Every finding on record at Cottingham Retirement Community

Based on medical record review, observation, staff interview, review of Self-Reported Incident (SRI) reports, review of the United States (US) Food and Drug Administration (FDA) Guide to Bed Safety: Bed Rails in Hospitals, Nursing Homes and Home Healthcare, review of the suffocation and strangulation hazard tag on bed rail, review of bed rail safety warning and assembly instructions, and policy review, the facility failed to thoroughly assess residents for the risk of entrapment and appropriateness for the use of bedrails. This resulted in Immediate Jeopardy and death for Resident #1 when the resident was found unresponsive and without vital signs with his head and neck through the opening of the bedrail on the left side of his bed. His right hand was grasping the top of the transfer rail, and his lower torso was on the floor next to the left side of the bed with his legs in a kneeling-like position. This had the potential to affect 39 residents with bed rails in place. The facility census was 57 residents. On 08/14/26 at 2:35 P.M. the Administrator, the Director of Nursing (DON), [NAME] President of Clinical Operations (VPCO) #925, Regional Director of Clinical Operations (RDCO) #920, and the Risk Director (RD) #915 were notified Immediate Jeopardy began on 08/08/26 at 4:05 P.M. when Resident #1 was discovered unresponsive with his head and neck through the opening of the transfer rail on the left side of the bed. He was grasping the top of the assist bar, and his lower torso was on the floor next to the left side of the bed. Emesis was found on the mattress, bed frame and floor. Certified Nursing Assistant (CNA) #550 assisted Registered Nurse (RN) #350 to remove Resident #1's head and neck from the transfer rail opening and placed the resident in the bed and positioned him on his back. RN #350 notified the resident's provider of the resident's condition and received an order to arrange to transport the resident's body to the funeral home. Resident #1's code status was Do Not Resuscitate Comfort Care (DNRCC.) Although the Immediate Jeopardy was removed on 08/18/26 at 10:00 A.M., the facility remained out of compliance at 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 plans and monitoring to ensure on-going compliance. On 08/08/26 at 6:27 P.M., the DON arrived at the facility, interviewed RN #350 and visualized Resident #1 and the bedrail still in place to the resident's bed. Resident #1 was supine in bed and was awaiting transportation to the funeral home. On 08/08/26 at 7:00 P.M., the DON, RDCO #920 and RD #915 identified 33 residents in the facility who had rails like those on Resident #1's bed (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #13, #14, #15, #16, #17, #21, #22, #23, #24, #25, #26, #33, #37, #38, #39, #44, #45, #47, #48, #50, #53 and #56) and made the decision to have staff immediately remove all of these rails from the beds. On 08/08/26 at 7:05 P.M. RD #915 educated the Administrator via telephone and Maintenance Director #200 on the following: all rails, assist bars, and bed accessories were to be approved by the Administrator and/or Maintenance Director prior to being installed on resident beds, need to perform testing of mattresses, rails/bars and gap testing on bedrails, nursing assessment must be in place prior to installing bedrails, installation of bedrails must follow manufacturer's instructions. On 08/08/26 by 10:00 P.M., Maintenance Director #200 removed bed rails from the beds of 33 residents, Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #13, #14, #15, #16, #17, #21, #22, #23, #24, #25, #26, #33, #37, #38, #39, #44, #45, #47, #48, #50, #53 and #56. On 08/08/26 at 10:30 P.M., Maintenance Director #200 completed gap testing for the residents in the facility who still had bed rail, Residents #12, #19, #30, #40, #49 and #57, that were of a different style than those to Resident #1's bed. On 08/08/26 at 10:38 P.M., the facility held an ad-hoc Quality Assurance Performance Improvement (QAPI) meeting with the following individuals in attendance: Medical Director (MD) #900 via telephone, the Administrator, DON, RDCO #920, Risk Director #915. On 08/08/26, the Administrator, the DON, RDCO #920 and Maintenance Director #200 completed a root cause analysis of the incident involving Resident #1 and classified it as a possible entrapment concern. Their analysis identified contributing factors to the incident included the following: Resident #1 appeared to have slid from bed, Resident #1 required assistance with bed mobility, Resident #1 had his hand on the bed cane and his feet were on floor, Resident #1 had poor body control and weakness, the type of rail used may have contributed to resident entrapment. On 08/09/26 at 12:03 A.M., the DON completed audits for the six remaining residents (Residents #12, #19, #30, #40, #49, #57) with bedrails in place that included ensuring there was a bedrail assessment in place, a current physician order for the bedrail and ensuring the resident's care plan was updated regarding the bedrail. On 08/09/26 at 12:27 A.M., the DON sent education via electronic message to all nurses, CNAs, and agency nurses regarding bed rail safety. On 08/09/26 at 8:49 A.M., the DON verified all of the nursing staff had completed the bed rail safety education. On 08/09/26 at 10:00 A.M., VPCO #925 reviewed the bed rail policy and procedure and determined no revisions were deemed necessary. On 08/10/26 at 9:30 A.M., Risk Director #915 re-reviewed with the Administrator, the DON and Maintenance Director the plan for the Administrator to give approval prior to use and installation of rails/ bed accessories to prevent future occurrences of installing devices that may not be appropriate such as the bedrail that had been installed on Resident #1's bed. On 8/10/26, an additional audit was completed by the Maintenance Director #200 of all beds in use in the facility, which included audit of entire bed. On 8/10/26, education was uploaded into the agency system to ensure future agency staff are educated on bed rails prior to working in the facility. Starting on 8/11/26, the DON completed an audit of two residents for assessment of assist rails, orders, care plans and informed consent. DON/designee would complete a twice-weekly audit of two residents. The audits would continue for four weeks in total. On 8/13/26, Maintenance Director #200 conducted a complete bed audit of all beds in use in the facility including frame, headboard, rails, mattresses. Starting on 08/13/26, Maintenance Director #200 completed a gap testing audit of two resident beds as part of follow up auditing for compliance. Maintenance Director #200/designee would complete a twice-weekly audit of two resident beds. The audits would continue for four weeks in total. Starting on 08/13/26, the Administrator initiated discharged resident room audits for bedrail safety to be completed two times per week for a period of four weeks with results submitted to the Quality Assurance Performance Improvement (QAPI) for review and recommendation. The QAPI committee will review the IJ corrective action plan monthly for 90 days to ensure ongoing compliance. On 08/14/26 at 4:44 P.M., RDCO 920 filed an initial Self-Reported Incident (SRI) of possible neglect with the Ohio Department of Health (ODH) regarding the incident involving Resident #1. On 08/17/26 at 4:16 P.M., the Administrator educated Human Resources Director (HRD) #125 on the required new hire education for nursing and maintenance employees regarding the bed rail policy. By 8/18/26 at 10:00 a.m. the DON/Designee had completed bed rail assessments for Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #13, #14, #15, #16, #17, #21, #22, #23, #24, #25, #26, #33, #37, #38, #39, #44, #45, #47, #48, #50, #53 #56 whose bed rails had been removed on 08/08/26. On 08/21/26 at 1:26 P.M. the Administrator finalized the SRI regarding Resident #1 and did not substantiate neglect had occurred. Review of the SRI revealed the facility staff had found Resident #1 deceased in his room on 08/08/26 against the bedrail with his feet on the floor. On 09/03/26 at 11:00 A.M., Quality Assurance Performance Improvement (QAPI) will be reconvened to assess the Maintenance Department siderail/transfer rail audits and make additional recommendations. Findings include: Review of the medical record for Resident #1 revealed an admission date of 05/29/24 with diagnoses including Alzheimer's disease, severe protein-calorie malnutrition, congestive heart failure, and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment, dated 05/26/26 revealed Resident #1 had moderate cognitive impairment, was always incontinent of bowel and frequently incontinent of bladder, utilized a manual wheelchair with supervision for mobility, required supervision for bed mobility, moderate assistance for oral and personal hygiene and toileting, maximal assistance for bathing and dressing, and supervision to moderate assistance for transfers. The MDS was not coded for the use of a bedrail or other device. Review of physician's orders revealed there were no orders for use of a bed rail of any type for Resident #1. Review of care plan revealed it included no documentation regarding use of a bedrail of any type for Resident #1. Resident #1's medical record did not contain documentation of a bedrail assessment for the resident. Review of nurse progress note dated 08/08/26 at 4:55 P.M. by Registered Nurse (RN) #350 revealed Certified Nursing Assistant #550 alerted the nurse for assistance. Upon entering the room, RN #350 found Resident #1 in a kneeling position on the left side of the bed with his head and neck through a transfer rail on the left side of the bed frame. The resident's head was facing downward with the top of his head facing the room door. Resident #1 appeared to be without signs of life. Resident #1's code status was verified as DNRCC. RN #350 and CNA #550 removed Resident #1's body from the transfer rail and floor and positioned the resident on his back in his bed. No pulse or respirations were noted. Review of the nurse progress note dated 08/08/26 at 4:45 P.M. by RN #350 documented the nurse notified Resident #1's medical provider of the incident involving the resident. There was a physician order dated 08/08/26 at 4:51 P.M. by MD #900 to release Resident #1's body to the funeral home of family choice. Review of the nurse progress note dated 08/09/26 at 12:31 A.M. by RN #360 documented Resident #1's body was transported to the funeral home as ordered. The facility's incident and accident log was reviewed and contained no documentation of the incident involving Resident #1's death on 08/08/26. During an interview on 08/13/26 at 4:28 P.M., CNA #550 stated Resident #1 was assigned to her care on the day shift. On 08/08/26, after the lunch meal, she placed Resident #1 back to bed and provided incontinence care before going to lunch herself. CNA #550 stated she completed her care for Resident #1 at approximately 1:45 P.M. After coming back from lunch, CNA #550 stated she provided a shower to a resident and then assisted the residents in another room. CNA #550 stated when starting last rounds at 4:05 P.M. she entered Resident #1's room, pulled the privacy curtain back and found Resident #1 in a kneeling-like position on the left side of his bed, his right hand grasping the top of the transfer rail, and with his head and neck through the opening of the transfer rail. The top of the resident's head was towards the door with eyes facing downward. Resident #1 was not breathing, and CNA #550 went to get the nurse (RN #350). During an interview on 08/13/26 at 4:51 P.M., RN #350 stated she was the nurse on duty 08/08/26 day shift when CNA #550 notified her of the situation involving Resident #1. RN #350 stated Resident #1 had transfer rails on both the left and right sides of the bed, and the opening in the transfer rails was large enough for him to fit his head and neck through. RN #350 stated Resident #1's left side of the bed faced the room door and the resident's head was through the left transfer rail with the top of the resident's head towards the room door and face looking down towards the floor. RN #350 stated Resident #1 was positioned in a manner that it appeared he had put his head through the opening of the transfer rail while lying in bed and then either fell out or attempted to get out of the left side of the bed and got stuck. The resident's lower torso was out of the bed, on the floor, with his legs in a kneeling-like position and his right hand grasping the top of the transfer rail. RN #350 stated the resident was not breathing and without vital signs and that she and CNA #550 were able to remove Resident #1 from this position and place him in bed on his back. RN #350 made notification to MD #900 who gave an order to transfer the resident's body to the funeral home. During an interview on 08/14/26 at 9:46 A.M., the Administrator stated she received a telephone call from the DON on 08/08/26 at approximately 5:00 P.M. that staff had found a resident with their head through a transfer rail, holding on to the transfer rail. The Administrator stated she was at a family gathering and was unable to come to the facility, but RD #915 and RDCO #920 had responded and were at the facility. The Administrator stated Resident #1's bedrails were the property of the facility, and no siderail/transfer rail assessment had been completed for Resident #1. The Administrator verified at the time of Resident #008's death there were approximately 20 other residents in the facility who had the same transfer rail that had been installed on Resident #1's bed. The Administrator verified the facility did not contact law enforcement about Resident #1's death and RD #915 did not contact the coroner about the incident until 08/13/26 at 5:18 P.M. During an interview on 08/14/26 at 10:28 A.M., Maintenance Director #200 stated the bedrails used by Resident #1 and the 33 additional residents who had identical bedrails in place at the time of the incident had been grandfathered which meant at some time the bedrail had been installed and was never removed. Bed rails remained on the beds as residents were admitted and discharged from the facility. Maintenance Director #200 stated he received a phone call from the Administrator on 08/08/26 at 6:22 P.M. who stated Resident #1 had passed away, and he was needed for corrective action to remove all transfer rails from resident beds. When removing the transfer rails from Resident #1's bed, Maintenance Director #200 stated he saw a large amount of emesis on the resident's floor, mattress and bed frame. Maintenance Director #200 verified after he removed the bedrails he stored them in a secure area. Maintenance Director #200 stated there was no previous history of bedrail audits or gap testing being completed until after the incident on 08/08/26. During an interview on 08/14/26 at 11:11 A.M., Medical Director #900 stated the RDCO #920 spoke with him by phone on 08/08/26 of Resident #1's death. MD #900 stated the facility told him the issue with the bedrail would be corrected by removing similar style bed rails. MD #900 stated he was not aware if the facility had performed any assessments of resident need for bed rails, but they had removed all of the bedrails like Resident #1's bed rail on 08/08/26. During an interview on 08/14/26 at 11:29 A.M., the DON stated Resident #1's bedrail and all other resident's bedrails were in place when he started at the facility. The DON stated as residents admitted and discharged the bedrails remained in place on the beds. The DON stated he received a call from RN #350 on 08/08/26 at approximately 5:00 P.M. who told him Resident #1 had been found nonresponsive with his head and neck through the left transfer rail, right hand grasping the top of the transfer rail and lower torso out of the left side of the bed with both knees on the floor. The DON stated he arrived at the facility at approximately 6:27 P.M. The immediate measures taken by the facility was to remove any and all bedrails which were like the ones that had been on Resident #1's bed. The DON verified he started educating nursing staff on bedrail protocol and to ensure completion of a bedrail assessment prior to use of bed rails. The DON stated the incident involving Resident #1 was not categorized as a fall and he was unable to provide an answer as to why the incident involving Resident #1 on 08/08/26 was not reflected on the incident and accident log, why law enforcement or the coroner were not initially notified, or who made the decision to ultimately call the coroner on 08/13/26 at 5:18 P.M. The DON verified the facility had not completed a bedrail assessment for Resident #1. During an interview on 08/14/26 at 12:15 P.M., County Coroner Death Investigator (CCDI) #910 stated she received a phone call from RD #915 on 08/13/26 at 5:18 P.M. who stated Resident #1 was found on 08/08/26 with his head in a siderail and was pronounced deceased at the facility. CCDI #910 verified the coroner's office was not planning to conduct an investigation of Resident #1's death. During an observation on 08/14/26 at 12:16 P.M., an identical bedrail to that of Resident #1's at the time of his death revealed the rail was identified as a Stander bed cane with an oval-shaped opening. It could be raised and lowered and was mounted to a rectangular piece of wood board that measured 22 inches long by 15 and three quarters inches wide. The bedrail was connected to the wood board by two nuts and bolts. The wood board slid between the mattress and bed frame and had a nylon strap attached to the opposite side of the bed frame to prevent the transfer rail from moving. The bedrail had pre-drilled holes where it could be raised or lowered approximately four inches. The bedrail had an oval shaped opening of 12 and one-quarter inches at its widest. There was an open area at the bottom of the oval that measured six inches wide. The rail had a suffocation and strangulation hazard tag which indicated gaps in and around the product could entrap and kill people with Alzheimer's Disease or dementia, and those who were sedated, confused or frail were at increased risk of entrapment. The warning indicated to never use unless product is tight around the mattress without gaps, and at least 12 and one-half inches from the headboard and footboard and never use the product without properly securing it to the bed. Incorrect installation could allow product to move away from the mattress and/or bed frame which could lead to entrapment and death. Bed Rail strap must go around bed frame. During an interview on 08/17/26 at 12:07 P.M., Maintenance Director #200 verified the mattress in place to Resident #1's bed at the time of the resident's death was six inches thick. Maintenance Director #200 stated the two bedrails removed from Resident #1's bed after the 08/08/26 incident, were connected with the nylon straps to the bed frame as per the manufacturer's instructions. Maintenance Director #200 verified neither bedrail to Resident #1's bed had the sewn organizer in place that covered the oval opening of the transfer rail. Maintenance Director #200 stated no knowledge as to when or who removed the sewn organizers to the resident's bed. Maintenance Director #200 verified he had never visualized, reviewed or utilized the manufacturer's installation and safety instructions for the Stander bed cane, the type of rail that had been installed on Resident #1's bed. Review of the manufacturer's instructions for the Stander bed cane, dated 2014 revealed the bed originally came with a sewn organizer that covered the oval opening of the transfer rail (bed cane). The safety warning and assembly instructions stated to never remove the sewn organizer from the handle. The sewn organizer helped to prevent entrapment. The mattress thickness must be between 12 inches and 16 inches thick with the top of the rail/handle no more than four inches above the top of the mattress. This product should only be used with innerspring or memory foam style mattresses. Review of the policy titled, Bed Rail Policy, dated January 2025, revealed it was the policy of this facility to identify and reduce safety risks and hazards commonly associated with bed rail use. The definition of a bed rail was bars that attached to the bed with examples that included but were not limited, to side rails, safety rails, grab bars and assist bars. It was the policy of the facility to conduct bed inspections in accordance with providing a safe, clean, comfortable and homelike environment. The Maintenance Director (or qualified designee) would be responsible for completion of bed inspections on a regular basis. Clinical assessments would be conducted prior to the initiation of bed rail use. The resident would be assessed to identify appropriate alternatives prior to installing bed rails. If the resident assessment indicated the need for bed rails, risks and benefits will be provided to the resident and/or resident representative along with obtaining informed consent. A physician order will be obtained to include indication of use. The residents would be reassessed quarterly to determine continued need. When installing or maintaining bed rails, the maintenance department staff would follow the manufacturer's recommendations. The Maintenance Department will conduct regular inspection of all bed frames, mattresses, and bed rails, as part of the regular maintenance program. When bed rails and mattresses are used and purchased separately from the bed frame, the facility will select equipment such as bed rails, mattresses and bed frames that are compatible. Review of the US FDA Guide to Bed Safety: Bed Rails in Hospitals, Nursing Homes and Home Healthcare revealed zones of bed entrapment included Zone 1 which referred space within the rail and indicated any open space between the perimeters of the rail can present a risk of head entrapment. The US FDA recommended space for openings in bed rails be less than four and three-quarters inches. This deficiency represents the non-compliance investigated under Complaint Number 3153574.

Based on observation, review of the freezer and refrigerator temperature logs, interview, and policy review, the facility failed to ensure food was stored and prepared under sanitary conditions. This had the potential to affect 56 out of 56 residents who eat food prepared in the kitchen. The facility identified one (Resident #08) who did not eat food by mouth. The facility census was 57.Findings Included:Observation of the dry food storage area on 02/09/26 at 6:33 P.M. revealed a package of opened, undated sandwich buns with mold growing on one of the buns. In addition, there was an opened, undated loaf of white bread. The Dietary Supervisor #132 verified the above items and discarded them.Observation of the walk-in refrigerator in the main kitchen on 02/09/26 at 6:44 P.M. revealed a loosely covered cart of pre-prepared foods with a date of 02/03/26. The cart contained five trays of individual prepared salads, a tray of individual servings of pumpkin pie, two trays of individual servings of coconut cream pie and two trays of individual dishes of pears. Located next to the cart dated 02/03/26 was an undated loosely covered smaller cart with a pan of diced ham, one container of onions, one tray of cooked omelets and one tray of uncooked bacon. On one of the shelves in the walk-in refrigerator there was an undated covered container of pre-made chili. All outdated and undated items were verified by the Dietary Director #123. Observation of the walk-in freezer in the main kitchen on 02/09/26 at 7:17 P.M. revealed an open box containing an opened, undated bag of frozen bread sticks. The opened bag of breadsticks were verified by the Dietary Director #123.Observation of the main kitchen on 02/11/26 at 10:50 A.M. revealed dirty kitchen ceiling tiles as well as three of four vents with dark dust coating much of the vent. The Dietary Supervisor #132 verified the ceiling tiles were dirty and revealed maintenance was in charge of cleaning the ceiling tiles and the vents. The Dietary Director #123 also verified the ceiling tiles were dirty and needed to be cleaned or replaced. Interview with Maintenance Director (MD) #500 on 02/11/26 at 3:25 P.M. verified the ceiling tiles and ceiling vents were dirty and needed cleaned in the main kitchen.Review of refrigerator and freezer temperature logs on 02/11/26 at 10:53 A.M. revealed missing temperature logs for the following dates: 09/25/25, 10/26/25 through 10/31/25. There were also missing temperature entries on 10/25/25. Review of facility policy titled Refrigerator/Freezer Temperature Records revealed temperatures shall be monitored on all refrigeration and freezer equipment twice daily and recorded on the Temperature Records Form.Review of facility policy titled Food Safety and Sanitation dated 2021 revealed food should be protected from contamination (dust, flies, rodents and other vermin). When food package was opened the food item should be marked to indicate the open date. This date is used to determine the discard date. The policy states that leftovers are to be used within 72 hours or discarded and that perishable food should be used prior to the use by date on the package.

Based on medical record review and staff interview, the facility failed to ensure discharge summaries were completed. This affected one (#01) of one resident reviewed for discharge. The facility census was 57.Findings include:Review of the closed medical record for Resident #01 revealed an admission date of 11/07/25 and a discharge date of 02/03/26. Diagnoses included Parkinson's disease without dyskinesia with fluctuations, hyperlipidemia, atherosclerotic heart disease of native coronary artery without angina pectoris, major depressive disorder, repeated falls, bipolar disorder, cerebrovascular disease, conversion disorder with seizures or convulsions, encephalopathy, other symbolic dysfunctions, and chronic viral hepatitis B without delta-agent.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 was cognitively intact. Resident #01 was assessed to require setup assistance for eating, oral hygiene, and personal hygiene, and partial/moderate assistance for toileting, bathing, dressing, bed mobility, and transfers.Review of the discharge summary for Resident #01 dated 01/30/26 revealed the assessment had not been completed, and the areas related to discharge destination, home health services, durable medical equipment, social service history, and dietary information were all blank.Review of the progress note dated 02/03/26 revealed Resident #01 discharged from the facility to the attached assisted living facility.Interview on 02/12/26 at 12:30 P.M. with the Director of Nursing (DON) verified the discharge summary had not been completed.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure care was coordinated with the hospice provider. This affected one (#29) of three residents reviewed for hospice services. The facility census was 57. Findings include:Review of the medical record revealed Resident #29 admitted to the facility on [DATE] with diagnoses including cerebral infarction, cognitive communication deficit, aphasia, hemiplegia (right side), unspecified convulsions, stenosis of right cerebral artery, diabetes, hyperlipidemia, hypertension and history of transient ischemic attacks. Review of the Minimum Data Set (MDS) assessment, dated 11/18/25, revealed Resident #29 was moderately cognitively impaired. Further review of Resident #29's medical record revealed a referral for hospice services on 11/06/25. Review of a progress note, dated 11/12/25 and authored by Social Service Director (SSD) #214, revealed a care conference was held with Resident #29's family and they felt a hospice referral would benefit the resident once she was discharged from skilled speech therapy (ST). Resident #29's granddaughter revealed she believed the resident had already been enrolled on hospice the previous week. SSD #214 had not heard of the resident being admitted to hospice services and would follow-up to confirm. Resident #29's granddaughter could not remember the exact admission date. SSD #214 confirmed with Hospice Nurse (HN) #403 that Resident #29 elected hospice service but could not recall the exact date. HN #403 stated the hospice marketer would bring a binder with all of Resident #29's information for SSD #214 to review. SSD #214 confirmed and updated Resident #29's code status to Do Not Resuscitate-Comfort Care (DNRCC) and made necessary changes the medical record. Review of Resident #29's hospice binder revealed and initial order sheet and hospice contact information. There was no plan of care, progress notes, or other documentation of the services hospice was providing for Resident #29. Interview with Resident #29 on 02/11/26 at 8:25 A.M. confirmed hospice staff saw her at the facility but she was unable to explain who came, how often, or what services were provided by hospice staff. Interview with Registered Nurse (RN) #310 on 02/11/26 at 8:37 A.M. revealed she was unsure if Resident #29 received hospice services. RN #310 sated she had not seen hospice staff visiting Resident #29 recently. Interview with the Administrator and SSD #214 on 02/11/26 at 9:05 A.M. revealed SSD #214 did most hospice referrals, but Resident #29 was referred by the Nurse Practitioner (NP). SSD #214 confirmed she knew nothing about the referral or the resident's election of hospice benefits. SSD #214 stated the care conference on 11/12/26 was the first she had heard about the hospice referral/admission. HN #403 confirmed with SSD #214 on 11/12/25 that Resident #29 had elected hospice benefits, but was unable to confirm a date and stated a binder should be brought in with all of that information in it. SSD #214 and the Administrator were unaware there was no plan of care or progress notes from the hospice provider available at the facility. A telephone interview on 02/11/26 at 1:20 P.M. with HN #403 revealed Resident #29 received hospice nursing services every Tuesday and a hospice aide every Thursday for a shower. HN #403 stated hospice staff completed their documentation in their EMR and was unaware no documentation was available at the facility.

Based on observation, staff interview, medical record review, and review of facility policy, the facility failed to have physician orders in place for the administration of oxygen. Additionally, the facility failed to ensure appropriate oxygen in use signage was posted. This affected one (#56) of two residents reviewed for oxygen therapy. The facility census was 57.Findings include: Review of the medical record for Resident #56 revealed an admission date of 02/14/2023. Diagnoses included multiple sclerosis, asthma, acute and chronic respiratory failure with hypoxia, morbid obesity, anxiety disorder, and major depressive disorder, recurrent, moderate.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment. Review of the physician orders revealed Resident #56 did not have orders for the administration of oxygen.Observations on 02/10/26 at 10:16 A.M. and on 02/11/26 at 10:45 A.M. revealed Resident #56 was receiving oxygen at two liters per minute (lpm) via an oxygen concentrator. Further observation revealed there was no signage on Resident #56's door indicating that oxygen was in use.Interview on 02/11/26 at 10:45 A.M. with Licensed Practical Nurse (LPN) #326 confirmed Resident #56 was receiving oxygen therapy at two lpm. Further interview with LPN #326 verified there were no physician orders for oxygen and Resident #56 returned to the facility from the hospital on [DATE] on two lpm of oxygen and to wean as appropriate. Additionally, LPN #326 there was no sign on the resident's door indicating oxygen was in use.Review of the facility policy titled, Oxygen Administration, revised date of April 2023, revealed oxygen was administered under orders of a physician. Additionally, oxygen warning signs must be placed on the door of the resident's room where oxygen is in use.

Based on medical record review, observations, staff interview, and review of facility policy the facility failed to ensure medications were stored in an appropriate manner. This affected one (#11) of four residents reviewed for medication storage. The facility census was 57.Findings include:Record review for Resident #11 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, chronic venous hypertension, Type II diabetes, and neuropathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had minimally impaired cognition.Review of the physician orders revealed Resident #11 received the following medications: gabapentin oral capsule 300 milligrams (mg), three capsules by mouth twice daily for neuropathy and carvedilol 3.125 mg, one tablet by mouth twice daily for hypertension.Review of the Medication Administration Record (MAR) for 02/10/26 and 02/11/26 revealed Resident #11 was administered gabapentin and carvedilol as ordered. Observation on 02/11/26 at 10:15 A.M. of Resident #11's room revealed two medications on the floor beside the bed, along with an empty medication cup. The two pills and the medication cup were picked up by Assistant Director of Nursing (ADON) #300, who verified the two medications were on Resident #11's room door and further stated she would attempt to identify them. Both medications were disposed of appropriately.Interview with ADON #300 on 02/11/26 at 10:47 A.M. revealed the two pills found on the floor of Resident #11's room were identified as gabapentin and carvedilol. ADON #300 stated she could confirm which medication administration the two pills were from, but verified the medications should not have been on the floor.Review of the facility's medication storage policy, effective September 2018, revealed all medications that did not require refrigeration or freezing were to be stored in a medication cart or other designated area.

Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure proper enhanced barrier precautions were donned when completing a wound treatment. This affected one (Resident #17) of three residents reviewed for infection control. In addition, the facility failed to develop and implement a water management plan to mitigate the risk of Legionella. This had the potential to affect all residents residing in the facility. The facility census was 57.Findings Include:1. Resident #17 was admitted to facility on 04/28/25. Diagnoses included Alzheimer's Disease, infection of the skin, low back pain, depression, anxiety disorder, diabetes, hypertensive retinopathy, dermatochalasis, chronic kidney disease, diabetic retinopathy, and kidney transplant. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #17 was severely cognitively impaired and suffered with moderate depression. Resident #17 had an infected diabetic foot ulcer; treatments included nonsurgical dressing and ointments. Resident #17 received insulin, antianxiety medications, antidepressant medication, an anticoagulant, an antibiotic, and a hypoglycemic medication. Review of the plan of care last revision date revealed Resident #17 had a infected left foot wound, interventions included Enhanced Barrier Precautions (EBP) implemented 11/20/25. Review of the medical record for Resident #17 included an order revised on 02/03/26 for treatment of the ball of the left foot: cleanse with normal saline, apply calcium alginate cut to fit wound, cover with bordered foam dressing daily and as needed (PRN). Assess for Eschar/Black, Dark, Hard Tissue; Any Drainage/Exudate. Observation and interview on 02/11/26 at 4:25 P.M. revealed Registered Nurse #310 gathered supplies for Resident #17's dressing change, took them into the room and placed the wound supplies on the residents' bedside table. RN #310 left the bedside and closed Resident #17's door and returned to the bedside without personal protective equipment (PPE) donned and was ready to unbandage Resident #17's foot wound. RN #310 when asked by the surveyor who was in enhanced barrier precautions RN #310 stated she thought Resident #17 was. RN #310 further stated the only time staff were required to wear PPE were when they were completing direct patient care. RN #310 then asked the surveyor if the wound treatment would be considered direct patient care. RN #310 left the room at that time and returned with donned PPE. Review of facility policy titled Enhanced Barrier Precautions (EBP) dated 04/01/24 revealed EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP is indicated for residents with any wounds and require gown and gloves for high contact resident care activities. The policy goes on to say that EBP would be used with any wound care; any skin opening requiring a dressing. 2. Review of the document titled Policy and Procedure: Water Management Plan – Legionella, revised 11/18/21, revealed it was a guide on developing a water management plan, including a list of commonly used control measures. The plan did not specifically address what actions the facility was taking to reduce the risk of Legionella. Interview on 02/12/26 at 4:26 P.M. with the Administrator verified the document provided for review was the only water management plan the facility had and was unable to provide any information related to measures used by the facility. This deficiency represents non-compliance investigated under Complaint Number 2718794.

Based on medical record review and staff interview, the facility failed to ensure timely provision of a pneumococcal vaccine to a resident once consented. This affected one (Resident #19) of five residents reviewed for pneumococcal vaccine administration. The facility census was 57.Findings Include:Review of the medical record for Resident #19 revealed an admission date of 08/06/2025. Diagnoses included unspecified dementia, chronic kidney disease, type 2 diabetes mellitus without complications, and muscle weakness.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe problems with thinking and memory. The resident was set up assistance for eating, supervision assistance for ambulation, moderate assistance for oral hygiene, upper body dressing, personal hygiene, sit to stand, and transfers, and maximal assistance for toileting, bathing and lower body dressing. Resident #19 was frequently incontinent of bowel and bladder and rejected care and had wandering behaviors one to three days a week.Further record review revealed Resident #19's representatives, her son and daughter-in-law, consented on 09/24/25 for the resident to receive a pneumococcal vaccine. Continued record review on 02/12/26 for Resident #19 provided no documentation of administration of the pneumococcal vaccine to date.Interview with Assistant Director of Nursing (ADON) on 02/12/2026 at 3:39 P.M. verified Resident #19's representative consented to the pneumococcal vaccine on 09/24/2025 and that as of 02/12/26 the resident had not received the vaccine. The ADON reported that the corporate office orders vaccines from the pharmacy for residents and the ADON was unsure what had delayed the delivery and provision of this vaccine to Resident #19.

Based on medical record review and staff interview, the facility failed to ensure timely provision of COVID-19 vaccine to a resident once consented. This affected one (Resident #55) of five residents reviewed for COVID-19 vaccine administration. The facility census was 57.Findings Include:Review of the medical record of Resident #55 revealed an admission date of 08/05/25. Diagnoses included nondisplaced lateral mass fracture of first cervical vertebra, subsequent encounter for fracture with delayed healing, muscle weakness, unspecified dementia, and anxiety disorder.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 had moderate problems with thinking and memory. The resident was independent mobilizing in her wheelchair, setup assistance for eating, supervision assistance for sit to stand and transfers, moderate assistance for oral hygiene, toileting, bathing, upper and lower body dressing, and personal hygiene. Resident #55 was always incontinent of bladder and frequently incontinent of bowel and she did not reject care or wander.Review the medical record revealed Resident #55's representative, her daughter, consented to the COVID-19 vaccine on 09/24/25. Further review of the record revealed no indication Resident #55 had received the COVID-19 vaccination to date.Interview with Assistant Director of Nursing (ADON) on 02/12/26 at 11:14 A.M. verified Resident #55's representative had consented to the COVID-19 vaccine on 09/24/25 and as of 02/12/26 the resident had not received the COVID-19 vaccine. The ADON reported the corporate office orders vaccines from the pharmacy for residents and the ADON was unsure what had delayed the delivery and provision of this vaccine to Resident #55.

Based on observation, resident and staff interviews, medical record review, and review of facility policy, the facility failed to ensure call lights were functional. This affected one (#12) of three residents reviewed for call lights. The facility census was 57. Findings include:Review of Resident #12's medical record revealed he was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dysphagia, glaucoma, congestive heart failure, atrial fibrillation, heart disease, dementia without behaviors, osteoporosis, benign prostatic hyperplasia, anxiety disorder, edema, gastro-esophageal reflux disease, and hypertension.Review or Resident #12's Minimum Data Set (MDS) assessment, dated 01/05/26, revealed the resident was mildly cognitively impaired. Resident #12 utilized a wheelchair for mobility, required set-up assistance for eating, and moderate assistance with toileting, oral hygiene, dressing, and personal hygiene. Interview with Resident #12 on 02/10/26 at 2:39 P.M. revealed his call light had not been working for quite some time and he alerted staff on multiple occasions. Concurrent observation revealed Resident #12 pushed his call light and the light in the hallway did not activate to show the resident required assistance. Interview on 02/10/26 at 2:39 P.M. with Certified Nursing Assistant (CNA) #344 confirmed Resident #12's call light did not light up in the hallway to show the resident needed assistance. CNA #344 entered Resident #12's room to ensure the call light was properly plugged into the wall. CNA #344 pushed the call light again and confirmed the outside hall light was not working. CNA #344 denied being aware the resident's call light was not functioning properly but added they had not worked the last several days. CNA #344 stated they would submit a work order to get the call light repaired. Review of the facility's call light policy, dated August 2022, revealed staff were to notify maintenance if a call light was not functioning.

Based on review of the medical record, observations, staff interviews and policy review, the facility failed to ensure Coronavirus-19 (COVID-19) precautions were implemented appropriately for all positive residents. This had the potential to affect all 58 residents residing in the facility. The facility census was 58. Findings include: Review of the medical record for 24 residents (#1, #4, #6, #8, #10, #12, #13, #15, #19, #21, #23, #26, #37, #41, #44, #45, #48, #49, #50, #53, #56, #58, #63, and #64) revealed the residents had tested positive for COVID-19 when the outbreak started in the facility on 12/08/25. Observation on 12/22/25 at 8:06 A.M. revealed Registered Nurse (RN) #30 went into Resident #26's room, who was COVID-19 positive, without wearing a N-95, gown, gloves, or face shield as required, to administer medications wearing a surgical mask only. Interview on 12/22/25 at 8:09 A.M. with RN #30 verified she did not wear the appropriate personal protective equipment (PPE) as required when entering Resident #26's room. RN #30 confirmed Resident #26 was positive for COVID-19. Observation on 12/22/25 at 8:28 A.M. revealed Certified Nursing Assistant (CNA) #10 was passing breakfast trays to residents. CNA #10 went into Resident #13's room, who was COVID-19 positive, to pass breakfast tray without wearing required PPE (gown, gloves, N-95, and face shield). CNA #10 was only wearing a surgical mask. Observation on 12/22/25 at 8:32 A.M. revealed CNA #10 entered Resident #6's room, who was COVID-19 positive, to pass breakfast tray without wearing required PPE (gown, gloves, N-95, and face shield). CNA #10 was only wearing a surgical mask. Interview on 12/22/25 at 8:34 A.M. with CNA #10 verified he did not wear the appropriate PPE when entering Resident #6's and forgot about it. CNA #10 confirmed Resident #6 was COVID-19 positive. Observation on 12/22/25 at 8:43 A.M. revealed CNA #11 was in Resident #21's room, who was COVID-19 positive, wearing only a surgical mask. Interview on 12/22/25 at 8:45 A.M. verified CNA #11 did not wear the required PPE while in a COVID-19 positive room. Observation on 12/22/25 at 8:49 A.M. revealed Licensed Practical Nurse (LPN) #20 went into Resident #5's room to administer medications. Resident #5's roommate, Resident #6, who was positive for COVID-19. LPN #20 did not don a gown, gloves, N-95, or face shield when entering the room. LPN #20 wore a surgical mask. Interview on 12/22/25 at 8:52 A.M. with LPN #20 verified she did not wear appropriate PPE when entering a COVID-19 positive room. Review of the contact and droplet precautions signage revealed proper PPE was gown, gloves, N-95, and a face shield. Review of the facility policy titled, CDC Recommendations regarding Outbreak, dated September 2025 revealed healthcare personnel (HCP) should follow all recommended infection prevention and control practices including wearing well-fitting source control, monitoring themselves for fever or symptoms consistent with COVID-19, and not reporting to work when ill or if testing was positive. HCP should wear appropriate PPE in the room (gown, gloves, eye protection, and respirator. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review, staff interview and policy review, the facility failed to ensure laboratory (lab) values were completed as ordered by the physician. This affected two (#01 and #44) out of three residents reviewed for labs being completed as ordered by the physician. The facility census was 58. Findings include: 1. Review of Resident #01's chart revealed the resident was admitted to the facility on [DATE] with unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, pressure ulcer to the left buttock unspecified stage, pressure ulcer to the right buttock unspecified stage, traumatic subdural hemorrhage without loss of consciousness, type two diabetes mellitus and cerebral atherosclerosis. Review of Resident #01's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #01 required set up assistance with eating, and oral hygiene. Resident #01 required moderate assistance with toileting, upper body dressing, lower body dressing, putting on and taking off footwear, personal hygiene, rolling left and right, sitting to lying, sitting to standing, chair transfers, toilet transfers, tub transfers and walking ten feet and supervision with lying to sitting. Resident #01 required maximal assistance with showering. Review of Resident #01's care plan initiated on 07/21/25 revealed the facility will obtain and monitor lab and diagnostic work as ordered. Review of Resident #01's progress note dated 08/26/25 at 11:54 A.M. revealed the Wound Care Nurse Practitioner (WCNP) was in the facility to see Resident #01 and gave orders for a complete blood count (CBC), complete metabolic panel (CMP), albumin, prealbumin, transferrin and hemoglobin A1c labs. Resident #01 and Resident #01's responsible party were aware. Review of Resident #01's physician order dated 08/26/25 revealed Physician #800 created a telephone order that stated the WCNP was in the facility to see Resident #01 and gave orders for a CBC, CMP, albumin, prealbumin, transferrin and hemoglobin A1c labs. Review of Resident #01's chart from 08/26/25 to 09/10/25 revealed Resident #01's CBC, albumin, prealbumin, transferrin and hemoglobin A1c lab results ordered on 08/26/25 were not on file at the facility. Review of Resident #01's lab results report dated 08/28/25 revealed the Resident #01's CMP was completed. Interview with the Director of Nursing (DON) on 09/10/25 at 2:00 P.M. verified Resident #01 was ordered a CBC, CMP, albumin, prealbumin, transferrin and hemoglobin A1c labs on 08/26/25 by the WCNP. The DON verified the facility received Resident #01's CMP but Resident #01's CBC, CMP, albumin, prealbumin, transferrin and hemoglobin A1c labs ordered on 08/26/25 were not obtained. 2. Review of Resident #44's chart revealed Resident #44 admitted to the facility on [DATE] with unspecified pseudobulbar affection, attention and concentration deficit following cerebral infarction, depression, Alzheimer's disease, type two diabetes mellitus with unspecified complications, hyperlipidemia, hypertension, anxiety disorder, chronic kidney disease stage two and other cerebrovascular disease. Review of Resident #44's quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and Resident #44 required set up assistance with eating. Resident #44 required moderate assistance with oral hygiene, upper body dressing, putting on and taking off footwear, personal hygiene, rolling left and right, lying to sitting, chair transfers, tub transfers and walking ten feet and maximal assistance with toileting, and lower body dressing. Resident #44 was dependent with showering and supervision with sitting to lying, sitting to standing, and toilet transfers. Review of Resident #44's care plan initiated on 08/12/25 revealed the facility will obtain and monitor lab and diagnostic work as ordered. Review of Resident #44's progress note dated 07/24/25 at 4:17 P.M. revealed Resident #44 received new orders for several labs on Monday 07/28/25. Resident #44's family was notified. Review of Resident #44's physician order dated 07/24/25 revealed Physician #800 ordered Resident #44 a complete blood count (CBC), complete metabolic panel (CMP), thyroid stimulating hormone (TSH), A1c, lipid panel, ferritin, B12 and vitamin D to be collected the next lab day on 07/28/25. Review of Resident #44's chart from 07/24/25 to 09/10/25 revealed Resident #44's CBC, CMP, TSH, lipid panel, ferritin, B12 and vitamin D labs that were ordered to be collected on 07/28/25 were not on file. Interview with the DON on 09/10/25 at 2:00 P.M. verified Resident #44's CBC, CMP, TSH, lipid panel, ferritin, B12 and vitamin D labs that were ordered to be collected on 07/28/25 were not collected or obtained by the facility. Review of the facility's clinical protocol and diagnostic test results policy dated November 2018 revealed the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. Staff will process test requisitions and arrange for testing. The laboratory will report the test results to the facility. This deficiency represents non-compliance investigated under Complaint Number 2602837.

Based on interview, record review, and facility policy review, the facility failed to failed to suspend staff pending an abuse investigation. This affected one (Resident #41) of three residents reviewed for abuse. The facility census was 50. Findings include: Record review for Resident #41 revealed she was admitted to the facility on [DATE]. She was under the care of hospice services. Her diagnoses included, heart failure, diabetes mellitus (DM), pruritus, gastro esophageal reflux disease (GERD), dementia, and anxiety disorder. Review of Resident #41's Minimum Data Set (MDS) assessment, dated 09/16/24, revealed she was severely cognitively impaired. Resident #41 was dependent on staff for medication administration. Resident #41 required maximum assistance from staff with eating, oral hygiene, toilet use, bathing, dressing, and personal hygiene. Resident #41 had an indwelling catheter and required hospice services. Review of the Self Reported Incident (SRI) dated 11/11/24 at 12:44 P.M. revealed Resident #41's daughter reported an allegation of neglect that occurred on 11/09/24. Resident #41's daughter alleged Registered Nurse (RN) #81 refused to give Resident #41 her medications. Resident #41's daughter called Emergency Medical Transport (EMT) and had her mother transferred to the hospital. Further review of the SRI investigation stated Assistant Director of Nursing (ADON) #89 interviewed Resident #41 and she stated she felt safe. The report stated RN #81 will no longer provide care to Resident #41. Further review revealed no indication RN #81 was suspended pending an investigation. Interview on 12/05/24 at 2:40 P.M. with the Administrator confirmed the incident of alleged abuse from RN #81 to Resident #41 was not reported until 11/11/24. The Administrator confirmed the facility began a facility investigation of alleged abuse. The Administrator confirmed RN #81 continued to work through the entire investigation and was never suspended pending the outcome of the investigation. The Administrator confirmed the investigation began on 11/11/24 at 12:44 P.M. and was closed on 11/15/24 at 11:28 A.M. Interview on 12/09/24 at 9:59 A.M. with RN #81 confirmed the facility never suspended her at any time from the date of the alleged incident 11/09/24 throughout the conclusion of the investigation 11/15/24. Review of RN #81's time card confirmed RN #81 worked full shifts on 11/11/24 and 11/15/24. Review of the facility policy titled, Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Resident Property, undated, confirmed employees accused of alleged abuse/neglect will be immediately removed from the facility and will remain removed pending the results of a thorough investigation. This was an incidental finding found during the course of the complaint investigation.

Based on observations, interviews, and policy review, the facility failed to ensure proper infection control measures were maintained during resident care. This affected two (#37 and #41) residents reviewed for incontinence care. The facility census was 50. Findings include: 1. Review of the medical record for Resident #37 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), type two diabetes mellitus (DM II), and congestive heart failure (CHF). Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require supervision with eating, substantial assistance with toileting, dressing, and transfers, and dependent with bathing. Review of section H for bowel and bladder revealed Resident #37 was always incontinent of bladder and frequently incontinent of bowel. Observation on 12/11/24 at 9:55 A.M. revealed Certified Nursing Assistant (CNA) #100 completed incontinence care to Resident #37. CNA #100 performed hand hygiene and applied gloves prior to providing care. During care, CNA #100 failed to change gloves and perform hand hygiene until after procedure was finished. CNA #100 cleaned Resident #37's perineal area, which was soiled with urine and feces. CNA #100 cleaned Resident #37's backside with the same gloves. After CNA #100 cleaned Resident #37, she placed a new depend on her, covered her with her blanket, and adjusted Resident #37 in bed with soiled gloves. CNA #100 cleaned her working area, removed her gloves, and performed hand hygiene. Interview on 12/11/24 at 10:04 A.M. with CNA #100 verified she did not change her gloves during incontinence care to Resident #37. Review of the facility policy titled, Hand Hygiene, dated 2022 revealed all staff were to perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The use of gloves did not replace hand hygiene. If your task required gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. 2. Review of the medical record for Resident #41 revealed an admitted [DATE]. Diagnoses included anxiety disorder, DM II, neuromuscular dysfunction of bladder, and heart failure. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of five. This resident was assessed to require substantial assistance with eating, toileting, bathing, dressing, and transfers. Review of section H for bowel and bladder revealed Resident #41 had an indwelling catheter and always incontinent of bowel. Review of the physician order dated 09/17/24 revealed Resident #41 was ordered foley catheter care every day and night shift. Observation on 12/11/24 at 9:47 A.M. revealed Certified Nursing Assistant (CNA) #100 performed catheter care to Resident #41. During care, Resident #41 was in Enhanced Barrier Precautions (EBP) related to catheter, which required staff to wear a gown and gloves during hands on care. CNA #100 did not apply a gown when providing care to Resident #41. Interview on 12/11/24 at 10:04 A.M. with CNA #100 verified she did not wear a gown when providing catheter care to Resident #41. Review of the facility policy titled, Enhanced Barrier Precautions, dated 04/01/24 revealed enhanced barrier precautions referred to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that employed targeted gown and glove use during high contact resident care activities. For residents for whom EBP are indicated, EBP was employed when performing the following high-contact resident care activities including hygiene, bathing, shower, and urinary catheter care. This was an incidental finding found during the course of the complaint investigation.

Based on record review, review of hospital records, staff interview, and review of facility policy, the facility failed to assess residents for fall risk factors and failed to conduct a thorough investigation to determine root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate a fall with injury. This resulted in Actual Harm when Resident #52 was not assessed for risk factors for falls, the resident had a fall on 12/25/22 which was not investigated, and the resident subsequently sustained a laceration to her head from the fall which required transportation to the emergency room for evaluation and treatment including suturing of a head injury. Additionally, the facility failed to conduct thorough investigations to determine root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls without injury following Resident #7, #34 and #37's falls which placed the residents at risk for more than minimal harm that did not result in harm to the residents. This affected four (#52, #7, #34 and #37) out of four residents reviewed for falls. The census was 50. Finding include: 1. Review of the medical record for Resident #52 revealed an admitted [DATE]. Diagnoses include major depressive disorder, cerebral infarction, metabolic encephalopathy, dementia with behavioral disturbance atherosclerotic heart disease, atrial fibrillation, hypothyroidism. Resident #52 discharged from the facility on 12/28/22. Review of the Minimum Data Set (MDS) for Resident #52 dated 12/24/22 revealed the resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's). Review of the medical record for Resident #52 revealed an admitted [DATE] with a diagnosis of Alzheimer's disease. Review of the medical record for Resident #52 revealed the facility had not completed a fall risk assessment to identify the resident's specific risk factors during her stay at the facility. Review of the care plan for Resident #52 last dated 09/14/22 revealed the resident was at risk for falls related to gait/balance problems, incontinence, psychoactive drug use, and unaware of safety needs. Interventions included the following: anticipated and meet resident needs, be sure call light is within reach and encourage resident to use for assistance, ensure resident was wearing appropriate nonskid footwear when out of bed, follow facility fall protocol, ensure alarm to bed and chair are in place, if restless and attempting to get out of bed, encourage to remain in recliner in common area for observation and activity, Review of December 2022 monthly physician orders for Resident #52 revealed orders dated 09/13/22 chair sensor alarm at all times, monitor functioning every shift and for bed sensor alarm at all times monitor functioning every shift. Review of the December 2022 Treatment Administration Record (TAR) for Resident #52 revealed the bed sensor alarm and chair sensor alarm are not signed off for the 7:00 A.M. to 7:00 P.M. shift on 12/25/22. Review of the nurse progress note for Resident #52 dated 12/25/22 per agency nurse revealed at 4:30 P.M. the nurse was alerted the resident was on the floor. Nurse noted Resident #52 in a prone position with her head on its left side facing down with blood coming from her head. Upon assessing the resident the nurse noted blood profusely draining from the resident's head. Resident #52 responded to commands but wasn't able to move and her pupils were non-reactive to light. The nurse called 911 and Resident #52 was transported to the hospital. Review of hospital notes for Resident #52 dated 12/25/22 revealed the resident received a tetanus shot and required sutures to the laceration to her head. Lidocaine was applied prior to sutures for pain control. Antibiotic ointment was applied to the wound. Resident #52 was to follow up with her attending physician at the facility. General discharge instructions for sutures included the following: keep the cut clean and dry, change dressing at least once a day, if it gets wet or dirty or ordered by the physician, wash cut with soap and water two times per day, rinse the cut with water and pat it dry with a clean towel, put a thin layer of medicated cream on the cut per physician order, have sutures removed as ordered by the doctor. Review of the facility incident log dated October 2022 through January 2023 revealed it did not include Resident #52's fall on 12/25/22. Interview on 01/18/23 at 2:48 P.M. with the Administrator and the Director of Nursing (DON) confirmed the facility had not assessed Resident #52 for fall risk factors prior to her fall on 12/25/22. DON confirmed the facility had not conducted a thorough fall investigation of Resident #52's fall on 12/25/22 to determine the root cause of the fall and if care planned fall interventions were in place at the time of the fall including the presence of bed and chair alarms nor had the facility reviewed the resident's care plan following the fall. DON confirmed Resident #52 sustained a laceration to her forehead during the fall on 12/25/22 which required sutures. 2. Review of the medical record for Resident #7 revealed an admitted [DATE]. Diagnoses include mood disorder, diabetes mellitus (DM), unspecified dementia with behavioral disturbance, and atherosclerotic heart disease. Review of the MDS for Resident #7 dated 12/28/22 revealed the resident was cognitively impaired and required extensive assistance of one staff with ADL's. Review of the fall risk assessment for Resident #7 dated 12/02/22 revealed the resident was at risk for falls. Review of the care plan for Resident #7 last updated 11/15/22 revealed the resident was at risk for falls related to decreased mobility, decreased safety awareness, use of antidepressant medication, generalized weakness, decreased vision, and incontinence. Interventions included the following: refer for behavior management, anticipate and meet resident needs, assist to toilet upon arising, after meals, at bedtime and as needed, be sure call light is within reach and encourage resident to use it for assistance as needed, provide prompt response to all requests for assistance, Dycem to wheelchair, scoop mattress to bed, ensure resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, ensure nonskid socks when in bed, review information on past falls and attempt to determine cause of falls, record possible root causes, alter or remove any potential causes if possible, educate resident/family/caregivers/interdisciplinary team (IDT) as to causes. Review of December 2022 monthly physician orders for Resident #7 revealed orders dated 10/12/22 for Dycem to wheelchair and non-skid footwear at all times. Review of the nurse progress note for Resident #7 dated 12/29/22 timed at 7:30 P.M. revealed the nurse was called to resident's room and observed resident on the floor in a supine position. Resident #7 was alert and oriented and stated she had hit her head and was experiencing head pain. Resident #7 was sent to the hospital via 911. Review of the nurse progress note for Resident #7 dated 12/29/22 timed at 11:42 P.M. revealed the resident returned from the hospital and scan of her head showed no injuries. Interview on 01/18/23 at 2:48 P.M. with the Administrator and the DON confirmed the facility had not conducted a thorough fall investigation of Resident #7's fall on 12/29/22 to determine the root cause of the fall and if care planned fall interventions were in place at the time of the fall including the presence of Dycem to chair and non-skid footwear nor had the facility reviewed the resident's care plan following the fall. 3. Review of the medical record for Resident #34 revealed an admitted [DATE]. Diagnoses include atrial fibrillation, DM, dementia with behavioral disturbance, and osteoarthritis. Review of the MDS for Resident #34 dated 12/20/22 revealed resident was cognitively impaired and required limited assistance with activities of daily living ADL's. Review of the fall risk assessment for Resident #34 dated 12/19/22 revealed the resident was at risk for falls. Review of the care plan for Resident #34 last updated 05/09/22 revealed the resident was at risk for falls related to confusion, gait/balance problems, incontinence, poor communication/comprehension, psychoactive drug use, and wandering. Interventions included the following: anticipate and meet resident needs, be sure call light is within reach and encourage resident to use it for assistance as needed, follow facility fall protocol, scoop mattress to bed, ensure resident is wearing appropriate footwear at all times, monitor /assist with transfers, ambulation using rolling walker. Review of January 2023 monthly physician orders for Resident #34 revealed orders dated 12/17/22 for non-skid socks at all times. Review of the facility incident log dated October 2022 to January 2023 revealed Resident #34 had a fall on 01/09/23. Review of the nurse progress notes for Resident #34 revealed there was no note regarding resident's fall on 01/09/23. Interview on 01/18/23 at 2:48 P.M. with the Administrator and the DON confirmed the facility had not conducted a thorough fall investigation of Resident #34's fall on 01/09/23 to determine the root cause of the fall and if care planned fall interventions were in place at the time of the fall including the presence of rolling walker and non-skid footwear nor had the facility reviewed the resident's care plan following the fall. DON confirmed the resident fell on [DATE] and per note in the facility's risk management files resident had a fall on 01/09/23 at approximately 3:15 P.M. which was witnessed by the agency nurse. Resident #34 slid off her wheelchair onto the floor in the living room and sustained no injuries. DON confirmed there was no nurse progress note in Resident #34's medical record regarding the fall. 4. Review of the medical record for Resident #37 revealed an admitted [DATE]. Diagnoses include traumatic subdural hematoma, atrial fibrillation, diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), dysphagia, chronic kidney disease (CKD), dementia with behavioral disturbance, atherosclerotic heart disease, and presence of pacemaker. Review of the MDS for Resident #37 dated 12/14/22 revealed resident was cognitively impaired and required extensive assistance of one to two staff with ADL's. Review of the fall risk assessment for Resident #37 dated 01/30/22 revealed the resident was at risk for falls. Review of the care plan for Resident #37 last updated 03/02/22 revealed resident was at risk for falls related to history of falls, decreased mobility, decreased safety awareness, generalized weakness, dementia, and incontinence. Interventions included the following: anticipate and meet resident needs, be sure call light is within reach and encourage resident to use it for assistance as needed, follow facility fall protocol, ensure resident is wearing appropriate footwear at all times, review information on past falls and attempt to determine cause of falls, record possible root causes, alter or remove any potential causes if possible, educate resident/family/caregivers/interdisciplinary team (IDT) as to causes. Review of the nurse progress note for Resident #37 dated 12/25/22 timed at 5:10 P.M. revealed the nurse and another staff assisted the resident off the floor and into a safer wheelchair. Resident #37 had a knot on the top of her forehead. The physician was notified and gave an order to send resident to the hospital via 911. Review of the hospital notes for Resident #37 dated 12/25/22 revealed the resident was evaluated related to fall with facial contusion and was sent back to the facility with no new orders. Interview on 01/18/23 at 2:48 P.M. with the Administrator and the DON confirmed the facility had not conducted a thorough fall investigation of Resident #37's fall on 12/25/22 to determine the root cause of the fall and if care planned fall interventions were in place at the time of the fall nor had the facility reviewed the resident's care plan following the fall. DON confirmed the staff had noted in the facility's risk management files that resident fell out of wheelchair on 12/25/22 after the wheel broke off resident's wheelchair. Review of the facility policy titled Falls and Fall Risk Managing dated 08/2022 revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the attending physician/nurse practitioner (NP) as needed, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. This deficiency represents non-compliance investigated under Complaint Number OH00138752.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure medication carts were locked when unattended. This had the potential to affect all residents residing in the facility. The census was 50. Findings include: Observation on 01/18/23 at 1:32 P.M. revealed the Long Hall medication cart and the Middle medication cart were unlocked and unattended. Approximately 20 residents were in the common area adjacent to the unlocked medication carts. Interview on 01/18/23 at 1:34 P.M. with Licensed Practical Nurse (LPN) #431 confirmed she had left the Long Hall medication cart unlocked and unattended for approximately one to two minutes. LPN #431 further confirmed she shared the Middle medication cart with the other nurse and she wasn't sure who had left the Middle medication cart unlocked. Observation on 01/18/23 at 1:34 PM. revealed the Short Hall medication cart was unlocked and unattended. Approximately 20 residents were in the common area adjacent to the unlocked medication cart. Interview on 01/18/23 at 1:38 P.M. with Registered Nurse (RN) #465 confirmed she had left the Short Hall medication cart unlocked and unattended for approximately five minutes. RN #465 was unsure if she had left the Middle medication cart unlocked or if the other nurse had left it unlocked. The facility confirmed all 50 residents have medications stored in the medication carts. Review of the facility policy titled Medication Administration dated 06/21/17 revealed the cart should remain unlocked only when the nurse or authorized individual is physically present at the cart and the medication cart should be kept locked at all times unless in use. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation, and staff interview, the facility failed to ensure the kitchen equipment and an environment was in safe operating condition. This had the potential to affect all residents residing in the facility as the facility identified all residents received food prepared in the kitchen. The census was 50. Findings include: Observation on 01/17/23 at 11:30 A.M. with Dietary Manager (DM) #225 of the facility kitchen revealed the bottom steamer on the steamer unit was inoperable. Observation of the steam kettle revealed it had a sign posted on it which read Out of order. Do not use. Observation of the oven revealed the top oven was working but the bottom oven was inoperable. Further observation revealed there was a large portion of the kitchen floor adjacent to the walk-in refrigerator which had missing floor tiles. There was a large portion of cement exposed underneath and the walking surface was uneven. Interview on 01/17/23 at 11:30 A.M. with DM #225 confirmed the bottom steamer had not been working for a while and he was unsure when the steamer would be replaced. DM #225 confirmed the steam kettle had been inoperable at least two years. DM #225 confirmed bottom oven had been inoperable for approximately five years. DM #225 confirmed the floor tiles had been missing since sometime in 2022 and the missing tiles presented a possible trip hazard. Observation on 01/18/23 at 1:17 P.M. with DM #225 and Registered Dietitian (RD) #350 revealed there were approximately 219 missing floor tiles in the kitchen adjacent to the walk-in refrigerator. Each tile was approximately six square inches. Interview on 01/18/23 at 1:17 P.M. with DM #225 and RD #350 confirmed there were approximately 219 missing floor tiles in the kitchen. DM #225 confirmed the tiles came off spontaneously a few at a time and he was unsure of the cause. Interview with RD #350 confirmed she had sent a text message to the previous Administrator on 09/15/22 which had photographs of several missing tiles from the kitchen. RD #350 showed surveyor the text message and photograph from her phone. Interview on 01/18/23 at 2:48 P.M. with the Administrator confirmed she had been employed with the facility in her role since 10/07/22. Administrator further confirmed she was unaware of the inoperable steamer, steam kettle and oven in the facility kitchen. Administrator further confirmed no one had notified her regarding the missing floor tiles in the kitchen. Administrator confirmed some in late December 2022 she observed the missing floor tiles in the kitchen and made a verbal request to the Maintenance Director to look into repairing the tiles. The facility confirmed all 50 residents receive their meals from the facility kitchen. This deficiency represents non-compliance investigated under Complaint Number OH00139362.

Based on record review, observation, and staff interview, the facility failed to ensure residents who could not feed themselves received timely assistance with eating. This affected one (#39) of three residents reviewed for assistance with activities of daily living (ADL's). The census was 50. Findings include: Review of the medical record for Resident #39 revealed an admitted [DATE]. Diagnoses include transient ischemic attack (TIA), dementia with behavioral disturbance, and mood disorder. Review of the Minimum Data Set for Resident #39 dated 12/08/22 revealed the resident was cognitively impaired and required extensive physical assistance of one staff with eating. Review of the care plan for Resident #39 dated 10/08/22 revealed the resident had a nutritional problem or potential nutritional problem related to status post COVID-19, dementia, depression, anxiety and resident required extensive assistance at meals. Interventions included staff to provide tray set up and assistance with meals as needed. Review of the January 2023 monthly physician orders Resident #39 revealed an order dated 01/15/23 for a regular diet with pureed texture consistency. Observation on 01/17/23 at 9:00 A.M. revealed State tested Nursing Assistants (STNA's) #700 and #750 were delivering trays to resident rooms. STNA #700 placed a covered tray in Resident #39's room on the resident's overbed table. Observation on 01/17/23 at 10:10 A.M. with Licensed Practical Nurse (LPN) #700 in Resident #39's room revealed resident's breakfast tray was still on top of the overbed table and appeared to have been untouched. Resident #39 was non-interviewable. Interview on 01/17/23 at 10:10 A.M. with LPN #700 confirmed Resident #39 had a physician's order for a regular diet with pureed textures. LPN #700 further confirmed Resident #39 was not able to feed herself. LPN #700 confirmed the breakfast tray on Resident #39's overbed table was the correct diet (pureed) and appeared to have been untouched. Interview on 01/17/23 at 10:12 A.M. with STNA #700 confirmed she had placed Resident #39's breakfast tray on the resident's overbed table while passing meal trays at approximately 9:00 A.M. on 01/17/23. STNA #700 further confirmed she had not assisted Resident #39 with feeding because she was waiting for information regarding resident's level of assistance required with eating. STNA #700 confirmed Resident #39's breakfast tray had been sitting on top of resident's overbed table untouched. Interview on 01/17/23 at 12:19 P.M. with the Administrator confirmed the facility did not have a policy regarding assistance with meals. This deficiency represents non-compliance investigated under Complaint Numbers OH00139362 and OH00138810.

Based on record review, staff interview, review of hospital records, review of facility inservice records, and review of facility policy, the facility failed to ensure residents received appropriate treatment and monitoring following a fall with injury and failed to ensure residents were assessed by a licensed nurse upon admission to the facility. This affected two (#52 and #53) of three residents reviewed for care and services. The census was 50. Findings include: 1. Review of the medical record for Resident #52 revealed an admitted [DATE]. Diagnoses include major depressive disorder, cerebral infarction, metabolic encephalopathy, dementia with behavioral disturbance atherosclerotic heart disease, atrial fibrillation, hypothyroidism. Resident #52 discharged from the facility on 12/28/22. Review of the Minimum Data Set (MDS) for Resident #52 dated 12/24/22 revealed the resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's). Review of the medical record for Resident #52 revealed an admitted [DATE] with a diagnosis of Alzheimer's disease. Review of the nurse progress note for Resident #52 dated 12/25/22 per agency nurse revealed at 4:30 P.M. the nurse was alerted that resident was on the floor. Nurse noted the resident in a prone position with her head on its left side facing down with blood coming from her head. Upon assessing the resident the nurse noted blood profusely draining from resident's head. Resident #52 responded to commands but wasn't able to move and her pupils were non-reactive to light. The nurse called 911 and the resident was transported to the hospital. Review of hospital notes for Resident #52 dated 12/25/22 revealed the resident received a tetanus shot and required sutures to the laceration to her head. Lidocaine was applied prior to sutures for pain control. Antibiotic ointment was applied to the wound. Resident #52 was to follow up with her attending physician at the facility. General discharge instructions for sutures included the following: keep the cut clean and dry, change dressing at least once a day, if it gets wet or dirty or ordered by the physician, wash cut with soap and water two times per day, rinse the cut with water and pat it dry with a clean towel, put a thin layer of medicated cream on the cut per physician order, have sutures removed as ordered by the doctor. Review of the nurse progress note for Resident #52 dated 12/28/22 revealed had a laceration to her forehead with a dressing intact noted. The resident was sent to the hospital with altered mental status and was admitted with a diagnosis of pneumonia and did not return to the facility. Review of the December 2022 Treatment Administration Record (TAR) for Resident #52 revealed there were no orders to treat or monitor the resident's laceration with sutures. Review of the medical record for Resident #52 revealed it did not include any neurological checks for resident following her head injury sustained on 12/25/22. Review of the medical record for Resident #52 revealed it not include an assessment of laceration to resident's forehead except for the mention of the laceration noted in the progress note dated 12/28/22. Interview on 01/18/23 at 2:48 P.M. with the Administrator and the Director of Nursing (DON) confirmed Resident #52 sustained a laceration to her forehead during the fall on 12/25/22 which required sutures. Interview on 01/19/23 at 9:46 A.M. with the DON confirmed the facility had not implemented any treatment orders for the laceration to Resident #52's forehead nor had the facility completed neurological checks for Resident #52 following her head injury sustained during the fall on 12/25/22. DON confirmed the facility did not have a policy regarding neurological checks. Review of the facility policy titled Wound Care dated 08/2022 revealed the facility would care for wounds in order to promote healing. The nurse would verify that there was a physician's order in place for treatment of wounds. 2. Review of the medical record for Resident #53 revealed an admitted [DATE]. Diagnoses include acute respiratory failure with hypoxia, viral pneumonia, hemiplegia and hemiparesis, aphasia following cerebral infarction, atrial fibrillation, hyperlipidemia, atherosclerotic heart disease, and depression. Resident #53 discharged from the facility on 12/26/22. Review of the Minimum Data Set (MDS) for Resident #53 dated 12/26/22 revealed the resident was discharged to the community on 12/26/22. Review of the discharge summary from the hospital for Resident #53 dated 12/25/22 revealed the resident had been treated at the hospital from 12/18/22 to 12/25/22 for pneumonia. Resident #53 had a history of cerebrovascular accident (CVA) with residual aphasia and right-sided weakness, atrial fibrillation, coronary artery disease, and status post coronary artery bypass graft who presented to the hospital complaint of shortness of breath and was found to be hypoxic. The hospital physical therapy recommend skilled nursing facility placement and resident was to be discharged to the facility for further rehab. Review of the nurse progress note for Resident #53 dated 12/25/22 revealed the resident was admitted to the facility at 6:45 P.M. from the hospital. The admission note included vital signs taken from the hospital paperwork and did not include an assessment of the resident. Review of the progress note for Resident #53 dated 12/27/22 per the Administrator revealed the Administrator spoke to Resident #53's daughter who stated resident's family had decided to care for the resident at home and prior to leaving the daughter had signed a form for leaving against medical advice (AMA). Review of the medical record for Resident #53 revealed it did not include an admission nursing assessment. Interview on 01/18/23 at 2:48 P.M. of the Administrator and the Director of Nursing (DON) confirmed the facility could not locate the AMA form Resident #53's daughter said she had signed on 12/25/22. Administrator confirmed Resident #53's daughter told her the resident had been discharged from the facility on 12/26/22 at approximately 3:00 P.M. The DON confirmed Resident #53's medical record did not include an admission nursing assessment. Interview on 01/19/23 at 9:46 A.M. with the DON confirmed the facility did not have a policy regarding admission nursing assessments but did confirm all residents should be assessed by a licensed nurse upon admission to the facility. This deficiency represents non-compliance investigated under Complaint Numbers OH00139362, OH00138810 and OH00138752.

Based on record review, review of hospital records, staff interview, and review of the facility policy the facility failed to ensure residents received medications as ordered. This affected one (#53) of three residents reviewed for medications. The census was 50. Findings include: Review of the medical record for Resident #53 revealed an admitted [DATE]. Diagnoses include acute respiratory failure with hypoxia, viral pneumonia, hemiplegia and hemiparesis, aphasia following cerebral infarction, atrial fibrillation, hyperlipidemia, atherosclerotic heart disease, and depression. Resident #53 discharged from the facility on 12/26/22. Review of the Minimum Data Set (MDS) for Resident #53 dated 12/26/22 revealed the resident was discharged to the community on 12/26/22. Review of the discharge summary from the hospital for Resident #53 dated 12/25/22 revealed the resident had been treated at the hospital from 12/18/22 to 12/25/22 for pneumonia. Resident #53 had a history of cerebrovascular accident (CVA) with residual aphasia and right-sided weakness, atrial fibrillation, coronary artery disease, and status post coronary artery bypass graft who presented to the hospital complaint of shortness of breath and was found to be hypoxic. The hospital physical therapy recommend skilled nursing facility placement and resident was to be discharged to the facility for further rehab. Further review of the discharge summary revealed it included a list of Resident #53's medications which were as follows: Tylenol as needed, Norvasc once daily, Eliquis twice daily, Atorvastatin once daily, melatonin once nightly, metoprolol tartrate twice daily, Remeron once nightly, pantoprazole twice daily with meals, Miralax once daily, Zoloft once daily, Flomax once daily. Review of the nurse progress note for Resident #53 dated 12/25/22 revealed the resident was admitted to the facility at 6:45 P.M. from the hospital. The admission note did not include information regarding admitting medication orders and/or contact with the physician to verify medication orders. Review of the progress note for Resident #53 dated 12/27/22 per the Administrator revealed the Administrator spoke to Resident #53's daughter who stated resident's family had decided to care for the resident at home and prior to leaving the daughter had signed a form for leaving against medical advice (AMA). Review of the December 2022 Medication Administration Record (MAR) for Resident #53 revealed there were no medications listed for resident. Review of the medical record for Resident #53 revealed it did not include admitting physician orders for medications. Interview on 01/18/23 at 2:48 P.M. of the Administrator and the Director of Nursing (DON) confirmed the facility could not locate the AMA form Resident #53's daughter said she had signed on 12/25/22. Administrator confirmed Resident #53's daughter told her the resident had been discharged from the facility on 12/26/22 at approximately 3:00 P.M. The DON confirmed Resident #53's medical record did not include orders for medications and that the admitting nurse should review the preadmission medications with the attending physician upon admission. DON confirmed Resident #53's December 2022 MAR was blank and resident's medical record included no documentation regarding medications and/or contacting the attending physician regarding admission medication orders. Review of the facility policy titled Medication Administration dated 06/21/17 revealed medications will be administered by legally authorized and trained persons in accordance to applicable state, local and federal laws and consistent with accepted standards of practice. This deficiency represents non-compliance investigated under Complaint Numbers OH00139362, OH00138810 and OH00138752.

Based on closed medical record review, review of the transportation service report, staff interviews, physician interview, and review of the facility policy regarding change in a resident's condition, the facility failed to timely notify the physician of a significant change of condition for one resident (#55). This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death when Resident #55 experienced abnormally low blood pressures over the course of four hours with no notification to the physician of the abnormal levels until Resident #55 was found unresponsive on [DATE] at 5:45 A.M. and subsequently expiring at the hospital later that evening. This affected one (#55) of four residents reviewed for a change in condition. The facility census was 57 residents. On [DATE] at 1:11 P.M., the Administrator, Director of Nursing (DON), and Regional Director of Clinical Services #500 were notified that Immediate Jeopardy began on [DATE] at 1:24 A.M. when Licensed Practical Nurse (LPN) #170 failed to notify a physician regarding a significantly low blood pressure for Resident #55. Resident #55's blood pressure on [DATE] at 1:24 A.M. was ,d+[DATE] millimeters of mercury (mm/Hg) (normal blood pressure is ,d+[DATE] mm/Hg). Documentation of the blood pressure at 5:45 A.M that morning revealed the blood pressure remained low at ,d+[DATE] mm/Hg and Resident #55 was unresponsive. Resident #55 was noted to be a Do-Not- Resuscitate Comfort Care Arrest (DNRCCA). The doctor gave the order to send the resident to the hospital for further evaluation and treatment related to her low blood pressure and unresponsive state. Resident #55 was taken to a local hospital where she was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident died later that evening. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE], Resident #55 ' s record was reviewed by the DON and Regional Director of Clinical Services #500. Resident #55 expired at the hospital on [DATE] at approximately at 8:00 P.M. with hospice services in place requested by her family. · On [DATE], all residents were assessed by the DON and/or designee that included vital signs and the resident's current condition. The nurse's focus is to determine the resident is within their normal baseline and if not, the Change in Condition Policy was followed. Findings included Resident #11 ' s blood pressure was out of the parameters and an order was in place for as needed hypertensive medication which was administered on [DATE] by LPN #166 with good results. · On [DATE], the Medical Director was notified of the Immediate Jeopardy findings and for Resident #55. · On [DATE], the DON discussed the hypertensive medications with the Medical Director and parameters were received regarding the administration of hypertensive medications. · On [DATE], a review of all residents receiving hypertensive medications was completed by the DON and Minimum Data Set (MDS) Nurse #130, and parameters were added as ordered for hypertensive medications. · On [DATE], the policy for changes in condition was reviewed by the Administrator and DON. · The definition and education provided to all employees, states Significant Change of condition is a major decline or improvement in the resident ' s status that: will not normally resolve without intervention by staff or implementing standard disease related clinical interventions (is not self-limiting). · On [DATE], re-education was provided by the DON and designee as it pertains to resident rights, change in condition, accurate assessments, and timely response to provide care needed to all nursing staff. No nursing staff will work before receiving this education. All staff was educated beginning [DATE] and completed [DATE]. · On [DATE], all staff will be educated by facility Administrator or designee to utilize the Stop and Watch tool, reporting any changes of condition they observe with any of the residents immediately to any Department Director available. This will be an ongoing tool. No staff member will work until they have received the education in this plan of correction up to 100 percent. Staff education was started on [DATE] and completed on [DATE]. · On [DATE], an audit tool was developed to interview staff and determine their understanding of the education provided on [DATE] as it relates any change in condition, adverse effects and specifically assessments for changes in condition. The DON and designee will complete interviews of five staff members weekly, for four weeks. Additional re-education will be provided as needed with the interviews. · The Clinical Managers, DON, Assistant Director of Nursing, and MDS Nurse #130 will view documentation daily with the weekend on call Manager reviewing Saturday and Sundays for four weeks. · On [DATE], an immediate Intradisciplinary Team (IDT) Quality Assurance (QA) meeting was held to discuss and develop a plan with the Medical Director. The plan was reviewed through discussion with the Administrator and Regional Director of Clinical Services #500. The Medical Director does not have any other recommendations and agrees with this plan as stated above. · The audit tools will be taken to the QA committee weekly for four weeks to determine the need to continue the plan, make any changes to the plan, or stop the audits as compliance has been achieved. · Interview on [DATE] at 8:45 A.M. with LPN #173 confirmed that she was educated by the DON regarding blood pressure parameters and significant changes/when to contact the doctor this last week. LPN #173 stated that she was given a phone call on [DATE] and given further education regarding the subject in person. · Interview on [DATE] at 8:50 A.M. with LPN #169 confirmed that she was educated by the DON regarding blood pressure parameters and significant changes. LPN #169 stated that the DON called her and provided her the education on [DATE]. · Interview on [DATE] at 8:55 A.M. with LPN #171 confirmed that she was educated by the DON in person on [DATE] regarding blood pressure parameters and significant changes in resident condition. This included education about when to call the doctor. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #55's medical record revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing admission assessment for Resident #55 dated [DATE] revealed the resident required extensive assistance from at least one staff member for all activities of daily living (ADLs) except for eating (limited assistance) and hygiene (total dependence). Resident #55 was noted to be alert and oriented to person and place. No abnormal findings were noted within the assessment of the resident. Vital signs were within normal limits upon admission were documented as follows: ,d+[DATE] mm/Hg (blood pressure), 97.8 degrees Fahrenheit (temperature), 98 beats per minute (pulse), and 94% (oxygen saturation-room air). Review of the Brief Interview for Mental Status (BIMS) score assessment dated [DATE] for Resident #55 revealed a score of 11 out of 15. This indicated an intact cognition. Review of the vital signs for Resident #55 revealed blood pressures of ,d+[DATE] mm/Hg dated [DATE] at 6:00 P.M., ,d+[DATE] mm/Hg dated [DATE] at 12:35 A.M., ,d+[DATE] mm/Hg dated [DATE] at 11:18 P.M., ,d+[DATE] mm/Hg dated [DATE] at 10:33 A.M., ,d+[DATE] mm/Hg dated [DATE] at 1:24 A.M., and ,d+[DATE] mm/Hg dated [DATE] at 5:45 A.M. Review of the physician orders for Resident #55 in [DATE] revealed the resident took two medications for high blood pressure. The resident took [MEDICATION(S)] 6.25 milligrams (mg) twice daily and [MEDICATION(S)] 120 mg once daily. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing note for Resident #55 dated [DATE] at 8:36 A.M. revealed that at around 5:45 A.M. that morning, the nurse was giving morning medications to other residents and went to check on Resident #55 when he found her unresponsive. Vital signs were taken and noted to be ,d+[DATE] mm/Hg (blood pressure), 73 beats per minute (pulse), 97.1 degrees Fahrenheit (temperature), 90% (oxygen saturation), and 20 breaths per minute (respirations). The note went on to say that the doctor was notified and wanted the resident sent to the emergency room for evaluation. LPN #170 stated that he notified the power of attorney as well. Review of the ambulance run report for Resident #55 dated [DATE], revealed the resident was non-responsive upon their arrival at 6:29 A.M. The interview with the nurse revealed that the patient caretaker in the room stated patient is normally verbal, asking questions, but has declined over the last two days. Phone interview on [DATE] at 2:00 P.M. with LPN #170 confirmed that he was the nurse on duty taking care of Resident #55 on the morning of [DATE]. LPN #170 doesn ' t specifically remember the details of the incident but confirmed what was written in his nursing note. He found Resident #55 unresponsive on the morning of [DATE] and took her vital signs. Based on his assessment, he called the doctor and was told to send the resident to the emergency room for further evaluation. LPN #170 doesn ' t remember taking her blood pressure earlier in the shift where he got a reading of ,d+[DATE] mm/Hg but stated that if his initials were in PCC (Point Click Care), then it ' s hard to dispute. LPN #170 went on to state that he doesn ' t remember calling the doctor with the blood pressure of ,d+[DATE] mm/Hg, but he knows they are constantly understaffed at night. The nurse was asked what he would normally do for a resident with a blood pressure of ,d+[DATE] mm/Hg, and he responded, I would call and notify the doctor. Phone interview on [DATE] at 2:30 P.M. with Medical Doctor (MD) #300, the resident ' s primary care physician, revealed that he can ' t remember the specifics around Resident #55. MD #300 went on to say that if it was months ago, it becomes hard to remember. The question was asked to MD #300 that if the resident had a blood pressure of ,d+[DATE] mm/Hg like she did at 1:24 A.M. on [DATE], should she be sent to the hospital? MD #300 stated If I were notified of such a blood pressure, my instructions would be for the facility to send that resident to the hospital for evaluation. There ' s not much the facility can do for a blood pressure that low. The doctor went on to explain that all residents on blood pressure medications don ' t come with parameters for those medications. His expectation is that the facility nursing staff take vitals each time a blood pressure medication is administered and use nursing judgement when administering those medications. This included holding medications for low blood pressures and calling the doctor with critically low blood pressures. Review of the CMS [CONDITION(S)] bundle compliance guide revealed Resident #55 exhibited two indicators of [CONDITION(S)] on [DATE] at 1:24 A.M. Resident #55 had a temperature below 96.8 degrees (96.7) and a documented systolic blood pressure less than 90 (,d+[DATE] mm/Hg). The compliance guide reiterated the importance of receiving treatment and testing within three hours of identification of [CONDITION(S)]. Review of the facility policy titled Change in a Resident ' s Condition or Status, dated ,d+[DATE], revealed The nurse will notify the resident ' s attending physician or physician on call when there has been a significant change in the resident ' s physical/emotional/mental condition. A significant change of condition is a major decline or improvement in the resident ' s status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions.

Based on medical record review, review of hospital records, staff, physician and pharmacist interview, policy review and review of online medication information from Medscape, the facility failed to ensure a cardiac medication was administered per physician orders resulting in a significant medication error. This resulted in Actual Harm when staff administered two like cardiac medications ([MEDICATION(S)] and [MEDICATION(S)]) and the resident was subsequently admitted to the hospital related to a hypotensive episode (low blood pressure) and [CONDITION(S)] (low pulse rate). This affected one (#56) of three residents reviewed for medication administration. The facility census was 56. Findings include: Review of the medical record for Resident #56 revealed an admitted [DATE] and a discharge to the hospital on 04/06/22. Resident #56 was readmitted to the facility on [DATE] and sent to the hospital on 04/25/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/04/22, revealed Resident #56 had impaired cognition. Resident #56 required extensive assist with bed mobility, transfers, and toileting. Resident #56 was supervision for eating. Review of the plan of care dated 09/24/21 revealed the Resident #56 had altered cardiovascular status related to [CONDITION(S)]. Interventions included assess fingers and toes for warmth and color, assess for chest pain and shortness of breath, assess vital signs as ordered, monitor changes in lung sounds on auscultation, [CONDITION(S)] and changes in weight and administer medication as ordered. Review of the hospital cardiology progress notes dated 04/07/22 revealed Resident #56 was hospitalized due to fall and with past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Assessment plan for Resident #56 revealed continuation of [MEDICATION(S)] (treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital cardiology progress note dated 04/10/22 for Resident #56 revealed [MEDICATION(S)] intravenous drops started in the emergency department and was discontinued after converting to sinus rhythm, restarted and stopped again, resident continues oral [MEDICATION(S)] 60 milligrams (mg) by mouth four times a day. Review of the hospital discharge orders for Resident #56 dated 04/13/22 at 11:32 A.M. revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Order Summary Report for Resident #56 dated 04/13/22 and signed by the physician on 04/13/22 revealed one order for [MEDICATION(S)] 90 mg-one tablet by mouth four times a day. Further review of the Order Summary Report revealed the physician returned the document to the facility via fax on 04/13/22 at 12:51 P.M. Review of physician orders revealed Resident #56 was ordered [MEDICATION(S)] tablet 60 mg-give one tablet every six hours by mouth dated 04/13/22 and [MEDICATION(S)] tablet 90 mg-give one tablet every six hours by mouth dated 04/13/22. Review of Medication Administration Records (MAR) for April 2022 revealed Resident #56 received [MEDICATION(S)] tablet 60 mg-give one tablet every six hours by mouth and [MEDICATION(S)] tablet 90 mg-give one tablet every six hours by mouth. Resident #56's medications were initiated on 04/14/22 at 6:00 P.M. Resident #56 received one [MEDICATION(S)] 60 mg and [MEDICATION(S)] 90 mg tablet (totaling 150 mg). Resident #56 received one tablet of [MEDICATION(S)] 90 mg and one tablet of [MEDICATION(S)] 60 mg four times a day for a total of 600 mg on 04/15/22, 04/16/22, 04/17/22, 04/18/22, 04/19/22, 04/20/22, 04/21/22, 04/22/22, 04/23/22, and 04/24/22. Resident #56 received [MEDICATION(S)] 90 mg and [MEDICATION(S)] 60 mg three times (totaling 450 mg dose) on 04/25/22. Review of a nurses note dated 04/25/22 at 1:03 P.M. revealed Resident #56 was transferred to the emergency room due to being lethargic at 12:53 P.M. Resident #56's blood pressure was 58/38 millimeters of mercury (mmHg) and pulse was 27 beats per minute. Review of the physician Emergency Department (ED) note dated 04/25/22 revealed Resident #56 presented for loss of consciousness, low heart rate and low blood pressure. An electrocardiogram (EKG) was consistent with complete heart block. The physician noted Resident #56 was previously discharged with [MEDICATION(S)] 90 mg every six hours but has been been receiving [MEDICATION(S)] 60 mg-one tablet by mouth every six hours and [MEDICATION(S)] 90 mg-one tablet every six hours. Resident #56 had a do not resuscitate comfort care order in place. Resident #56 was admitted to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital cardiology physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Plan for Resident #56 included treatment with potassium, ruling out infections and then reassess if needed. Review of the hospital cardiology physician note dated 04/27/22 for Resident #56 revealed the resident was assessed for [CONDITION(S)] (low heart rate) due to excessive calcium channel blockers ([MEDICATION(S)]). No acute events overnight. Assessment: Resident #56 was initially found with altered mental status and [CONDITION(S)]. Resident #56 was receiving high doses of [MEDICATION(S)] (90 mg every six hours and 60 mg every six hours). Resident #56 currently with [CONDITION(S)] and acceptable heart rate. Resident #56 improving with urinary tract infection treatment. Interview on 04/28/22 at 1:28 P.M., Regional Clinical Director Registered Nurse (RN) #150 verified Resident #56 had a medication error involving [MEDICATION(S)] or [MEDICATION(S)]. RN #150 further stated an investigation was started and they were unsure where the second order for [MEDICATION(S)] for Resident #56 came from. Additionally, RN #150 verified the investigation of the medication error was ongoing. Interview on 04/28/22 at 2:01 P.M. with the Assistant Director of Nursing (ADON) stated Resident #56 had a fall the day prior to being sent to the hospital on 04/25/22. ADON verified the blood sugar was checked prior to transfer to the hospital and was within normal limits. The ADON further stated Resident #56's blood pressure was 58/39 when she was found in her room prior to lunch service. Additionally, the ADON stated staff called 911 and Resident #56 was transferred to the hospital. ADON stated the hospital called the facility to verify medications and that is when the medication error involving the [MEDICATION(S)] and [MEDICATION(S)] was identified. Interview on 05/06/22 at 1:41 P.M. with Medical Director (MD) #103 stated the nurses called him to go over Resident #56's medications on admission. MD #103 stated he was only advised of [MEDICATION(S)] 90 mg every six hours upon admission. Additionally, MD #103 stated he was unsure how the [MEDICATION(S)] 60 mg dosage was added and stated it was a nursing error unfortunately that caused Resident #56's re-hospitalization for low blood pressure and pulse readings. Interview on 05/19/22 at 9:34 P.M. with the Administrator verified Licensed Practical Nurse (LPN) #201 was no longer employed at the facility due to poor work performance and medication error involving Resident #56. The Administrator verified no other medication errors have been identified. Interview on 05/19/22 at 10:30 A.M. with LPN #27 states she assisted with the admission of Resident #56. LPN #27 stated she entered in all the medication into the electronic health record, printed off an Order Summary Report and faxed the document to the physician. LPN #27 stated the physician reviewed the document, signed it and returned it to the facility via fax on the same day of admission. LPN #27 verified only one [MEDICATION(S)] order for 90 mg-one tablet every six hours was written on the order form. LPN #27 states she advised LPN #201 of the work she had completed for Resident #56's admission. LPN #27 further stated the facility uses a check off system and she marked on the document what she had completed. Interview on 05/19/22 at 11:30 P.M. with LPN #201 stated another nurse told her that Resident #56's [MEDICATION(S)] should have been 60 mg four times a day and not 90 mg. LPN #201 stated she entered the order for [MEDICATION(S)] 60 mg four times a day into Resident #56's electronic health record without verifying the information. LPN #201 verified she did not receive the order for the [MEDICATION(S)] 60 mg-four times a day from a physician, but another nurse and she is unable to recall which nurse gave her the order. LPN #201 stated she administered the medication on multiple occasions and did not question the orders as one order used the name brand, and the second order used the generic name. Interview on 05/19/22 at 2:05 P.M. with Pharmacist #250 stated the pharmacy software recognized both orders for [MEDICATION(S)] 90 mg dosage and [MEDICATION(S)] 60 mg dosage. Pharmacist #250 stated the software identified the second order as a duplicate alert. Pharmacist #250 stated this type of order requires a call out to the facility for clarification and that call out to the facility for additional clarification did not occur as it should have. Additionally, Pharmacist #250 verified the maximum daily dose for [MEDICATION(S)] is 540 mg a day for Resident #56 prescribed form/type of medication. Interview on 05/19/22 at 12:12 P.M. with the Director of Nursing (DON) verified the orders are filled from the pharmacy on receipt. DON stated the physician would sign off orders at the end of the month when they are printed for him to review. The DON stated the physician was not aware of the additional order for [MEDICATION(S)] 60 mg-four times a day for Resident #56. Review of the online medication reference Medscape.com revealed [MEDICATION(S)] (also know as [MEDICATION(S)]). [MEDICATION(S)] is an antidysrhythmics and calcium channel blockers used to treat [CONDITION(S)] (chest pain) hypertension, [CONDITION(S)]/flutter and [CONDITION(S)] supraventricular [CONDITION(S)]. [MEDICATION(S)] tablet dosages should not exceed a daily recommended dose of 540 mg per day. Review of the facility policy titled, Medication Administration, revised 04/2019, revealed medications would be administered in accordance with prescriber orders, including any required time frame. Medications would be administered within one hour of their prescribed time unless otherwise specified. Review of the facility policy titled, Adverse Consequences and Medication Errors, revised 04/2019, revealed when a new medication is ordered it will be evaluated for the following, the dose, route of administration, duration, and monitoring are in agreement with the current clinical practice and guidelines. The policy further indicated in the event of a significant medication related error immediate action in taken as necessary to protect the resident safety and welfare. Review of the pharmacy policy titled Provider Pharmacy Requirements dated 09/2018, revealed letter indicated the pharmacy will screen each new medication order of an appropriate indication of diagnosis, medication interactions, duplicate of therapy with other drugs in the same therapeutic class and appropriate drug dose, interval and route of administration. This deficiency substantiates Master Complaint Number OH 225.