obstructive sleep apnea.Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #54 experienced mild cognitive impairment and did not display any behaviors at the time of the assessment. She utilized a walker and a manual wheelchair and required maximal assistance with transfers. Resident #54 required moderate assistance with activities of daily living. This assessment indicated she utilized dialysis services.Observation on 04/29/26 at 9:40 A.M. of Resident #54's private room revealed a nasal cannula on the floor next to an oxygen concentrator and the cannula was not labeled with the date it was initiated. Continued observation revealed a Continuous Positive Airway Pressure (CPAP) machine on the nightstand next to the bed. The tubing was not labeled with the date it was initiated and the mask was not covered to protect it from dust and germs. Additionally, there was a portable oxygen tank next to the dresser with a nasal cannula on the floor that was not labeled with date it was initiated.Interview on 04/29/26 at 11:55 A.M. with Licensed Practical Nurse (LPN) #101 confirmed the above observations of the respiratory equipment in Resident #54's room. LPN #101 stated oxygen and CPAP tubing should be dated, nasal cannulas should not be on the floor, and CPAP masks should be cleaned and bagged daily after use.Interview on 04/29/26 at 12:30 P.M. with the Director of Nursing revealed the facility did not have a policy or procedure regarding the maintenance of oxygen nasal cannulas and nebulizer tubing. Continued interview confirmed oxygen nasal cannulas should not be on the floor and tubing should be changed and labeled with the date of initiation once weekly.Review of facility policy titled, CPAP/BiPAP Cleaning, dated 2025, revealed CPAP masks should be cleaned and dried daily after use then stored in a plastic bag.2. Review of the medical record for Resident #58 revealed she was admitted on [DATE] with diagnoses including depression, anxiety, rheumatoid arthritis, osteoarthritis, hyperlipidemia and chronic obstructive pulmonary disease (COPD).Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #58 experienced mild cognitive impairment and did not display any behaviors nor refusals of care at the time of the assessment. She utilized a manual wheelchair, was dependent for transfers, and was independently mobile. Resident #58 required moderate assistance with activities of daily living.Observation on 04/29/26 at 11:35 A.M. of Resident #58's room revealed a nebulizer machine on her nightstand with tubing that was not labeled with the date it was initiated.Interview on 04/29/26 at 11:40 A.M. with Certified Nurse Assistant #102 confirmed the tubing connected to the nebulizer machine on Resident #58's nightstand was not dated.Interview on 04/29/26 at 12:30 P.M. with the Director of Nursing revealed the facility did not have a policy or procedure regarding the maintenance of nebulizer tubing. Continued interview confirmed nebulizer tubing should be changed and labeled with the date of initiation once weekly.This was an incidental finding found during the course of the complaint investigation.

Based on medical record review, observation, staff interviews, and review of facility policy, the facility failed to ensure medication was administered and stored in a secure manner. This affected one (Resident #58) of one resident reviewed for medication administration and storage. The facility census was 60.Findings include:Review of the medical record for Resident #58 revealed she was admitted on [DATE] with diagnoses including depression, anxiety, rheumatoid arthritis, osteoarthritis, hyperlipidemia and chronic obstructive pulmonary disease (COPD).Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #58 experienced mild cognitive impairment and did not display any behaviors nor refusals of care at the time of the assessment. She utilized a manual wheelchair, was dependent for transfers, and was independently mobile. Resident #58 required moderate assistance with activities of daily living.Observation on 04/29/26 at 11:35 A.M. of the bedside table in Resident #58's room revealed a medication cup with one green oblong pill, one white oblong pill, and four white round pills. Additionally, an inhaler was next to the medication cup. The nurse was not present in Resident #58's room.Interview on 04/29/26 at 11:40 A.M. with Certified Nurse Assistant #102 confirmed the above noted medications on Resident #58's bedside table.Interview on 04/29/26 at 11:50 A.M. with Licensed Practical Nurse #101 confirmed she was the nurse responsible for the above noted medication on Resident #58's bedside table. Continued interview confirmed residents should be observed consuming their medications when they are administered.Review of facility policy titled, Medication Administration, dated 2025, revealed nursing staff administering medications should observe the resident consuming their medications.Review of facility policy titled, Medication Storage, dated 2026, revealed medications would be under the direct observation of the person administering medications, or locked in a medication cart.This was an incidental finding found during the course of the complaint investigation.

Based on medical record reviews, staff interviews, and review of facility policy, the facility failed to notify residents' representatives when they experienced a change in condition. This affected two (Residents #54 and #58) of three residents reviewed for notifications. The facility census was 60.Findings include:1. Review of the medical record for Resident #54 revealed she was admitted on [DATE] with diagnoses including acute kidney failure, asthma, cataracts, difficulty walking, obesity, unspecified psychosis, depression, fatty liver, symptomatic epilepsy, cognitive communication deficit, heart failure, stage three chronic kidney disease, hypertension, gastrointestinal hemorrhage, and obstructive sleep apnea.Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #54 experienced mild cognitive impairment and did not display any behaviors at the time of the assessment. She utilized a walker and a manual wheelchair and required maximal assistance with transfers. Resident #54 required moderate assistance with activities of daily living. This assessment indicated she utilized dialysis services.Review of a progress note dated 02/02/26 for Resident #54 revealed she experienced chest pain and was sent to a local emergency room for treatment. There was no indication Resident #54's power of attorney (POA) had been notified of this change in condition.Interview on 04/29/26 at 3:15 P.M. with the Administrator revealed Resident #54's (POA) had not been notified of the change in condition SR #54 experienced on 02/02/26.2. Review of the medical record for Resident #58 revealed she was admitted on [DATE] with diagnoses including depression, anxiety, rheumatoid arthritis, osteoarthritis, hyperlipidemia and chronic obstructive pulmonary disease (COPD).Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #58 experienced mild cognitive impairment and did not display any behaviors nor refusals of care at the time of the assessment. She utilized a manual wheelchair, was dependent for transfers, and was independently mobile. Resident #58 required moderate assistance with activities of daily living.Review of a progress note dated 03/11/26 for Resident #58 revealed she was experiencing abdominal pains and spasms, and audible wheezing. Imaging, labs, and medications were ordered. There was no indication Resident #58's POA had been notified of this change in condition.Interview on 04/29/26 at 3:43 P.M. with the Administrator revealed Resident #58's POA had not been notified of the change in condition Resident #58 experienced on 03/11/26.Review of facility policy titled, Change in a Resident's Condition or Status, dated 02/26/25, revealed the facility would notify a resident's representative if they experienced a significant change in condition.This deficiency represents non-compliance investigated under Complaint Number 2985811.

Based on record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure resident water cups were clean and free from mold. The facility also failed to ensure there were no strong odors of urine in the facility. This affected one resident (#62) of four residents reviewed for a safe, clean environment. The facility census was 70. Findings include: Review of Resident #62's medical record revealed an admission date of 12/12/24. Diagnoses included metabolic encephalopathy, unspecified protein-calorie malnutrition, insomnia, hypertensive heart disease with heart failure, and hypertension. Review of Resident #62's care plan dated 09/22/25 revealed Resident #62 had functional bladder incontinence and required peri-care to be completed with each incontinence episode. Review of Resident #62's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 had severe cognitive impairment and was dependent for toileting and showers. Furthermore, Resident #62 was always incontinent of bowel and bladder. 1. Interview on 09/29/25 at 9:45 A.M. with Resident #62 revealed she would like to use her water cup but she did not know where her water cup was.Observation on 09/29/25 at 10:34 A.M. of Resident #62's water cup that was sitting on her dresser revealed a black substance to be on the bottom of the inside of the cup where there was approximately 60 milliliters of water. Floating on the top of the water was a small film and multiple areas in the water contained floating substances.Interview on 09/29/25 at 10:36 A.M. with Certified Nursing Assistant (CNA) #176 verified Resident #62's water cup contained a black substance that CNA #176 identified as mold.Interview on 09/29/25 at 3:04 P.M. with Dietary Manager (DM) #193 revealed the dietary staff were responsible for cleaning all the residents' water cups. Furthermore, DM #193 stated they did not have any documentation regarding the cleaning of resident water cups. DM #193 stated as a corrective action, the facility would be switching to disposable cups instead of regular cups.2. Observation on 09/29/25 at 9:27 A.M. of the hallway outside of Resident #62's room revealed an extremely strong odor of urine and stool coming from Resident #62's room. Interview on 09/29/25 at 9:45 A.M. with Resident #62 revealed her incontinence brief had been changed at approximately 8:45 A.M. on 09/29/25 but stated the staff did not wake her in the night to change her incontinence brief. Interview and observation on 09/29/25 at 9:49 A.M. with CNA #182 verified the strong smell of urine and stool in the hallway by Resident #62 ' s room. CNA #182 stated when she had changed Resident #62 ' s brief in the morning she did not have the chance to change the resident's bed sheets. Concurrent observation of Resident #62 revealed her mattress sheets were saturated in urine with stool present on the sheets. A strong odor of urine was present. CNA #182 confirmed Resident #62's sheets remained soiled and wet. Review of the facility policy titled Homelike Environment with a last revision date of February 2021 revealed residents should be provided with a safe, clean, sanitary, comfortable, and homelike environment that includes a clean bed and bath linens that are in good condition and pleasant, neutral scents.This violation represents non-compliance investigated under Complaint #2624787 and Complaint #2626557.

Based on record review, observation, resident interview, staff interview, and facility policy review, the facility failed to ensure residents received timely incontinence care. This affected one resident (#62) of three residents reviewed for incontinence. This had the potential to affect 39 residents who the facility identified as incontinent. The facility census was 70. Findings include: Review of Resident #62's medical record revealed an admission date of 12/12/24. Diagnoses included metabolic encephalopathy, unspecified protein-calorie malnutrition, insomnia, hypertensive heart disease with heart failure, and hypertension. Review of Resident #62's care plan dated 09/22/25 revealed Resident #62 had functional bladder incontinence and required peri-care to be completed with each incontinence episode. Review of Resident #62's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 had severe cognitive impairment and was dependent for toileting and showers. Furthermore, Resident #62 was always incontinent of bowel and bladder. Observation on 09/29/25 at 9:27 A.M. of the hallway outside of Resident #62's room revealed an extremely strong odor of urine and stool coming from Resident #62's room. Interview on 09/29/25 at 9:45 A.M. with Resident #62 revealed her incontinence brief had been changed at approximately 8:45 A.M. on 09/29/25 but stated the staff did not wake her in the night to change her incontinence brief.Interview on 09/29/25 at 9:15 A.M. it with Certified Nurse Aide (CNA) #182 revealed she had changed Resident #62's brief in the morning when she began her shift and Resident #62's incontinent care products were saturated with urine and stool from the overnight shift. CNA #182 stated the stool was stuck to the resident's skin. CNA #182 confirmed incontinent care was not timely completed for Resident #62. Interview and observation on 09/29/25 at 9:49 A.M. with CNA #182 verified the strong smell of urine and stool in the hallway by Resident #62's room. CNA #182 stated when she had changed Resident #62's brief in the morning she did not have the chance to change the resident's bed sheets. Concurrent observation of Resident #62 revealed her mattress sheets were saturated in urine with stool present on the sheets. A strong odor of urine was present, and Resident #62 had an incontinent brief with the securement tabs removed from the brief inside the brief she was wearing as an additional incontinent pad inside her brief. CNA #182 confirmed Resident #62's sheets remained soiled and wet, and confirmed the resident had multiple incontinent care products in use stating she was told by the facility to use an additional incontinence brief with the securement straps torn off as a pad inside resident's incontinent briefs. Interview on 09/30/25 at 2:56 P.M. with the Director of Nursing (DON) revealed possible adverse outcomes of incontinence care not being provided every two hours may include skin breakdown and Urinary Tract Infections (UTI). The DON stated they use liners in incontinence briefs for residents who are heavily incontinent and the briefs should be checked and changed every two hours. Review of the undated facility policy titled Perineal Care revealed perineal care would be provided to incontinent residents as needed to promote cleanliness and comfort, prevent infection, and prevent skin breakdown. This violation represents non-compliance investigated under Complaint #2624787.

Based on observation, medical record review, staff interview and facility policy review, the facility failed to maintain and monitor a resident's urinary catheter system. This affected one (#1) of two residents reviewed for a urinary catheter. The facility identified two residents (#1 and #3) with an indwelling urinary catheter. The facility census was 61. Review of the medical record revealed Resident #1 admitted to the facility on [DATE] with diagnoses including, quadriplegia, seizure disorder, mood disorder, neuromuscular dysfunction of bladder, protein calorie malnutrition, tracheostomy, gastrostomy, supra pubic catheter, urinary tract infection, and a tibia fracture. Review of the most current minimum data set assessment dated [DATE] revealed Resident #1 was cognitively intact and had no behaviors, had impaired range of motion to bilateral upper and lower extremities, was dependent on staff for the completion of activities of daily living including bed mobility, was incontinent of bowel, had a suprapubic catheter, received regular diet, and was at risk for pressure ulcer with no skin break down. Review of the nursing plan of care revealed the care plan was revised 04/11/25 to address Resident #1's use of a suprapubic urinary catheter due to neurogenic bladder. Interventions included positioning the catheter bag and tubing below the bladder, when providing assistance, check the tubing to ensure there is urine present and collecting in the catheter bag, empty the catheter drainage bag and as needed, notify the nurse if there is only a small amount or urine or none present in the drainage bag, or if the urine appears cloudy or dark yellow/brown. The care plan did not contain interventions to monitor the suprapubic stoma (catheter insertion site) or to record the amount of urine collected in the catheter drainage bag. Review of physician orders noted on 08/03/25 an order was initiated to cleanse suprapubic catheter with wound cleanser and apply dry dressing every day. According to the medical record no documentation indicated the suprapubic catheter site was cleansed with a dressing applied on 08/04/25, 08/05/25, 08/06/25, 08/19/25, 08/23/25, 08/24/25. The medical record also lacked assessment of the suprapubic catheter stoma site. Observation on 08/27/25 at 9:47 A.M. with Licensed Practical Nurse (LPN) #300 and Certified Nurse Aide (CNA) #200 noted Resident #1 in bed. CNA #200 exposed Resident #1 suprapubic insertion site (stoma) and verified no dressing was in place as ordered by the physician. Review of electronic task documentation lacked urinary output recorded each shift or for a 24-hour period on the following days; 07/30/25- None, 08/04/25 recorded once at 12:55 P.M.- 400 cubic centimeters (cc), 08/06/25- None, 08/16/25 at 6:29 A.M.- 1300 cc, 08/18/25 at 6:11 A.M.- 50 cc, 08/20/25- None, 08/21/25- None, 08/22/25 at 6:29 A.M.- 500 cc, 08/24/25- None, 08/26/25 at 9:38 P.M.-200 cc. On 08/27/25 at 2:40 P.M. interview with the Director of Nursing (DON) during a review of the medical record confirmed the lack of documentation regarding Resident #1 suprapubic catheter stoma condition, stoma site treatment application, and urinary output. Review of the facilities undated Catheter Care policy stated catheter care will be performed every shift and as needed by nursing personnel. Privacy bags will be changed out when soiled, and with a catheter change or as needed. Empty drainage bags when bag is half full or every three to six hours. This deficiency represents non-compliance investigated under Complaint Number 2594947.

Based on observation, staff interview, and review of a facility policy, the facility failed to provide a clean, well-maintained, and homelike environment. This had the potential to affect all 69 residents residing in the facility. Findings included: 1.) Observation on 07/28/25 at 9:14 A.M. of Resident #44's room revealed large spots on the floor by the resident bed, scuffs on the wall throughout the room, and two gouges on the floor each approximately three inches in diameter. Interview on 07/30/25 at 3:03 P.M. with the Administrator verified the large spots by the bed, scuff marks on the walls, and the two gouges on the floor. 2.) Observation on 07/28/25 at 10:03 A.M. of the common area in the 200-hall revealed dirt and debris coating the floor by the nurse's station. Interview on 07/30/25 at 3:03 P.M. with the Administrator verified the dirt and debris coating on the floor by the 200-hall nurse's station. 3.) Observation on 07/30/35 at 6:15 A.M. of the hall by four resident (#4, #5, #3, and #50) rooms revealed the wall to the left of Resident #50's rooms entry door was soiled with an unidentified black substance, the hallway flooring had eight cracked tiles, and the wall next to the entry to Resident #4's room was splattered with an unidentified brown substance. Interview on 07/20/25 at 6:18 A.M. with Licensed Practical Nurse (LPN) #208 verified there was an unidentifiable black substance by Resident #50's room, the hallway flooring had eight cracked tiles, and the wall next to the entry to Resident #4's room was splattered with an unidentified brown substance. 4.) Observation on 07/30/25 at 6:15 A.M. of the dining room in the 200-hall with Licensed Practical Nurse (LPN) #208 verified 14 spots of unidentified food on the floor, a cigarette butt by the scale, and the floor under the air filter was coated with an unidentified black substance and debris. Review of the facility policy titled Homelike Environment dated February 2021 revealed residents are provided with a safe, clean, comfortable, and homelike environment. This was an incidental finding discovered during the course of the complaint investigation.

Based on observation, test tray review, resident interview, staff interview, review of facility policy, and review of Food and Drug Administration (FDA) guidelines, the facility failed to ensure foods were served at a proper temperature and were palatable. This affected four residents (#32, #51, #54, and #62) of seven residents reviewed for food and had the potential to affect an additional 64 residents who received meals prepared by the kitchen. The facility identified Resident #66 as receiving no food from the kitchen. The facility census was 69. Findings included:Interview on 07/28/25 at 9:28 A.M. with Resident #62 revealed she eats all of her meals in her room and her meals were always cold when delivered and were typically not palatable. Interview on 07/28/25 at 9:30 A.M. with Resident #54 revealed she eats all of her meals in her room and while the quality of the food was acceptable, her meals were never warm when they were delivered to her. Interview on 07/28/25 at 9:39 A.M. with Certified Nursing Assistant (CNA) #201 revealed when resident food was delivered to resident rooms, it was typically room temperature.Interview on 07/28/25 at 9:45 A.M. with Resident #32 revealed the food served in the facility was not palatable. Interview on 07/28/25 at 11:15 A.M. with Dietary Manager #130 revealed there have been concerns voiced in Resident Council regarding the temperature of food and as a result of these concerns, the dietary department has instituted a new process of warming plates in the plate warmer and placing them on an insulated base and covering them with an insulated cover in an attempt to keep food warmer. Interview on 07/29/25 at 6:32 A.M. with Licensed Practical Nurse (LPN) #205 revealed she has received complaints from residents the food was not palatable.Interview on 07/29/25 at 7:54 A.M. with Registered Nurse (RN) #206 revealed he has received complaints from residents regarding the palatability and temperature of facility food. Observation on 07/29/25 from 12:15 P.M. through 12:22 P.M. of tray delivery to the 200-hall revealed all of the Jell-O on the trays was not appropriately set up and were in a liquid state.Interview on 07/29/25 at 12:25 P.M. with Dietary Manager #130 verified the Jell-O served was not adequately congealed and was in a liquid state. She stated the Jell-O was made the evening of 07/28/25 and she feels that it was not prepared with hot enough water to allow the gelatin to melt and congeal properly. Review of the test tray with Dietary Manager #130 and conducted on 07/29/25 at 12:27 P.M. revealed the contents of the tasting tray included a fish sandwich with American cheese, carrots, green beans, pears, and a carton of one-percent milkfat milk. Temperatures of the food on the test tray was conducted with a kitchen thermometer, the surveyor, and Dietary Manager #130 and the readings were as followed: Fish sandwich with American cheese 123 degrees Fahrenheit (F), carrots 110 degrees F, green beans 108 degrees F, and a the milk was 53 degrees F. The fish sandwich was cold, had a mushy texture, and was overwhelmingly salty, making it not palatable. Interview on 07/29/25 at 12:29 P.M. with Dietary Manager #130 verified the fish sandwich was served cold, had a mushy texture, was overwhelmingly salty, and unpalatable. Interview on 07/29/25 at 1:16 P.M. with Resident #51 stated she didn't like the fish sandwich and it was cold when it was delivered to her room. Interview on 07/29/25 at 1:26 P.M. with Residents #54 and #62 stated their lunch was cold and was not palatable. Review of the FDA Food Safety and Inspection Service Guidelines for Safe Food Temperatures, dated 07/18/17, revealed hot foods are to be served at temperatures of 140 degrees F or above and cold foods are to be served at temperatures of 40 degrees F or below. The temperature range between 40 degrees F and 140 degrees F is known as the danger zone and this temperature range allows for bacteria in food to grow. Review of the facility policy titled Food and Nutrition Services dated October 2017 revealed each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into considerate the preferences of each resident. This deficiency represents non-compliance investigated under Complaint Number OH00164298.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure the physician was notified when the resident refused their anti-seizure medications. This affected one (Resident #10) of three residents reviewed for notification of change. Findings include: Review of the medical record for Resident #10 revealed an admission date of 05/25/25. Diagnoses included epilepsy. Review of the Medicare five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. Review of Resident #10's physician order for July 2025 revealed an order for 1,000 milligrams (mg) of Keppra (a medication used to treat seizure disorders) to be administered orally (PO) twice a day (BID) for seizures. Review of the July 2025 medication administration record (MAR) for Resident #10 revealed on 07/19/25 Resident #10 refused her physician ordered dose of Keppra in the morning (AM) as well at bedtime (HS). On 07/20/25, Resident #10 refused her physician ordered dose of Keppra in the AM. The medical record including the MAR and progress notes did not indicate the physician was notified of Resident #10's refusal to take Keppra for three consecutive doses. Interview on 07/29/25 at 2:24 P.M. with the Director of Nursing (DON) verified there was no documentation the facility notified the physician of Resident #10's refusals of three consecutive doses of Keppra. Review of the facility policy titled Change in a Resident's Condition or Status dated February 2021 revealed the nurse will notify the resident's attending physician or physician on call when there has been a refusal or treatment or medications two or more consecutive times. This was an incidental finding discovered during the course of the complaint investigation.

Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure residents were provided with interventions to prevent skin breakdown in accordance with physician orders and nursing plans of care. This affected three (#1, #2, #3) of three sampled residents reviewed for skin integrity. Facility census was 69. Findings include: 1. Resident #1 admitted to the facility on [DATE] with diagnoses including, polyosteoarthritis, anemia, chronic fatigue, polyneuropathy, congestive heart failure, peripheral vascular disease, spondylosis, absence right leg above knee, and covid-19. According to the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had severe cognitive impairment, was dependent on staff for the completion of activities of daily living including bed mobility, always incontinent of bowel and bladder, and was at risk for pressure ulcer development with no skin breakdown. Review of nursing plans of care noted on 07/07/23 a care plan was developed to address Resident #1's potential/actual impairment to skin integrity related to fragile skin. Interventions included, follow facility protocols for treatment of injury, the resident needs low air loss mattress to protect the skin while in bed, and offloading boots to foot while in bed. Further review of the medical record discovered an additional plan of care dated 01/24/23 addressing Resident #1's bowel incontinence related to immobility with interventions including, check resident every two hours and assist with toileting as needed. On 08/30/24 a Braden scale for predicting pressure sore risk scored Resident #1 at risk for pressure sore development. According to weekly wound evaluation documentation dated 10/30/24 Resident #1 was assessed with a healed stage two pressure ulcer to the sacrum that was acquired on 10/09/24. Instructions included continued application of zinc. On 11/04/24 weekly skin observation documentation noted the resident with intact skin. Risk factors for impaired skin integrity were incontinence and limited mobility with interventions including check and change and low air loss mattress. Observation on 11/05/24 at 7:34 A.M. with Certified Nurse Aide (CNA) #201 discovered Resident #1 in bed with two incontinence briefs applied. Resident #1 was unable to indicate when last checked for incontinence or repositioning. CNA #201 stated she assumed care of Resident #1 at 7:00 A.M. and this was her first observation of the resident. CNA #201 went on to state CNA #202 provided care for the resident on the previous shift and had left the facility before CNA #201 received a report regarding the last incontinence check or repositioning for Resident #1. Resident #1 was also discovered without the offloading boot in place and Resident #1 left foot resting on the mattress surface. CNA #201 was unaware the offloading boot was to be applied and was unable to locate the boot in Resident #1's room. According to task, bowel and bladder monitoring documentation, Resident #1 was documented as incontinent on 11/04/24 at 9:23 P.M. with repositioning documented as taking place at 9:24 P.M. No further bowel and bladder tracking was documented in the medical record. On 11/05/24 at 7:45 A.M. interview with the Director of Nursing (DON) revealed residents are not to be double briefed due to creating an increased potential for skin breakdown and infections. CNA's are to document incontinence checks and repositioning in the medical record under tasks. The DON also stated resident skin breakdown interventions are contained in the nursing plan of care and also included incontinence frequency checks for the specific resident. 2. Resident #2 admitted to the facility on [DATE] with diagnoses including, rheumatoid arthritis, major depressive disorder, dysphagia, congestive heart failure, muscle wasting and atrophy, protein calorie malnutrition, anxiety disorder, hypertension, atrial fibrillation, type 2 diabetes mellitus, right eye blindness and atrioventricular septal defect. According to the most current MDS assessment dated [DATE] revealed Resident #2 had severe cognitive impairment, was dependent on staff for the completion of activities of daily living including bed mobility, always incontinent of bowel and bladder, and was at risk for pressure ulcer development with no current skin breakdown. On 09/19/24 Braden scale for predicting pressure sore risk scored Resident #2 at moderate risk for pressure sore development. On 09/21/24 a Bladder Incontinence Data Collection Tool was completed and Resident #2 was assessed as incontinent of bladder requiring staff to complete incontinence care. Resident does not verbalize the need to use toilet. A nursing plan of care was developed on 09/30/24 to address Resident #2's Activity of Daily Living (ADL) self-care performance deficit related to fatigue, impaired balance, limited mobility, vision loss, osteoarthritis, and episodes of pain. Resident transfers extensive assist of one but Hoyer lift with assist of two is often needed. Interventions included, the resident is totally dependent on one to two staff to provide bath/shower as necessary, for bed mobility, the resident requires extensive to dependent assistance by two staff, the resident is bedfast all or most of the time, the resident requires skin inspection with care, observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse, the resident is totally dependent on two staff for toilet use, and the resident is totally dependent on two staff for transferring. On 09/23/24 to address Resident #2's potential alteration in elimination frequently incontinent of bowel and bladder, interventions included the following: monitor for skin redness and irritation and provide incontinent care as needed (PRN). No frequency was indicated related to providing turning or repositioning or checking the resident for incontinence episodes. On 11/04/24 weekly skin observation documentation noted the resident with intact skin. Risk factors for impaired skin integrity were incontinence and limited mobility with interventions including check and change and low air loss mattress. According to task, bowel and bladder monitoring and repositioning documentation, Resident #2 was documented as incontinent on 11/04/24 at 11:48 P.M. No further bowel and bladder tracking or reposition was documented in the medical record. Observation on 11/05/24 at 7:02 A.M. noted Resident #2 in bed. Certified Nurse Aide (CNA) #203 entered the room and proceeded to complete an incontinence check. CNA #203 discovered Resident #2 had two adult incontinence briefs applied and the resident was soiled of a moderate amount of urine. CNA #203 indicated she had just assumed the shift at 7:00 A.M. and was unaware when the resident was last provided with an incontinence care. CNA #203 stated CNA's were informed by nurses not to place two briefs on residents. On 11/05/24 at 7:08 A.M. interview with Licensed Practical Nurse (LPN) #301 revealed she was unaware Resident #2 was placed in two incontinence briefs and was unaware when the resident was last provided repositioning or observed for incontinence episodes. On 11/05/24 at 8:40 A.M., telephone interview with CNA #204 confirmed providing care to Resident #2 between 11/04/24 at 10:30 P.M. and 11/05/24 at approximately 12:30 A.M. CNA #204 stated she turned care over to CNA #205 at that time. CNA #204 also confirmed oncoming staff was not at the facility at the end of the shift and no report was provided. CNA #204 ended the shift on 11/05/24 at 6:30 A.M. On 11/05/24 at 8:46 A.M., telephone interview with CNA #205 denied assuming care of Resident #2 during the shift on 11/05/24. CNA #205 verified she did not check Resident #2 for incontinence or provide turning with repositioning during her shift on 11/05/24 between 12:30 A.M. and 6:30 A.M. On 11/05/24 at 7:45 A.M., interview with the Director of Nursing (DON) revealed residents are not to be double briefed due to creating a increased potential for skin breakdown and infections. CNA's are to document incontinence checks and repositioning in the medical record under task. The DON also stated resident skin breakdown interventions are contained in the nursing plan of care and also included incontinence frequency checks for the specific resident. 3. Resident #3 admitted to the facility on [DATE] with diagnoses including, cerebral infarction, type 2 diabetes mellitus, protein calorie malnutrition, hypertension, anemia, dysphagia, acute kidney failure, and muscle disorder. According to the most current MDS assessment dated [DATE] revealed Resident #3 with the inability to make needs known, severe cognitive impairment, dependent on staff for the completion of ADLs including bed mobility, always incontinent of bowel and bladder, and at risk for pressure ulcer development with no current skin breakdown. Review of nursing plans of care revealed on 05/18/24 a plan of care was developed to address Resident #3's ADL self-care performance deficit related to disease process. Interventions included the following; for bed mobility, the resident is able to complete task with limited to extensive assist of one to two staff members, for toilet use, the resident is able to complete task with extensive to total assist of one to two staff members, for transfers, the resident is able to complete task with extensive to total assist of one to two staff members, monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, and declines in function. No turning or repositioning frequency was indicated in the nursing plans of care. On 09/03/24 a Braden scale for predicting pressure sore risk scored Resident #3 at high risk for pressure sore development. On 09/03/24 a Bladder Incontinence Data Collection Tool was completed and noted resident is incontinent of bladder all or most of the time. A physician order was initiated on 10/10/24 to provide additional ADL assistance related to diagnosis of Hemiplegia and Cerebral Infarction. Please refer to plan of care. On 11/04/24, weekly skin observation documentation noted risk factors for impaired skin integrity were due to impaired mobility and incontinence of bowel and bladder. Interventions to preserve skin integrity included weekly skin assessment and two hour turns per facility protocol. Observation on 11/05/24 at 7:13 A.M with Certified Nurse Aide (CNA) #201 discovered Resident #3 in bed with two incontinence briefs applied. Resident #3 was unable to indicate when last checked for incontinence and was observed to require total dependence of care from CNA #201. CNA #201 stated she assumed care of Resident #3 at 7:00 A.M. and the observation was her first observation of the resident. CNA #201 went on to state the previous CNA identified to provide care to Resident #3 left the facility before giving report regarding the last turning and repositioning or incontinence check for Resident #3. CNA #201 stated Resident #3 required two hour incontinence episode checks with repositioning. According to task bowel and bladder monitoring documentation Resident #3 was documented to be checked and found incontinent on 11/04/24 at 8:22 A.M. No further bowel and bladder tracking or documentation of incontinence monitoring was documented in the medical record. Review of repositioning documentation noted on 11/04/24 at 11:57 P.M. Resident #3 was provided with repositioning. No further repositioning was noted in the medical record. On 11/05/24 at 7:45 A.M. interview with the Director of Nursing (DON) revealed residents are not to be double briefed due to creating a increased potential for skin breakdown and infections. CNA's are to document incontinence checks and repositioning in the medical record under task. The DON also stated resident skin breakdown interventions are contained in the nursing plan of care and also included incontinence frequency checks for the specific resident. Review of facility undated Pressure Injury Prevention and Management policy revealed the facility shall establish and utilize a systematic approach for pressure injury prevention and management. The approach will include prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors: monitoring the impact of the interventions; modifying the interventions as appropriate. Interventions for prevention and to promote healing included the development of a care plan to include measurable goals with appropriate interventions. Basic or routine care interventions include redistribution of pressure, minimize exposure to moisture. Review of facility undated Turing and Repositioning policy instructed that all residents at risk of or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to a medical condition. Turning and repositioning is a primary responsibility of nursing assistants. The frequency of turning and repositioning will be documented in the residents plan of care. Repositioning while in the chair directed every one hour repositioning for a resident unable to reposition or make position changes.

Based on observation, medical record review, and staff interview, the facility failed to ensure incontinence interventions were implemented in a timely manner and in accordance with nursing plans of care. This affected three (#1, #2, #3) of three sampled residents reviewed for incontinence care and treatment. Facility census was 69. Findings include: 1. Resident #1 admitted to the facility on [DATE] with diagnoses including, polyosteoarthritis, anemia, chronic fatigue, polyneuropathy, congestive heart failure, peripheral vascular disease, spondylosis, absence right leg above knee, and covid-19. According to the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 with severe cognitive impairment, dependent on staff for the completion of activities of daily living including bed mobility, always incontinent of bowel and bladder, and at risk for pressure ulcer development with no skin breakdown. On 09/20/24, a Bladder Incontinence Data Collection Tool was completed and noted resident was incontinent of bladder requiring staff to complete incontinence care. Resident does wet through brief and pants when urinating. Resident does not verbalize the need to use the toilet. Review of Resident #1's nursing plan of care dated 01/24/23 revealed Resident #1 had bladder incontinence. Interventions included, clean peri-area with each incontinence episode. No documentation indicated a frequency to monitor Resident #1 for urinary incontinence. On 01/24/23 a plan of care was implemented to address Resident #1 bowel incontinence related to immobility with interventions including; check resident every two hours and assist with toileting as needed. Observation on 11/05/24 at 7:34 A.M. with Certified Nurse Aide (CNA) #201 discovered Resident #1 in bed with two incontinence briefs applied. Resident #1 was unable to indicate when last checked for incontinence. CNA #201 stated she assumed care of Resident #1 at 7:00 A.M. and this was her first observation of the resident. CNA #201 went on to state CNA #202 provided care for the resident on the previous shift and had left the facility before CNA #201 received a report regarding the last incontinence check for Resident #1. According to task bowel and bladder monitoring documentation Resident #1 was documented as incontinent on 11/04/24 at 9:23 P.M. with repositioning documented as taking place at 9:24 P.M. No further bowel and bladder tracking was documented in the medical record. On 11/05/24 at 7:45 A.M. interview with the Director of Nursing (DON) revealed residents are not to be double briefed due to creating a increased potential for skin breakdown and infections. CNAs are to document incontinence checks in the medical record under task and resident incontinence frequency checks are indicated in the nursing plan of care. 2. Resident #2 admitted to the facility on [DATE] with diagnoses including, rheumatoid arthritis, major depressive disorder, dysphagia, congestive heart failure, muscle wasting and atrophy, protein calorie malnutrition, anxiety disorder, hypertension, atrial fibrillation, type 2 diabetes mellitus, right eye blindness and atrioventricular septal defect. According to the most current MDS assessment dated [DATE] assessed Resident #2 with severe cognitive impairment, dependent on staff for the completion of activities of daily living including bed mobility, always incontinent of bowel and bladder, at risk for pressure ulcer development with no current skin breakdown. On 09/21/24 a Bladder Incontinence Data Collection Tool was completed and Resident #2 was assessed as incontinent of bladder requiring staff to complete incontinence care. Resident does not verbalize the need to use toilet. A nursing plan of care was developed on 09/23/24 to address Resident #2's potential alteration in elimination frequently incontinent of bowel and bladder. Interventions included the following: monitor for skin redness and irritation and provide incontinent care as needed (PRN). No frequency was indicating related to checking the resident for incontinence episodes. According to task bowel and bladder monitoring documentation Resident #2 was documented as incontinent on 11/04/24 at 11:48 P.M. No further bowel and bladder tracking was documented in the medical record. Observation on 11/05/24 at 7:02 A.M. noted Resident #2 in bed. Certified Nurse Aide (CNA) #203 entered the room and proceeded to complete an incontinence check. CNA #203 discovered Resident #2 had two adult incontinence briefs applied and the resident was soiled of a moderate amount of urine. CNA #203 indicated she had just assumed the shift at 7:00 A.M. and was unaware when the resident was last provided with an incontinence observation. CNA #203 stated CNA's were informed by nurses not to place two briefs on residents. On 11/05/24 at 7:08 A.M. interview with Licensed Practical Nurse #301 revealed she was unaware Resident #2 was placed into two incontinence briefs and was unaware when the resident was last observed for incontinence episode. On 11/05/24 at 8:40 A.M. telephone interview with CNA #204 confirmed providing care to Resident #2 between 11/04/24 at 10:30 P.M. and 11/05/24 at approximately 12:30 A.M. CNA #204 stated she turned care over to CNA #205 at that time. CNA #204 also confirmed oncoming staff was not at the facility at the end of the shift and no report was provided. CNA #204 ended the shift on 11/05/24 at 6:30 A.M. On 11/05/24 at 8:46 A.M. telephone interview with CNA #205 denied assuming care of Resident #2 during the shift on 11/05/24. CNA #205 verified she did not check Resident #2 for incontinence or provide turning with repositioning during her shift between 11/05/24 at 12:30 A.M. and 6:30 A.M. According to task bowel and bladder monitoring documentation Resident #2 was documented to be checked and found incontinent on 11/04/24 at 11:48 P.M. No further bowel and bladder tracking or documentation of incontinence monitoring was documented in the medical record. On 11/05/24 at 7:45 A.M. interview with the Director of Nursing (DON) revealed residents are not to be double brief due to creating a increased potential for skin breakdown and infections. CNAs are to document incontinence checks in the medical record under task and resident incontinence frequency checks are indicated in the nursing plan of care. 3. Resident #3 admitted to the facility on [DATE] with diagnoses including, cerebral infarction, type 2 diabetes mellitus, protein calorie malnutrition, hypertension, anemia, dysphagia, acute kidney failure, and muscle disorder. According to the most current MDS assessment dated [DATE] revealed Resident #3 with the inability to make needs known, severe cognitive impairment, dependent on staff for the completion of activities of daily living (ADL) including bed mobility, always incontinent of bowel and bladder, at risk for pressure ulcer development with no current skin breakdown. Review of nursing plans of care revealed on 05/18/24 a plan of care was developed to address Resident #3's ADL self-care performance deficit related to disease process. Interventions included for toilet use, the resident is able to complete task with extensive to total assist of one to two staff members. On 09/03/24 a Bladder Incontinence Data Collection Tool was completed and noted resident is incontinent of bladder all or most of the time. A physician order was initiated on 10/10/24 to provide additional ADL assistance related to diagnoses of Hemiplegia and Cerebral Infarction. Please refer to plan of care. Observation on 11/05/24 at 7:13 A.M. with Certified Nurse Aide (CNA) #201 discovered Resident #3 in bed with two incontinence briefs applied. Resident #3 was unable to indicate when last checked for incontinence and was observed to require total dependence of care from CNA #201. CNA #201 stated she assumed care of Resident #3 at 7:00 A.M. and the observation was her first observation of the resident. CNA #201 went on to state the previous CNA identified to provide care to Resident #3 left the facility before giving report regarding the last incontinence check for Resident #3. CNA #201 stated Resident #3 required two hour incontinence episode checks with repositioning. According to task bowel and bladder monitoring documentation Resident #3 was documented to be checked and found incontinent on 11/04/24 at 8:22 A.M. No further bowel and bladder tracking or documentation of incontinence monitoring was documented in the medical record. On 11/05/24 at 7:45 A.M. interview with the Director of Nursing (DON) revealed residents are not to be double brief due to creating a increased potential for skin breakdown and infections. CNAs are to document incontinence checks in the medical record under task and resident incontinence frequency checks are indicated in the nursing plan of care. This deficiency represents non-compliance investigated under Complaint Number OH00159047.

Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure interventions and treatments were implemented for a resident assessed at risk for pressure ulcers to prevent deterioration of an existing stage four pressure ulcer (full-thickness skin and tissue loss) and the development of additional pressure ulcers and failed to ensure pressure ulcer treatments were applied as ordered by the physician. Actual harm occurred to Resident #31 when the facility failed to initiate an alternative pressure relieving cushion or additional pressure reliving intervention to the resident's wheelchair after an existing cushion was damaged and removed and treatments were not administered as ordered. This resulted in Resident #31 developing two stage three in-house acquired pressure ulcers (full-thickness skin loss) with related worsening and drainage. This affected one (#31) of two sampled residents reviewed for pressure ulcer prevention and care in a facility census of 61. Findings include: Review of Resident #31's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including, cervical cord syndrome, paraplegia, traumatic brain injury, type II diabetes mellitus, poly neuropathy, atrial fibrillation, venous thrombosis and embolism, respiratory failure, chronic obstructive pulmonary disease, ulcerative pancolitis, and spinal stenosis. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #31 with intact cognition. The resident was dependent on staff for the completion of activities of daily living (ADLs) including bed mobility and repositioning. The resident utilized an indwelling catheter and colostomy, and was assessed at risk for pressure ulcer development with one or more unhealed pressure ulcers/injuries including a stage three pressure ulcer not present at the time of admission, one stage four present on admission, and one unstageable pressure injury (obscured full-thickness skin and tissue loss) present upon admission. Review of a nursing plan of care initiated on 10/11/21 revealed Resident #31 had actual impairment to skin integrity related to paraplegia including a stage four pressure ulcer to the right ischium. Interventions included to follow facility protocols for treatment of the injury; identify and document potential causative factors and eliminate and resolve where possible; monitor and document the location, size, and treatment of the skin injury, and report abnormalities, failure to heal, signs or symptoms of infection, or maceration to the physician; and weekly treatment documentation to include measurement of each area of skin breakdown with width, length, depth, type of tissue and exudate, and any other notable changes or observations. Review of the wound specialist physician evaluation documentation on 05/01/24 revealed a chronic stage four right ischium pressure ulcer present greater than 761 days. Further review revealed the wound evaluation description was noted with moderate serous exudate (drainage) and measured 3.3 centimeters (cm) long by (x) 1.8 cm wide x 1.1 cm deep. The recommended interventions included to off-load the wound, turn side to side and front to back in bed every one to two hours if able when in bed, lay flat in wheelchair for one hour every three hours, reposition per facility protocol, and continue application of specialized cushion (ROHO, pressure-reliving cushion) to the specialized wheelchair. On 05/02/24 the physician modified a treatment to the right ischium to cleanse Resident #31's wound with wound cleanser (Vashe), pat dry, apply a collagen sheet, then apply calcium alginate/AG to the wound bed, and cover with bordered gauze once daily and as needed every day shift for a pressure injury. Review of the pressure risk assessment dated [DATE] Resident #31 was assessed at moderate risk of pressure ulcer development. Review of wound specialist physician evaluation documentation on 07/19/24 noted a chronic stage four right ischium pressure ulcer. Further review of the wound evaluation description noted moderate serous exudate and measured 3.0 cm long x 1.9 cm wide x 0.5 cm deep. The recommended interventions included to off-load the wound, turn side to side and front to back in bed every one to two hours if able when in bed, lay flat in wheelchair for one hour every three hours, reposition per facility protocol, and continue application of ROHO cushion to specialized wheelchair. The primary dressing for the wound included the application of a collagen sheet apply once daily for 30 days, and alginate calcium with silver apply once daily for 30 days. On 07/31/24 a weekly wound evaluation noted Resident #31's stage four right ischium pressure ulcer was documented as worsening due to resident non-compliance with wound care and broken ROHO cushion. The wound description revealed there was moderate serous exudate, and the wound measured 4.2 cm long x 3.0 wide x 0.7 cm deep. No additional intervention was implemented to replace the broken ROHO cushion. In addition, two in-house pressure ulcers were discovered. Documentation indicated wound #1, which was a right buttock stage three pressure ulcer, was noted on 07/30/24 and was described with a small amount of serous exudate and measured 7.5 cm long x 4.0 cm wide x 0.1 cm deep. Treatment of the wound included to cleanse with soap and water apply Triad paste every shift and as needed. Wound #2, which was identified as left ischium moisture associated skin damage (MASD), measured 4.0 cm long x 7.5 cm wide x 0.1 cm deep with no drainage. The same treatment was applied as wound #1. Review of a wound specialist evaluation dated 07/31/24 noted the physician indicated Resident #31's custom ROHO cushion was taken to see if a repair could be made. The document continued that the resident continued to stay in his chair for 14-plus hours per day without getting up to off-load and had caused a quick breakdown of his skin. Resident #31 was encouraged to get back into bed or at least lay on his side when he got back into bed. The wound specialist documented the facility will also see if physical therapy might have a ROHO cushion available to use until they find out what was happening with the resident's personal ROHO cushion. Resident #31's wound progress was documented as exacerbated due to patient non-compliant with wound care and broken ROHO cushion. Wound measurement to the right ishium was 4.2 cm long x 3.0 cm wide x 0.7 cm deep with moderate serous drainage. Recommendations included to off-load the wound, reposition per facility protocol, and therapy consultation for ROHO cushion options. On 08/07/24 the wound specialist documented Resident #31's ROHO cushion was being repaired and his wounds and skin are breaking down further. The resident's right ischium was assessed with moderate serous drainage and measured 4.0 cm long x 2.7 cm wide x 1.0 cm deep with a new treatment to apply Methylene blue foam once daily for 30 days. The right buttock was assessed with moderate serous exudate and measured 3.5 cm long x 4.5 cm wide x 0.2 cm deep with wound treatment to apply Methylene blue foam apply once daily for 30 days. The left ischium MASD measured 0.5 cm long x 1.0 cm wide x 0.1 cm deep with continued application of Triad paste apply twice daily. In addition, a third in-house acquired wound was discovered to the posterior scrotum described as a stage three pressure wound measuring 2.0 cm long x 5.0 cm wide x 0.1 cm deep with no drainage. Treatment for this wound included application of Triad paste to be applied twice daily. Review of the medical record lacked documentation of additional interventions to address pressure relief while the resident was in the wheelchair, or a therapy evaluation related to temporary replacement of the ROHO cushion. Review of Resident #31's wound treatment orders dated 08/07/24 included, for the right buttock, right ischium, and left ischium, to cleanse with wound cleanser (Vashe), pat dry, apply Methylene Blue (Hydrofera Blue) to the wound bed, and cover with bordered gauze once daily and as needed every day shift for the pressure injuries. The treatment order for the posterior scrotal wound was to cleanse with soap and water and apply Triad paste every shift and as needed. Observation on 08/12/24 at 10:49 A.M. with State tested Nurse Aide (STNA) #409 noted Resident #31 in his room after being transferred with a mechanical lift. Resident #31 was placed in a specialized electric wheelchair, dressed, and groomed. Interview with Resident #31 at the time of the observation stated he was waiting on repair of his ROHO cushion for four weeks. STNA #409 stated Resident #31 developed an open area to his buttock with no treatment applied for two weeks. Observation at that time revealed Resident #31's wheelchair was noted without a pressure relief cushion to the seat. On 08/13/24 at 10:38 A.M. observation with STNA #409 and STNA #450, during morning activities of daily living with Resident #31, noted the resident was positioned to the left side and revealed exposed wounds to the bilateral ischium, right buttock, and posterior scrotum. There was no dressing or treatment applied to the wounds and blood-tinge drainage was identified contained in the incontinence brief under the resident. Interview with STNA #409 at the time of the observation verified no dressing was in place since assuming care of Resident #31 at 7:00 A.M. Interview on 08/13/24 at 10:43 A.M. with Licensed Practical Nurse (LPN) #422 revealed she was unaware Resident #31 required a dressing application to wounds on the ischium or buttock. LPN #422 indicated she thought a wound barrier cream was to be applied. Observation at that time revealed LPN #422 proceeded to obtain dressing treatment supplies following review of Resident #31's medical record and went to Resident #31's room. Interview with LPN #422 during observation of the resident confirmed no treatment was applied to the resident's wounds. Further observation revealed LPN #422 cleansed the resident's right ischium, right buttock, posterior scrotum, and left ischium with wound cleanser (Vashe) and patted them dry. LPN #422 applied Methylene Blue (Hydrofera Blue) to the wound bed of the bilateral ischium and right buttock, applied barrier cream to the posterior scrotum and peri-wounds, and covered all of the wounds with two absorbent dressings (ABD). Observations on 08/13/24 at 11:00 A.M., 12:20 P.M., 1:03 P.M., 08/14/24 at 12:10 P.M., and 2:00 P.M. noted Resident #31 seated in the wheelchair without a pressure relieving cushion to the seat. On 08/14/24 at 6:45 A.M. interview with the Director of Nursing (DON), during a review of the medical record, confirmed Resident #31 specialized pressure relief cushion (ROHO) to the wheelchair was removed approximately two weeks ago and no intervention was implemented in place of the cushion. The DON verified Resident #31 remained in the wheelchair for extended periods and was unable to reposition himself. Interview on 08/14/24 at 7:20 A.M. with Wound Specialist Physician (WSP) #503 confirmed Resident #31 had a ROHO cushion in place until a couple weeks ago when the cushion was broken, and no current intervention was placed in the chair to replace the missing cushion while being repaired. WSP #503 stated since the cushion had been removed the resident had developed new skin breakdown and deterioration of an existing wound. Observation on 08/14/24 at 9:08 A.M. with WSP #503 and LPN #500 noted Resident #31 in bed. LPN #500 positioned Resident #31 to the left and exposed the dressings. WSP #503 removed the dressings and noted a moderate amount of serous drainage. WSP #503 obtained wound descriptions with measurements to the right ischium wound as measuring 5.0 cm long x 2.0 cm wide x 1.4 cm deep, measurements to the right buttock wound were 5.0 cm long x 3.6 cm wide x 0.1 cm deep, the wound to the left buttock was noted as healed, and the wound to the posterior scrotum measured 5.0 cm long x 1.5 cm wide x 0.2 cm deep. Observation noted Resident #31 to exhibit verbal pain with evaluation of the right ischium wound and indicated the pain was a level of eight on a 10-point scale, with 10 being the worse pain. WSP #503 stated Resident #31 did not express pain when this wound was evaluated previously and indicated the wound appeared more tender and sensitive. Review of the undated pressure injury prevention and management policy revealed interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment. Evidence-based interventions for prevention will be implemented for all residents at risk or who have pressure injury present. Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have pressure injury present. Review of the undated clean dressing change policy revealed the facility will provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes.

Based on staff interview, record review, and review of the Certification and Survey Provider Enhanced Reporting system (CASPER) Report, the facility failed to have an effective quality assurance program to address repeated quality concerns identified during three consecutive annual surveys. This affected all 61 residents in the facility. The census was 61. Findings include: Review of the CASPER Report dated 08/02/24 revealed the facility received deficiencies for failing to provide activities of daily life (ADL) care to dependent residents during the annual surveys conducted in August 2019 and August 2022. 1. Review of the medical record for Resident #24, during the current annual survey, revealed an admitted [DATE]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had intact cognition and was dependent on staff for personal hygiene. Observations on 08/12/24 at 10:33 A.M., 08/13/24 at 3:57 P.M. and 08/14/24 at 3:20 P.M. revealed Resident #24's fingernails and thumbnails on her right and left hands had dark debris under them. Interview and observation on 08/14/24 at 3:23 P.M. with Licensed Practical Nurse (LPN) #446 confirmed Resident #24's nails on her left and right hands were dirty. 2. Review of Resident #44's medical record, during the current annual survey, revealed the resident admitted to the facility on [DATE] with a diagnosis of vascular dementia. Review of the MDS assessment dated [DATE] revealed Resident #44 had moderately impaired cognition, and was dependent on staff for the completion of activities of daily living. Observation on 08/12/24 at 9:34 A.M. noted Resident #44 seated in a wheelchair in his room. The resident was observed with long, jagged finger nails with black/brown debris under the nails, and heavy facial hair growth. On 08/13/24 at 9:14 A.M. interview with State tested Nurse Aide (STNA) #450 verified the resident with heavy facial hair growth and fingernails jagged with debris. Review of the policy titled, Quality Assurance and Performance Improvement (QAPI), copyright 2024, revealed the effectiveness of performance improvement activities will be monitored in QAA (Quality Assessment and Assurance) Committee meetings in accordance with the QAPI plan, but no less than annually to ensure improvements are sustained.

Based on observation, medical record review, resident and staff interview, and facility policy review, the facility failed to ensure the facility environment was maintained in a safe and sanitary manner. This affected five (#35, #36, #43, #46, and #47) of five residents reviewed for physical environment. The census was 61. Findings include: 1. Review of the medical record noted Resident #36 was admitted to the facility on [DATE] with the diagnoses including epilepsy, extended spectrum beta lactamase resistance, type II diabetes mellitus, hypertension, acute kidney failure, anxiety disorder, hypothyroidism, muscle wasting and atrophy, and dysphagia. Review of the current Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #36 with moderately impaired cognition, and the resident required partial to moderate assist with activities of daily living including toileting, and was frequently incontinent of bowel and bladder. Observation on 08/12/24 at 11:15 A.M. noted Resident #36 room with a strong urine odor. A four-foot section of drywall at the baseboard next to the shower was pealing paint, at the room entry a five-foot section of wall was identified with paint removed and exposed drywall, and at the head of the bed were large gouges were discovered in the wall with drywall exposed. On 08/12/24 at 11:20 A.M. observation with Licensed Practical Nurse (LPN) #446 verified Resident #36's room condition. Observation and interview on 08/15/24 at 8:42 A.M. with Maintenance Director (MD) #406 confirmed Resident #36's room condition. 2. Observation on 08/13/24 at 9:28 A.M. in Resident #43's room identified a foul odor and two soiled incontinence briefs were placed on the floor next to the bed with soiled clothing and linen. The room floor had scattered debris throughout. Located inside the bathroom discovered two soiled towels on the floor next to the toilet with brown stains, soiled toilet paper with a brown substance on floor next to the toilet, and the toilet seat also with a brown substance. On 08/13/24 at 10:32 A.M. interview with Housekeeper #495, during observation, verified the condition of Resident #43's room. Housekeeper #495 stated the room was frequently discovered in soiled condition when attempting to complete daily housekeeping. 3. Review of the medical record noted Resident #35 admitted to the facility on [DATE] with the diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left side, coronary artery disease, chronic obstructive pulmonary disease, type II diabetes mellitus, cardiomyopathy, hypertension, major depression, vascular dementia, muscle wasting and atrophy, and congestive heart failure. Review of the most current MDS assessment dated [DATE] assessed Resident #35 with moderate cognitive impairment, and was dependent on staff for the completion of activities of daily living including bed and wheelchair mobility. Observation on 08/13/24 at 11:47 A.M., 12:09 P.M., and 1:21 P.M., and on 08/14/24 at 12:20 P.M. and 3:09 P.M. discovered Resident #35 seated in a wheelchair. The chair was not equipped with an armrest pad to the left side and Resident #35's left arm was resting on a thin pipe without padding. On 08/14/24 at 12:20 P.M. interview with State tested Nurse Aide (STNA) #454 verified no arm rest was applied to the left side of Resident #35's wheelchair, and STNA #454 was unaware the armrest was missing. 4. Review of the medical record for Resident #46 revealed an admitted d of 06/10/22. Interview on 08/12/24 at 12:59 P.M. with Resident #46 stated her room air conditioning unit had dirt inside the cover. Observation of Resident #46's room on 08/12/24 at 12:59 P.M. revealed the air conditioning unit and the filters had dust on it that was rolling up when taken out of the filter holder on the air conditioning unit. Interview on 08/14/24 at 4:28 P.M. with STNA #443 verified the dust rolled in the filters and the dirty air conditioning unit in Resident #46's room. Interview on 08/14/24 at 4:48 P.M. with Activities Director (AD) #467 verified maintenance was responsible for cleaning the air conditioning unit filters. 5. Review of the medical record for Resident #47 revealed an admitted [DATE] with diagnoses of neoplasm of brain and anxiety. Review of the annual MDS assessment dated [DATE] revealed Resident #47 had intact cognition. Interview and observation on 08/12/24 at 2:25 P.M. with Resident #47 revealed his air conditioning unit vents in his room were coated with a brown substance along the front and top of the unit. The substance appeared stuck to the vents and was not removable with a swipe of the finger. Additionally, the window blinds had a heavy buildup of dust. Resident #47 stated the facility had not cleaned the air conditioning unit in three years although he stated he had cleaned it himself once. Resident #47 stated the dirty appearance of his air conditioner and blinds bothered him. Observation and interview on 08/12/24 at 2:55 P.M. with LPN #426 confirmed there was heavy dirty buildup and possible staining on all vent blades of the the air conditioning unit and there was heavy dust building on the window blinds in Resident #47's room. Observation on 08/15/24 at 10:35 A.M. revealed Resident #47 was cleaning out his room and a large chair was blocking the entrance, waiting for maintenance to remove it. Observation and interview with Resident #47 from his doorway revealed the air conditioning unit remained coated and discolored. Resident #47 stated the window blinds remained dusty. Resident #47 stated staff came in and cleaned the blades inside the unit. Observation and interview on 08/15/24 at 10:42 A.M. with Housekeeper #417, from the doorway of Resident #47's room, confirmed Resident #47's air conditioning unit was visibly dirty and Housekeeper #417 confirmed he planned to deep-clean Resident #47's room later in the day. Review of the policy titled, Safe and Homelike Environment, copyright 2024, revealed the facility, in accordance with residents' rights, will provide a safe, clean, comfortable, and homelike environment. 47057 44815

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure hand hygiene was practiced during meal service. This affected six (#24, #155, #160, #161, #162, and #154) of six residents observed during meal service. The facility census was 61. Findings include: Observation on 08/12/24 at 12:17 P.M. revealed a cart with lunch trays was delivered to the 300 hall. Observation on 08/12/24 at approximately 12:18 P.M. revealed Licensed Practical Nurse (LPN) #426 pushing Resident #40 in a wheelchair to the scale in the lounge. LPN #426 assisted Resident #40 by touching his sleeve while he stood on the scale and she obtained his weight. LPN #426 then assisted Resident #40 back into his wheelchair and pushed him back to his room. LPN #426 did not practice hand hygiene before opening the meal cart and removing Resident #24's meal tray. LPN #426 entered Resident #24's room, moved items from her overbed table, and set down Resident #24's meal on the table. Interview on 08/12/24 at 12:24 P.M. with LPN #426 confirmed she did not clean her hands after assisting Resident #40 and providing Resident #24's meal. Continuous observation on 08/12/24 beginning at 12:24 P.M. revealed State tested Nurse Aide (STNA) #469 entered Resident #155's room and came out with her dirty breakfast tray. STNA #469 placed the dirty tray on top of the tray cart, then, without cleaning her hands, reached inside the cart and picked up Resident #155's lunch tray and delivered it. STNA #469 returned to the cart and picked up Resident #160's tray and delivered it to her. STNA #469 moved Resident #160's wheelchair and overbed table to make Resident #160 more comfortable to eat her meal. STNA #469 then closed Resident #155's door, then picked up and provided Resident #161's tray. STNA #469 returned to the tray cart and picked up Resident #162's tray and upon entering his room, picked up his fall mat from the floor, moved his tray table, set the tray down and removed the lid from his tray. STNA #469 did not clean her hands after touching Resident #162's personal items. Continued observation revealed Resident #160 asked for some salt and STNA #469 reached into the tray cart, found a salt packet and attempted to hand it to Resident #160. The salt packet fell on the floor and STNA #160 picked the salt packet up off the floor and handed it to Resident #160 who proceeded to open it and sprinkle salt on her meal. STNA #469 then returned to the tray cart to get Resident #154's lunch tray and provided it to him. At no time during this continuous observation was STNA #469 observed to perform hand hygiene. Interview on 08/12/24 at 12:31 P.M. with STNA #469 confirmed she touched several personal items and picked items up from the floor while delivering meal trays to multiple residents. STNA #469 confirmed she did not perform hand hygiene at any time while she was passing meal trays. STNA #469 believed she was expected to perform hand hygiene before she passed the first meal tray, and after she passed the final meal tray. Concurrent interview with LPN #426, who interjected into the interview, advised STNA #469 hand hygiene should be performed after contact with each resident. Review of the policy titled, Hand Hygiene, with the accompanying document titled, Hand Hygiene Table, copyright 2023, revealed staff should perform hand hygiene between resident contacts.

Based on observation medical record review, resident interview, and staff interview, the facility failed to adequate ensure nail care was provided to residents dependent on staff for care. This affected two (#24 and #44) of three residents reviewed for assistance with activities of daily life (ADLs). The facility census was 61. Findings include: 1. Review of the medical record for Resident #24 revealed an admitted [DATE] with diagnoses of type II diabetes mellitus and anxiety. Review of the modified admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had intact cognition and was dependent for personal hygiene. Review of the current care plan for Resident #24 revealed she had an ADL self-care performance deficit. Interventions included checking nail length and trimming and cleaning on bath day and as necessary. Observation and interview on 08/12/24 at 10:33 A.M. with Resident #24 revealed the nails on her left hand were long and had dark debris under them. Resident #24 stated she tried to clean them every day and she wanted her nails trimmed. Resident #24 heard someone came to the facility on ce a month to do nails. Observation on 08/13/24 at 3:57 P.M. revealed staff transferred Resident #24 from the chair to the bed. Continued observation when Resident #24 was settled in bed revealed the fingernails on her left hand continued to be long and have dark debris under them. Interview and observation on 08/14/24 at 3:20 P.M. revealed Resident #24 lying in bed. Her nails on the left hand remained long and had some dark debris under them. Additionally, the thumbnail on her right hand and dark debris under it. Resident #24 stated her sister visited earlier in the day and helped clean under her fingernails. Interview on 08/14/24 at approximately 3:21 P.M. with State tested Nurse Aide (STNA) #412 revealed Resident #24's showers were scheduled for Mondays and Thursdays on first shift. Interview and observation on 08/14/24 at 3:23 P.M. with Licensed Practical Nurse (LPN) #446 confirmed Resident #24's nails on her left and right hands were dirty. LPN #446 stated STNAs were responsible for nail care. Interview on 08/14/24 at 3:27 P.M. with STNA #469 revealed residents' nails were usually cleaned and trimmed on shower days; however, if she saw dirty nails she would clean them. 2. Resident #44 admitted to the facility on [DATE] with the diagnoses including, pervasive developmental disorder, schizoaffective disorder, moderate intellectual disorder, vascular dementia, depression, and obstructive and reflux uropathy. Review of the most current MDS assessment dated [DATE] revealed Resident #44 was assessed with moderately impaired cognition and was dependent on staff for the completion of activities of daily living. Review of Resident #44's plan of care dated 06/20/24 revealed a focus area was initiated to address Resident #44's ADL self-care performance deficit related to disease process and impaired balance. Interventions included the resident was dependent on one to two staff for bathing, was dependent of one to two staff to assist with dressing, and was dependent on one staff with personal hygiene and oral care. Observation on 08/12/24 at 9:34 A.M. noted Resident #44 was seated in a wheelchair in his room. The resident was observed with long jagged finger nails with black/brown debris under the nails and heavy facial hair growth. On 08/13/24 at 9:14 A.M. interview with STNA #450 verified Resident #44 with heavy facial hair growth and jagged fingernails with debris under them. 15816

Based on medical record review, resident interview, and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately. This affected two (#47 and #155) of 30 residents reviewed for MDS assessments. The facility census was 61. Findings include: 1. Review of the medical record for Resident #47 revealed an admitted [DATE] with diagnoses of neoplasm of the brain and anxiety. Review of the annual MDS assessment dated [DATE] revealed Resident #47 had intact cognition and no functional limitations in range of motion to his upper extremity (shoulder, elbow, wrist, hand). Review of the physical therapy progress report and updated therapy plan dated 07/08/24 through 08/06/24 revealed Resident #47 was assessed on 07/07/24 and 07/08/24 and was found to have left shoulder range of motion from zero to 90 degrees, with standard range of motion defined as zero to 120 degrees. Interview and observation on 08/12/24 at 2:25 P.M. with Resident #47 revealed he had pain in his left shoulder and demonstrated he could not lift his arm any higher than the level of his shoulder while holding it straight out in front of him. Interview on 08/15/24 at 3:10 P.M. with Rehabilitation Services Director #404, along with concurrent review of Resident #47's physical therapy progress note, confirmed a range of motion of 90 degrees was considered a limited range of motion to Resident #47's left shoulder. 2. Review of the medical record for Resident #155 revealed an admitted [DATE] with a diagnosis of a wound to the right forearm. Review of the MDS assessment dated [DATE] revealed Resident #155 had intact cognition and had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Review of the weekly wound evaluation dated 07/31/24 revealed Resident #155 was admitted with a trauma injury to her right forearm. Review of the skin observation tool, dated 08/02/24, revealed Resident #155 had a right forearm trauma/injury. Interview on 08/15/24 at 4:04 P.M. with the Director of Nursing (DON) confirmed Resident #47's range of motion was documented incorrectly in the MDS assessment dated [DATE] and Resident #155's trauma wound was documented incorrectly in the MDS assessment dated [DATE].

Based on medical record review, review of hospital records, review of a 911 Incident Detail Report, guardian interview, and staff interview, the facility failed to follow the healthcare provider's orders to transport a resident to the hospital when a resident experienced a change in condition. This resulted in Actual Harm when Resident #03's healthcare provider's orders to transport the resident to the hospital when experiencing a low oxygen (O2) saturation level were not immediately followed, delaying transport of the resident to the hospital for several hours, which delayed medical interventions to improve the resident's respiratory status, including mechanical ventilation. This affected one (#03) of three residents reviewed for change in condition. The facility census was 54. Findings include: Review of Resident #03's medical record revealed an admitted [DATE] with a readmitted [DATE]. Diagnoses included metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), morbid obesity, anxiety disorder, major depressive disorder, schizophrenia, hypertension, dysphagia, diabetes, and acute and chronic respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/15/23, revealed Resident #03 was cognitively intact. Review of a plan of care focus area, revised on 07/23/19, revealed Resident #03 had an alteration in respiratory function related to COPD. Interventions included administer medication as ordered. Review of a nursing progress note dated 04/19/23 at 4:29 P.M., revealed the Director of Nursing (DON) was called into Resident #03's room by the nurse on duty due to the resident's O2 saturation being in the 70s. The DON applied a non-rebreather mask with oxygen at 15 liters (L) per minute while another nurse call Certified Nurse Practitioner (CNP) #400 to provide an update on Resident #03's condition. With the non-breather mask in place Resident #03's O2 saturation was 88 percent (%). CNP #400 gave orders for an immediate (STAT) chest x-ray, prednisone 40 milligrams (mg) now and daily for five days, breathing treatment every six hours and send Resident #03 to the emergency department (ED) for further evaluation if O2 saturation was not maintained at 88% or higher. Resident #03's guardian was contacted and updated on the resident's condition with a request to be updated throughout the remainder of the day. Review of physician orders dated 04/19/23 revealed orders for a STAT chest x-ray one time for shortness of breath, prednisone oral tablet 20 mg two tablets by mouth one time for shortness of breath, ipratropium-albuterol solution one applicator inhale orally every six hours for shortness of breath, vitals every three hours for 24 hours for monitoring, and send to the hospital for O2 less than 88%. Review of a nursing progress note dated 04/19/23 at 5:54 P.M. revealed Resident #03 tested negative for COVID-19. Resident #03 was currently sitting up in bed with O2 saturation at 87%. There is no evidence the physician or CNP was notified of the O2 saturation less than 88%. Review of the Medication Administration Record (MAR) dated April 2023 revealed on 04/19/23 at 6:00 P.M., Resident #03 was administered ipratropium-albuterol solution one applicator (breathing treatment) and the resident's O2 saturation was 85%. There is no evidence the physician or CNP was notified of the O2 saturation less than 88%. Review of a nursing progress note dated 04/19/23 at 7:47 P.M. revealed Resident #03's O2 saturation was rechecked and was at 82%. Per CNP order Resident #03 was sent to the ED. Review of a hospital History and Physical,dated 04/19/23,revealed Resident #03 was hypoxic (inadequate oxygenation) with O2 saturations in the 70s at the nursing home and was not normally on O2. Upon presentation to the ED the resident had O2 saturations in the 70's. Her O2 was increased to 8 L with failure to improve significantly. Respiratory therapy identified the resident was absent of breath sounds on the left. Resident #03 was intubated shortly after arrival to the ED and sedated. The chest x-ray revealed opacity and volume loss to the left lung. The electrocardiogram (EKG) revealed sinus tachycardia. Further review of the exam revealed lung sounds were absent on the left and rhonchi (gurgling and bubbling) on the right. Diagnoses included acute hypoxic and hypercapnic respiratory failure and white out of the left lung, suspect secondary to a large mucous plug. Review of the record revealed Resident #03 was readmitted to the facility on [DATE] with a physician order for O2 2 L continuous. Review of a 911 Incident Detail Report revealed the facility called 911 to transport Resident #03 on 04/19/23 at 7:19 P.M. Interview on 04/27/23 at 10:18 A.M. with Resident #03's guardian revealed she had been contacted on 04/19/23 regarding the resident having low O2 saturation levels. The guardian was informed CNP #400 had given orders and Resident #03 was being monitored. Later that evening another family member went to visit the resident. During the visit the guardian was on the phone with the family member. The family member requested Resident #03's O2 saturation be checked. The nurse stated it had been checked an hour ago and it was fine. At the insistence of the guardian and family member, the guardian stated the nurse did check it and it was 82%. The guardian stated the nurse did not believe Resident #03 needed to be sent to the ED and the resident was sent only at her insistence. The guardian stated soon after her arrival to the ED Resident #03 was intubated and placed on a ventilator because her O2 saturation was so low and she was unable to breathe adequately. Interview on 04/27/23 at 10:57 A.M. with Licensed Practical Nurse (LPN) #142 confirmed she was the nurse working with Resident #03 on 04/19/23. LPN #142 stated the resident had seemed fine and stated as much throughout the day. LPN #142 stated around 4:00 P.M. Resident #03's color was funny and her eyes were watery and red, which prompted LPN #142 to check the resident's vitals. LPN #142 stated Resident #03's O2 saturation was in the 70s. LPN #142 requested assistance from the DON and a non-breather mask was applied to the resident and oxygen was administered at 15 L. CNP #400 was contacted and gave orders for a breathing treatment, a STAT chest x-ray, and prednisone. LPN #142 stated she believed Resident #03 was stable. Around 7:00 P.M., a family member came to the facility to visit Resident #03 and requested LPN #142 check the resident's O2 saturation. LPN #142 stated she believed it was around 86%. At that time, the family member was on the phone with the resident's guardian and the guardian insisted Resident #03 be sent to the hospital. LPN #142 stated they were still waiting for the mobile x-ray company to come to do the STAT chest x-ray but the guardian did not want to wait for that to occur and insisted Resident #03 be sent to the hospital. LPN #142 stated she did not believe Resident #03 needed to be sent to the hospital at that time and her condition probably could have been managed in the facility. Interview on 04/27/23 at 12:40 P.M. with the DON confirmed on 04/19/23 LPN #142 called her to Resident #03's room due to the resident experiencing a low O2 saturation. The DON confirmed she applied a non-breather mask and O2 at 15 L, which raised the resident's O2 saturation to 88%. In the meantime the Assistant Director of Nursing (ADON) contacted CNP #400 for orders. The DON stated she left the facility for the day a little after 5:00 P.M. and Resident #03 appeared stable at that time. At approximately 7:15 P.M., the DON called the facility to check on the resident's condition and was told Resident #03 was being sent out to the ED. The DON verified the O2 saturation documented in Resident #03's medical record on 04/19/23 were 87% at 5:54 PM. and 85% at 6:00 P.M These O2 saturation levels would have required Resident #03 be sent to the ED based on orders given by CNP #400 at approximately 4:29 P.M. Interview on 04/27/23 at 1:02 P.M. with CNP #400 confirmed she was contacted on 04/19/23 related to Resident #03's O2 saturation being low. CNP #400 verified she would have expected Resident #03 to have been sent to the ED sooner than she was if her O2 saturation was not maintained above 88%. In addition, CNP #400 stated Resident #03 had whiteout lung and would have needed to be placed on a ventilator. This deficiency represents non-compliance investigated under Master Complaint Number OH00142244.

Based on medical record review, review of hospital records, staff interviews, interview with the wound physician and review of facility policy, the facility failed to timely assess, monitor, and implement treatments for Resident #08's newly developed pressure ulcers (localized injury to the skin or underlying tissue, usually over a bony prominence, as a result of unrelieved pressure) on the bilateral heels and failed to accurately assess/stage Resident #08's pressure ulcers. This resulted in Actual Harm when Resident #08 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #08 was admitted to the hospital on 04/02/22 due to infection of the right foot and required excisional debridement (surgery) of the right foot on 04/03/22. Additionally, the facility failed to ensure physician orders for wound treatments were completed after staff were aware the resident was identified with a stage two pressure ulcer to the scrotum on 03/23/22. This affected one resident (#08) of three residents reviewed for pressure ulcers. The facility census was 60. Findings include: Review of the medical record for Resident #08, revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment, dated 01/21/22, revealed Resident #08 had intact cognition. The resident required extensive assistance of one person for transfers, bed mobility, and toileting. Resident #08 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a risk assessment dated [DATE] revealed the resident was at high risk for skin breakdown. Review of the plan of care dated 06/22/21 revealed Resident #08 had impaired skin integrity related to impaired mobility and [CONDITION(S)]. Resident #08 had surgical wounds to the right and left hip, right and left ischium, and scrotum. Resident #08 had an abrasion to the right knee. The resident was noted with a behavioral problem and refused to stay off wounds to lessen the chance of wounds getting worse. Interventions included to assist the resident with turning and repositioning in bed frequently as tolerated, educate on importance of relieving pressure while up in chair, Hoyer lift only due to wounds, inspect skin during routine daily care, pad and protect skin as needed, document education attempts made with resident in relation to compliance, and educate resident and family on negative outcomes related to non-compliance. Review of a skin observation tool assessment dated [DATE] revealed Resident #08 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . However, there was no further assessment of Resident #08's wounds including no wound measurements, and no wound stage. Further review of the medical record revealed the physician was not notified of the pressure ulcers and no treatment orders were initiated for the bilateral heel pressure ulcers. Review of a late entry skin/wound progress note dated 03/22/22 at 9:31 A.M. revealed Resident #08 was seen by the wound physician. Wound assessments were completed for a stage four pressure ulcer to the right ischium, stage four pressure ulcer to the left ischium, stage four pressure ulcer to the sacrum, stage four pressure ulcer to the left buttock, stage four pressure ulcer of the left hip, stage three pressure ulcer of the right hip, and a pressure ulcer to the left lateral thigh with no stage documented. There was no assessment of Resident #08's right or left heel. Review of a skin/wound progress note dated 03/29/22 at 2:49 P.M. revealed wound assessments were completed for Resident #08's stage three pressure ulcer to the right hip, stage four pressure ulcer to the left hip, stage four pressure ulcer to the right hip, stage four pressure ulcer to the left ischium and stage four pressure ulcer to the right ischium, stage four pressure ulcer to the left buttock, stage four pressure ulcer of the sacrum, stage two pressure ulcer of the scrotum, stage two pressure ulcer of the left lateral thigh. However, there was no assessment of the pressure ulcers to Resident #08's right heel or left heel. Review of Resident #08's weekly physician wound notes dated 03/23/22 and 03/29/22 revealed wound assessments were completed for a post-surgical wound of the right hip, a post-surgical wound of the left ischium, a post-surgical wound of the sacrum, a post-surgical wound on the left hip, a post-surgical wound of the right ischium, a full thickness wound of the left lateral thigh, a partial thickness wound of the left lateral knee, a stage three pressure ulcer of the left buttock and a partial thickness wound on the scrotum. However, there was no documented assessment of the pressure areas on Resident #08's bilateral heels. Further review of the weekly physician wound note dated 03/23/22 revealed the treatment plan for the partial thickness wound of the scrotum revealed to apply hydrogel daily for 30 days. Review of the treatment administration record (TAR) from 03/24/22 through 04/02/22 revealed the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #08's medical record revealed there was no documentation the resident's pressure ulcers were surgically repaired or closed with a flap or graft. Therefore, Resident #08's wounds were inaccurately assessed as surgical wounds and should have been assessed as pressure ulcers. Review of a nurse's note dated 04/02/22 at 1:26 P.M. revealed Resident #08 had altered mental status. The physician ordered to send the resident to the emergency room . Review of the emergency department documentation dated 04/02/22 at 2:49 P.M. revealed Resident #08 had extensive unstageable coccygeal wounds with wound dressing in place but connected to device. Resident #08 had stage two ulcerations of bilateral hips. Resident #08 had necrotic appearing wounds to the plantar surface of the right foot with foul smelling purulent discharge. Resident #08's right lower extremity was noted as necrotic and malodorous. The right foot x-ray showed signs consistent with acute [CONDITION(S)]. Physician documentation on 04/02/22 at 10:53 P.M. revealed Resident #08 had gangrene of toes of his right foot with evidence of [CONDITION(S)]. Resident #08 was noted with multiple unstageable ulcerations with necrotic tissue to the right lateral foot extending to the plantar aspect of the foot and multiple unstageable ulceration to the dorsum of the right toes and interdigital tissues. Review of the hospital operative report dated 04/03/22 revealed Resident #08 required excisional debridement of the right lateral foot wound including skin subcutaneous tissue, muscle, fascia, down to including fascia measuring 20 centimeters (cm) in length by seven cm in width and two cm in depth. Interview on 04/21/22 at 10:54 A.M. with Wound Care Registered Nurse (WCN) #302 revealed Resident #08 had multiple pressure ulcers in various stages. WCN #302 revealed he was unsure why Wound Physician #12 was documenting the pressure ulcer wounds as surgical wounds. Interview on 04/25/22 at 3:43 P.M., the Director of Nursing (DON) revealed WCN #302, and Wound Physician #12 should have clarified if Resident #08's wounds were surgical or pressure. The DON stated the facility used the physician's wound classification. The DON stated she had no documentation indicating the wounds were surgical. Further interview on 04/29/22 at 2:42 P.M., the DON revealed Wound Physician (WP) #12 indicated Resident #08's wounds were surgical because the wounds were surgically debrided. The DON also stated Wound Physician #12 also indicated he was informed by another physician the wounds were surgical. The DON stated the physician was educated regarding wound classification. The DON also revealed there was no documentation of wound assessments or treatment regarding wounds on Resident #08's bilateral heels and feet. The DON stated the WCN #302 was responsible for completing a head-to-toe assessment of the resident's skin during weekly wound rounds. The DON revealed WCN #302 had resigned from the facility this past week. Interview on 05/03/22 at 7:53 A.M., WP #12 revealed he had not been notified of any wounds or pressure ulcers to the resident's heel or feet. WP #12 revealed Resident #08's wounds were documented as surgical because the wounds had been surgically debrided. WP #12 was not aware a pressure ulcer could not be reclassified as a surgical wound after surgical debridement unless there was a skin graft or skin flap. WP #12 was not aware of Resident #08 ever having a skin graft or skin flap on his wounds. Continued interview on 05/03/22 at 10:45 A.M., the DON verified the skin assessment completed on 03/21/22 noted Resident #08 had pressure ulcers to the bilateral heels. The DON stated Licensed Practical Nurse (LPN) #286, who completed the assessment, believed the areas were not new. The DON stated LPN #286 should have checked if the areas were new skin breakdown. The DON verified Resident #08's physician and family were not notified of the new areas. The DON also verified there were no orders for treatments for the areas to the heels. The DON stated the WCN #302 should have also noticed the areas during the resident's weekly wound assessments. The DON revealed WCN #302 also had not reported any wounds on Resident #08's heels or feet. The DON also verified nursing staff had not completed a weekly skin assessment on 03/28/22. Interview on 05/03/22 at 11:40 A.M., Licensed Practical Nurse (LPN) #286 could not recall completing the skin assessment on 03/21/22 for Resident #08 and could not recall the pressure ulcers she assessed on the resident's bilateral heels. LPN #286 stated if the areas were new then she would have notified the DON and the wound care nurse. LPN #286 could not recall any discoloration on Resident #08's feet or toes. Interview on 05/03/22 at 12:59 P.M., the Administrator stated Resident #08's hospital notes mentioned gangrene one time and never mentioned it again. The Administrator stated Resident #08's wounds were debrided twice in the hospital and there was a vascular consult. Interview on 05/05/22 at 2:58 P.M., the DON verified the initial assessment for the pressure ulcer to the resident's scrotum was completed on 03/22/22. The DON was not sure why the physician noted the area as present for greater than six days in the wound assessment on 03/23/22. The DON verified the physician ordered treatments for the pressure ulcer to the resident's scrotum were not completed from 03/23/22 through 04/02/22. The DON also verified there was no notification provided to the family regarding the wound to the scrotum. Review of the facility policy, Prevention of Pressure Injuries, dated 04/2020, revealed to assess the resident on admission for existing pressure injury risk factors and repeat the risk assessment weekly and upon any changes in condition. Skin assessments would be conducted upon admission, with each risk assessment and as indicated according to the resident's risk factors. Skin including pressure points would be inspected daily when performing or assisting with personal care or activities of daily living to identify any signs of developing pressure injuries. Staff would evaluate, report and document potential changes in the resident's skin. Review of facility policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised 04/2018, revealed for each pressure ulcer the nurse would describe, document and report a full assessment of the pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue, a pain assessment, resident's mobility status, current treatments, including support surfaces and all active diagnoses. This deficiency substantiates Complaint Number OH 824.

Based on medical record review, observation, staff interview, and review of a facility policy, the facility failed to remove a brace to the left lower extremity which was causing pressure to areas of the skin. This resulted in actual harm when Resident #43 had a brace applied to the left lower extremity, the facility staff never contacted the prescribing physician for directions for removing the device, the device was left in place for an extended period of time and Resident #43 developed three unstageable pressure ulcers on her left leg as a result. This affected one (#43) of three (#10, #38, #43) residents reviewed for pressure ulcers. The facility census was 53. Findings include: Medical record review revealed Resident #43 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment, dated 07/28/19, revealed Resident #43 was cognitively intact. The resident was dependent on two staff for bed mobility. The resident had one unstageable pressure ulcer due to a non-removable dressing/device and two unstageable pressure ulcers with slough and/or eschar. Review of Resident #43's nurses notes dated 05/19/19 at 12:00 A.M., revealed the resident returned from an acute care hospital with a cast on her left leg. A nursing note dated 06/05/19 at 4:25 P.M., revealed the resident returned from an orthopedic appointment with orders for non-weight bearing on her left lower extremity. Review of a physician progress notes [REDACTED]. Review of Resident #43's physician orders [REDACTED]. Review of the resident's shower sheet, dated 06/08/19, revealed no new skin issues on the resident's left leg. Review of a weekly skin assessment, dated 06/07/19, revealed the resident did not have any pressure or non-pressure skin issues. Review of a shower sheet, dated 06/12/19, revealed the resident had multiple reddened areas to both of her legs. Review of a nursing note dated 06/13/19 at 12:08 P.M., revealed the resident had two new pressure ulcer areas to her left lower extremity. Review of a pressure ulcer skin grid dated 06/13/19, revealed the resident had a new stage three pressure ulcer, measuring 3.1 centimeters (cm) long by 1.0 cm wide by 0.1 cm deep, on the left rear thigh (wound identifier #136). Wound #136 had 75% granulated tissue, 25% slough, a scant amount of serous (thin and clear) drainage, and had no signs or symptoms of infection. The original date of wound #136 was 06/13/19. Review of a physician order [REDACTED]. Further review revealed the resident's hinged knee brace was able to be removed except while in active therapy. An order dated 06/19/19 was written to apply a hinged knee brace for Resident #43 while in therapy. On 06/20/19 a physician order [REDACTED]. Review of a pressure ulcer skin grid dated 06/20/19, revealed the resident had an unstageable pressure ulcer on her left rear calf (wound identifier #44). The original date of wound #44 was 06/13/19. Wound #44 measured 4.0 cm long by 1.8 cm wide by 0.1 cm deep, was covered 100% with slough, had moderate serosanguinous (pale red or pink colored) drainage, and had no signs or symptoms of infection. Review of a pressure ulcer skin grid dated 06/25/19, revealed the resident had a stage three pressure ulcer on her left knee (wound identifier #38). Wound #38 measured 0.2 cm long by 1.6 cm wide by 0.1 cm deep, there was 100% granulated tissue, a scant serosanguinous drainage, no signs or symptoms of infection and there was scar tissue surrounding the wound. A pressure ulcer skin grid dated 07/23/19 revealed wound #38 was healed. Wound #38 was identified to be a pressure ulcer obtained secondary to placement of a medical device. Review of wound care notes from Certified Nurse Practitioner (CNP) #400, revealed on 06/25/19 the resident was treated for [REDACTED]. The resident was also treated for [REDACTED]. The etiology of the three pressure ulcers was they were caused by a medical device. A wound care note, dated 07/09/19, revealed the pressure ulcer on the resident's left knee was healed. CNP #400's wound care notes, dated 08/06/19, revealed the resident continued to have an unstageable pressure ulcer on her posterior left thigh and left calf. The ulcer on her posterior left thigh measured 0.6 cm long by 0.4 cm wide by 0.1 cm deep and was unchanged from the previous assessment. The ulcer on her left calf measured 0.9 cm long by 0.9 cm wide by 0.1 cm deep and was unchanged from the previous assessment. Review of a pressure ulcer skin grid dated 08/06/19 revealed wound #136 measured 0.6 cm long by 0.4 cm wide by 0.1 cm deep and was unstageable. The wound was covered with 100% slough, had a scant amount of serous drainage, had no signs or symptoms of infection, was unchanged from the prior week's assessment and there was scar tissue surrounding the wound. Wound #136 was identified to be from a medical device. Review of a pressure ulcer skin grid dated 08/06/19 revealed wound #44 measured 0.9 cm long by 0.9 cm wide by 0.1 cm deep and was covered 100% by slough, had scant serosanguinous drainage, no signs or symptoms of infection and was unchanged from the prior week's assessment. Wound #44 was identified to be from a medical device. Observation of Resident #43's dressing changes on 08/06/19 at 9:27 A.M., with Assistant Director of Nursing (ADON) #123, CNP #400, Licensed Practical Nurse (LPN) #132, and State tested Nursing Assistant #129, revealed the resident continued to have two pressure ulcers on her left lower extremity; wound #136 and wound #44. Wound #136 measured 0.6 cm long by 0.4 cm wide by 0.1 cm deep and was unstageable due to 100% coverage of slough. The wound had scant amounts of serous drainage with no signs or symptoms of infection. Wound #44 measured 0.9 cm long by 0.9 cm wide by 0.1 cm deep and was unstageable due to 100% slough, scant amounts of serosanguinous drainage with no signs or symptoms of infection. Interview on 08/06/19 at 7:31 A.M., ADON #123 confirmed on 06/13/19, the resident was found to have two pressure ulcers. ADON #123 revealed, on 06/06/19 Resident #44 went to an orthopedic appointment and had a soft cast removed from her left lower leg. The physician placed a removable hinge brace on the leg and gave an order for [REDACTED].#123 stated there was no order indicating when or if the brace could be removed for care and confirmed the facility staff did not call the physician to have the order verified. ADON #123 confirmed the resident remained in the hinged brace until 06/13/19, when the resident was noted to have skin breakdown. ADON #123 stated at that point she called the physician herself to clarify when the brace could be removed. ADON #123 verified wound #136, wound #44, and wound #38 were pressure ulcers caused by the resident's removable hinged brace. ADON #123 further stated nursing staff should have clarified when the brace should have been removed when the resident returned from her appointment on 06/06/19. Interview on 08/06/19 at 10:17 A.M., CNP #400 confirmed she started treating Resident #43 on 06/25/19 for pressure wounds. CNP #400 confirmed the pressure wounds were caused from a removable medical device. Review of an undated facility policy titled Pressure Ulcer Prevention and Risk Identification, revealed the facility would establish measures to prevent the development of pressure ulcers and/or prevent further decline of already existing pressure ulcers.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of invoice, and review of a facility policy, the facility failed to completely assess a newly developed pressure ulcer, failed to notify the physician of the pressure ulcer, failed to update the plan of care for an actual pressure ulcer, failed to implement physician order [REDACTED]. This caused actual harm to occur when one resident (#1) developed an open area on the coccyx which progressed to an unstageable pressure ulcer, and continued to increase in size and depth. This affected one (#1) of three residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. The facility census was 61. Findings include: Review of Resident #1's medical record revealed an original admission date of [DATE] an a re-admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #1 was discharged from the facility on 02/28/18. Review of an admission nursing assessment dated [DATE] revealed Resident #1 had no skin impairments. Review of a re-admission nursing assessment dated [DATE] revealed Resident #1 remained with no skin impairments. Review of a pressure ulcer risk assessment dated [DATE] revealed Resident #1 was a moderate risk for acquiring pressure ulcers. Review of the admission Minimum Data Set (MDS) assessment, dated 02/04/18, revealed Resident #1 required extensive two person assistance with bed mobility and transfers, and was assessed with [REDACTED]. Review of a care plan dated 01/25/18 revealed Resident #1 had potential for impaired skin integrity. Interventions included observing skin during morning and night care, encouraging nutritional intake by mouth, and repositioning in bed every two hours. Review of skilled nursing progress notes dated between 01/28/18 and 02/02/18 revealed no documentation of any skin impairments. Review of a skilled nursing progress note on 02/03/18 revealed Resident #1 had a small open area on the buttocks from an incontinence brief and cream was applied. There was no documentation in the medical record of an assessment of the wound or notification to a physician of the open area. Skilled nursing progress notes on 02/04/18 and 02/05/18 revealed Resident #1 had no new skin changes. Review of skilled nursing progress notes on 02/06/18 revealed Resident #1 had a red buttocks with cream applied, and on 02/07/18 documentation revealed coccyx cream applied. There was no documentation in the medical record of an assessment of the red area or notification to a physician. Review of a wound assessment dated [DATE], completed by a wound nurse practitioner, revealed Resident #1 was assessed with [REDACTED]. Resident #1 was ordered to have her wound cleansed with normal saline, patted dry, and applied a skin protectant cream with a foam dressing to be changed daily and as needed, frequent adult incontinence brief changes, continue frequent position changes, and an alternating low air loss mattress to offload the coccyx. The care plan was revised on 02/09/18 and indicated an actual impaired skin integrity of the coccyx, however, no new interventions were documented. Review of a treatment administration record (TAR) from (MONTH) (YEAR) and nursing progress notes revealed Resident #1 received no scheduled pressure ulcer wound treatments on 02/08/18, 02/09/18, and 02/11/18. Review of an invoice dated 02/14/18 revealed Resident #1's alternating low air loss mattress was delivered to the facility. There was no documentation of the mattress being applied to Resident #1's bed. Review of progress notes, physician orders, and a pressure ulcer care plan between 02/08/18 and 02/28/18 revealed no documentation of Resident #1 with an alternating low air loss mattress to the bed while in the facility. Review of a wound assessment completed on 02/15/18 revealed Resident #1's pressure ulcer was assessed as a Stage III (full-thickness skin loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible) pressure ulcer with 70% granulation tissue and 30% slough measuring 4.8 cm long by 3.3 cm wide by 0.2 cm depth. Review of a physician order [REDACTED]. Review of a TAR from (MONTH) (YEAR) and nursing progress notes revealed Resident #1 received no scheduled pressure ulcer wound treatments on 02/15/18, 02/17/18, 02/18/18, 02/21/18, 02/22/18, and 02/26/18. Interview on 06/05/18 at 1:23 P.M, the Director of Nursing (DON) verified Resident #1 acquired a pressure ulcer while in the facility. The DON verified the physician was not contacted and no skin assessment was completed when Resident #1 presented with a small open area on the buttocks on 02/03/18. The DON verified there was no documentation of an alternating air loss mattress applied to Resident #1's bed and Resident #1 did not receive wound treatments as ordered on [DATE], 02/09/18, 02/11/18, 02/15/18, 02/17/18, 02/18/18, 02/21/18, 02/22/18, and 02/26/18. Review of a facility policy titled Skin Integrity Standard, updated (MONTH) (YEAR), revealed all admissions will have a skin risk assessment completed by a licensed nurse or designated wound nurse and based on the assessment intervention strategies will be implemented. If skin integrity issues are identified post-admission, documentation of the wound in the medical record will include wound specifics (location, size, amount of drainage, description of the wound bed, odor, signs or symptoms of infection, description of surrounding tissue, and identifying the wound type.) The policy noted if a wound is identified there would be notification of the physician and updating the care plan to reflect the current status of the wound, treatment plan, turning and repositioning program, and additional interventions to promote healing. Review of the facility's corrective action revealed the following actions were implemented and the deficiency was corrected as of 05/04/18. · Resident #1 was discharged from the facility on 02/28/18. · All residents identified as requiring assistance with turning and repositioning were identified by the facility. · Licensed nurses and state tested nurses aides (STNA) were re-educated on policies and procedures regarding documentation each shift of turning and repositioning and placement of pressure relieving devices by the DON on 03/28/18. · Documentation for turning and repositioning and pressure device placement were audited three to five times weekly on different shifts for four weeks and randomly thereafter until sustained compliance noted. Audits were completed and approved on 05/04/18. The facility continued to ensure preventative skin care and repositioning use of pressure relieving devices are documented per policy. · The results of turning and positioning and pressure relieving device placement audits will be reported to the Quality Assurance and Performance Improvement (QAPI) committee monthly for tracking and trending and recommendations. This action was completed and approved on 05/04/18. This deficiency substantiates Master Complaint Number OH 159.

This is an incident of continued noncompliance at a higher scope and severity then what was cited during the standard survey conducted on [DATE]. Based on medical record review, staff interview, pharmacy staff interviews, review of hospital medical records, manufacturer's drug information and facility policy review, the facility failed to administer an anticoagulant (blood thinning) medication as ordered by the physician to one (#100) of five sampled residents receiving anticoagulant medications. This resulted in Immediate Jeopardy for Resident #100 who did not receive a prescribed anticoagulant medication ([MEDICATION NAME]) for forty-five days. The facility identified four residents who were currently receiving anticoagulant medication out of a total census of 99. On [DATE] at 4:40 P.M., the Administrator and the Director of Nursing (DON) were notified that Immediate Jeopardy began on [DATE], five days after Resident #100 received her last dose of [MEDICATION NAME]. The facility did not administer [MEDICATION NAME] for an additional 40 days. On [DATE] at 7:30 P.M., Resident #100 developed shortness of breath, wheezing and was transferred to the emergency department. The resident was diagnosed with [REDACTED]. The resident was admitted to the hospital where she subsequently expired on [DATE]. The Immediate Jeopardy was removed on [DATE] at 4:30 P.M. when the facility implemented the following corrective actions: -On [DATE], the staff development nurse, Registered Nurse (RN) #14, conducted a mandatory in-service training for all licensed nursing staff regarding medication errors, including [MEDICATION NAME] administration. - On [DATE], Assistant Director of Nursing (ADON) #1 reviewed the medical records of all three residents (#51, #94 and #120) currently receiving anticoagulation therapy to ensure they were receiving the prescribed dosage. The DON and ADON #1 verified all orders pertaining to anticoagulant therapy were implemented as prescribed by the physician. - On [DATE] the facility developed a nurse management team that consists of the DON, ADON #1, RN #14 and RN #17. The team will complete "Anti-coagulant Audit Logs" daily which will be reviewed at the daily morning meetings. - On [DATE], the facility implemented a new change over team. The team of five licensed practical nurses (LPNs) and two RNs will complete the change over by comparing the physician's orders [REDACTED]. -On [DATE], review of medical records for Residents #51, #94 and #120 revealed "Anticoagulant Administration and Billing Records" (the medication administration records for [MEDICATION NAME]) were in place and all required lab tests were obtained as ordered. -On [DATE], all licensed nurses were observed and evaluated by ADON #1, RN #14 and pharmacy technicians during a medication administration to ensure competency. -On [DATE] from 8:50 A.M. to 10:20 A.M., LPNs #19,#23, #36 and #49 were interviewed and demonstrated knowledge of the facility's "Anticoagulant Administration and Billing Records," "Anticoagulant Therapy" policy, and their responsibilities for ensuring anticoagulation medication is administered as ordered. Although the Immediate Jeopardy was removed when the facility audited the medical records of all residents to ensure residents receiving anticoagulant therapy had current physician orders [REDACTED]. Findings Include: Review of Resident #100's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The form entitled "Discharge Instructions for Care" dated [DATE] revealed the resident was admitted to the facility with a physician order [REDACTED]. Review of Resident #100's anticoagulation therapy care plan dated [DATE] noted a goal for the INR level to remain therapeutic as specified by the physician. Interventions to accomplish this goal included to administer medications as ordered; labs as ordered; notify physician/[MEDICATION NAME] clinic of results; notify the physician of any abnormal signs or symptoms such as black tarry stools, red or dark brown urine, coffee ground emesis, red spots on skin (petechiae), unusual bruising, bleeding from the gums or nose, nausea, vomiting, dizziness, headache, [MEDICAL CONDITION], pallor, and [MEDICAL CONDITION] The care plan did not include interventions to address signs and symptoms of sub-therapeutic levels of [MEDICATION NAME]. physician's orders [REDACTED]. Review of Resident #100's "Anticoagulant Administration and Billing Record" dated [DATE] revealed the resident received [MEDICATION NAME] 5 mg on [DATE] and [DATE] and then [MEDICATION NAME] 4 mg daily from [DATE] until [DATE]. Review of the signed monthly physician's orders [REDACTED]. The first order was for [MEDICATION NAME] 3.5 mg daily at bedtime and the second order was for [MEDICATION NAME] 4 mg daily. Review of Resident #100's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" dated [DATE] and [DATE] revealed no documented evidence that any [MEDICATION NAME] was administered. According to a manufacturer of [MEDICATION NAME], Bristol-Myers Squibb Pharmaceutical Company, the anticoagulation effect of [MEDICATION NAME] generally occurs within 24 hours after drug administration. However, peak anticoagulant effect may be delayed 72 to 96 hours. The duration of action of a single dose of [MEDICATION NAME] ([MEDICATION NAME]) is two to five days. Nurse's notes dated [DATE] at 1:30 P.M., written by LPN #7, revealed the physician was called concerning Resident #100's nausea and vomiting. Orders for lab tests, x-rays and anti-nausea medication were received. On [DATE] at 4:30 P.M., RN #9 documented in nurse's notes that Resident #100's skin was warm and clammy. Review of her vital signs obtained at this time revealed her respiratory rate was elevated at 27 breaths per minute (normal is 12 breaths per minute) and her blood pressure was elevated at ,[DATE] (normal is ,[DATE].). At 7:30 P.M. on [DATE], RN #9 documented the resident was transported to the hospital. Review of the "Resident Transfer Form" dated [DATE] (no time specified), completed by RN #9, indicated the reason for the transfer was due to the resident's shortness of breath, wheezing, rhonchi, and increased white blood cell count. The "Resident Transfer Form" further indicated the resident complained of nausea most of the day and was bringing up a bile emesis. The resident's breath sounds were diminished with rhonchi bilaterally throughout. The resident was grunting on expiration and had oxygen applied. Review of the history and physical examination [REDACTED]. The physician progress notes [REDACTED]. Review of the pharmacy "Proof of Delivery Shipment Detail" form dated [DATE] through [DATE] revealed the last delivery of [MEDICATION NAME] for Resident #100 was shipped to the facility on [DATE]. The shipment contained two 5 mg tablets of [MEDICATION NAME]. During interview on [DATE] at 8:50 A.M., the Director of Nursing verified the facility did not have any documented evidence that [MEDICATION NAME] had been administered to Resident #100 as ordered by the physician during May and [DATE]. Interview with LPN #12 on [DATE] at 4:35 P.M. revealed she cared for Resident #100 and administered her medication during her stay at the facility from [DATE] through [DATE]. LPN #12 stated, "The resident was on [MEDICATION NAME] when she first came in but she hadn't been on that in awhile." Interview with Pharmacist #1 on [DATE] at 8:40 A.M. verified the last [MEDICATION NAME] order the pharmacy filled for Resident #100 was on [DATE] for two 5 mg tablets of [MEDICATION NAME]. She also verified the pharmacy never sent Resident #100's [MEDICATION NAME] 4 mg dose to the facility. Review of the facility's policy entitled "Anticoagulant Therapy" dated [DATE] indicated the purpose of the policy is to monitor anticoagulant therapy so that therapeutic drug parameters are maintained. Also, administer anticoagulant therapy in accordance with the physician's orders [REDACTED]. "This deficiency substantiates Master Complaint Number OH 261."