Every finding on record at Country View of Sunbury

Based on observation, record review, interview, and policy review, the facility failed to properly store drugs and biological's in the 200 hall medication cart. This had the potential to affect 18 residents (#4, #7, #11, #12, #13, #26, #48, #50, #51, #55, #59, #62, #63, #72, #80, #81, #84, and #194) who resided on the 200 hall and received medications from the 200 hall medication cart. The facility census was 96. Findings include: Observation of the 200 hall medication cart on [DATE] at 9:45 A.M. revealed a bottle of Vitamin B-12 with an open date of 09/2024 and an expiration date of 05/2025, a bottle of Vitamin D with an expiration date of 05/2025 with no open date, and a bottle of Iron with an open date of [DATE] and an expiration date of 04/2025. Interview on [DATE] at 9:48 A.M. with Assistant Director of Nursing #143 confirmed that the bottle of Vitamin B-12 had an opened date of 09/2024 and had expired on 05/2024, the bottle of Vitamin D did not have an opened date and it had expired on 05/2025, and the bottle of Iron had an opened date of [DATE] and an expiration date of 04/2025. Review of the facility policy titled Medication Storage revealed outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction.

Based on record review, observations, resident and staff interviews and interview with Wound Physician #500, the facility failed to implement an intervention for pressure relief for one resident. This affected one (#22) of three residents reviewed for pressure ulcers. The facility census was 85. Findings include: Review of the record for Resident #22 revealed an admission to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual minimum data set (MDS) assessment dated [DATE], revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had no cognitive deficits no behaviors or rejection of care. He required extensive assistance of two staff members for bed mobility, transfers, and locomotion on and off the unit and utilizes a wheelchair for locomotion on and off the unit. Review of the plan of care dated 05/05/21, indicated the resident had alteration in skin integrity as evidenced by maceration to bilateral buttocks with a Stage II pressure ulcer to his left buttocks. Interventions included a pressure reduction cushion to his chair. Review of the Pressure Ulcer assessments beginning 06/02/21, revealed the resident returned from a hospital stay on 06/02/21, with maceration to bilateral buttocks and a Stage II pressure ulcer to his left buttock. The buttocks were observed and a Stage II ulcer was measured weekly by Wound Physician #500. Review of the nursing progress notes from 06/02/21 through 07/12/21, revealed no documentation the resident had refused a pressure relief cushion in his chair. Review of the July 2021 Treatment Administration Record (TAR), revealed the resident was to have a pressure reduction cushion to the chair every shift. The TAR was initialed on both shifts 07/01/21 to 07/13/21, indicating the resident had a pressure reduction cushion in his chair everyday. Review of Wound Physician #500's skin/wound note dated 07/07/21, revealed the Stage II pressure ulcer on the left buttocks measured 0.3 centimeter (cm.) length by 0.7 cm. width by 0.1 cm. depth. Observation on 07/12/21 at 10:30 A.M., 12:40 P.M., and 4:04 P.M., revealed Resident #22 was sitting in a recliner in his room with his feet down on the floor. There was no pressure reduction cushion in the recliner. Observation on 07/13/21 at 10:00 A.M., 12:30 P.M., 2:18 P.M., 3:40 P.M. and 4:00 P.M., revealed Resident #22 was sitting in a recliner in his room with his feet down on the floor. There was no pressure reduction cushion in the recliner. On 07/13/21 at 3:45 P.M. with Licensed Practical Nurse (LPN) #220, verified the pressure reduction cushion was in his wheelchair and he was in the recliner. She verified there was no pressure reduction cushion in the recliner and stated Resident #22 does not want the pressure relieving cushion in his recliner. On 7/13/21 at 4:00 P.M. with the Director of Nursing, verified Resident #22 had been up in the recliner for several hours on 07/12/21 and 07/13/21, without a pressure reduction cushion in his recliner. He stated the resident was non compliant. He stated he would talk to the resident about a pressure reduction cushion to his recliner. Review of the nursing progress note dated 07/13/21 at 4:08 P.M., written by Registered Nurse (RN) revealed she discussed the residents plan of care with the resident and offered a pressure reduction cushion to Resident #22 in the recliner. The progress note stated Resident #22 was hesitant to accept and then agreed. Interview with Wound Physician #500 on 07/14/21 at 12:30 P.M., verified the resident's entire buttocks was extremely red. She stated she felt the best treatment was to continue the Triad Cream and ensure the resident had pressure relief when in a chair and to limit the time in the chair.

Based on record review, observations, staff interview and review of the facility policy, the facility failed to update the plan of care to reflect the current needs of the residents. This affected two (#49 and #40) of 23 residents reviewed for care plans. The facility census was 85. Finding include: Review of the record for Resident #49 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was unable to complete the Brief Interview for Mental Status ( BIMS) due to short and long memory deficits. She did not display behaviors or rejection of care. She was non ambulatory requiring extensive assistance with all activities of daily living. She was totally dependent on staff for eating via a tube feeding and did not experience any fall since the last assessment. Review of the plan of care initiated 05/23/19, with a target date of 08/26/21, revealed the resident was at risk for falls with interventions including a sounding alarm to chair to alert staff of the resident attempting to get up and a tab alarm when in bed. The plan of care did not mention fall mats to be placed by a low bed as a fall intervention. Observation on 07/13/21 at 2:21 P.M., revealed Resident #49 was lying in bed with fall mats on each side of the bed. No bed or chair alarms were in place. Observation on 07/14/21 at 8:45 A.M., revealed Resident #49 was up in a chair in the common area with other residents and a staff member. There was no alarm on the chair. Observation on 07/14/21 at 10:30 P.M., revealed Resident #49 was in a low bed with bilateral fall mats by the bed. There were no alarms on the bed or the chair which were in the room. Observation on 07/14/21 at 12:30 P.M., revealed Resident #49 was up in a chair out in common area with no alarm on the chair. Observation on 07/14/21 at 2:30 P.M., Resident # 49 was in low bed with bilateral mats by bed. No alarms were on the bed. On 07/15/21 at 8:45 A.M. with Licensed Practical Nurse (LPN) #420, verified there were no alarms on the the residents chair or bed. She stated they had not used alarms for quite some time. She stated when the resident was first admitted she was very restless and needed alarms as a fall intervention, however, she does not need them anymore. She verified there was fall mats the staff put by her low bed as fall interventions. On 07/15/21 at 9:00 A.M. with LPN #425, verified the current plan of care had alarms to the bed and chair as current fall interventions to the bed and chair. She stated the resident has not required alarms on her bed and chair for Resident #49 for quite some time and they had not been using alarms. She verified the nurses were signing the June and July 2021 TAR's indicating the bed and chair alarms were in place each shift. Interview with MDS Coordinator Registered Nurse (RN) #425, verified she had completed and updated the plan of care for Resident #49. She stated no one had told her the resident no longer needed alarms and was using fall mats as fall interventions. 2. Review of the medical record for Resident #40 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the minimum data set (MDS) assessment dated [DATE], revealed a brief interview of mental status score of three, indicating the resident was cognitively impaired. The resident required extensive assistance with bed mobility and transfers, limited assistance with walking in room, corridor, and locomotion on unit. Resident #40 was not steady and was only able to stabilize with staff assistance for surface-to-surface transfers, when moving from a seated to a standing position and walking with assistive device if used, turning around and facing the opposite direction while walking, and moving on and off the toilet. Review of the physician orders revealed orders were in place for a chair alarm to alert staff of unassisted transfers/ambulation every shift for fall intervention with a start date 05/02/21. Physician orders were changed on 07/13/21, reflecting the discontinuation of the chair alarm at 6:14 P.M. The Medical Doctor (MD) and Power of Attorney (POA) were made aware. A health status note was entered at 6:24 P.M. with an effective time of 3:20 P.M. by Registered Nurse Manager of Clinical Care Operations, indicated may discontinue pressure sensor alarm to chair and physician and POA were notified. Review of the care plan dated 05/24/21, revealed Resident #40 was at risk for falls with potential for injury related to personal history of falls, use of [CONDITION(S)] medication, severe impaired cognition, impaired balance with transfers and gait secondary to dementia, cerebral atherosclerosis, depression, and anxiety. Interventions did not include the chair alarm as ordered. Interventions included staff to assist resident at all times when resident was seen ambulating. Review of the Physical Therapy (PT) discharge summary, dated 05/13/21 through 06/11/21, revealed the resident was discharged [DATE]. Discharge recommendations included: assistance with independent activities of daily living (IADLs), assistive device for safe functional mobility and 24 hour care with supervision and set up. Interview on 07/13/21 at 6:01 P.M. with Registered Nurse Manager of Clinical Care Operations revealed Resident #40's chair alarm had been reviewed earlier that day in the interdisciplinary meeting and was to be discontinued as it was no longer needed. Registered Nurse Manager of Clinical Care Operation verified the current physician orders reflected a chair alarm to alert staff of unassisted transfer/ambulation every shift for fall. Interview on 07/14/21 at 10:40 A.M. with Registered Nurse Manager of Clinical Care Operations verified the fall and activities of daily living (ADL) care plans were now updated to reflect set up/supervision for ambulation. The fall interventions now included the removal of the intervention for the resident to be assisted at all times with ambulation. Registered Nurse Manager of Clinical Care Operations verified the care plan had called for staff to assist resident at all times when resident was seen ambulating. Review of the facility policy titled, Nursing Policy/Procedure Manual Subject Fall Management, dated 10/17/16, revealed each resident will be assessed throughout the course of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interdisciplinary plan of care will be developed, implemented, reviewed and updated as necessary to reflect each resident's current safety needs and fall reduction interventions. A plan will be identified and implemented as necessary to protect the resident and/or others from recurrence. Procedures included the resident's care plan was updated as needed to reflect the resident's health status and safety needs, and new fall reduction interventions were communicated to care givers as needed. Review of the facility policy titled, Provider Services Policy/Procedure Manual Subject MDS, Care Area Assessment (CAA) and Care Plan Completion, dated 01/01/15, revealed it was the policy of this facility to follow guidelines in the Resident Assessment Instrument (RAI) Manual related to MDS, CAA and Care Plan completion. Procedures included the facility will have the updated version of the RAI Manual either in hard copy form or electronic format accessible to members of the team responsible for completion of these areas.

Based on record review and resident and staff interviews, the facility failed to re-evaluate one residents clinical status for the continued use of enteral feedings. This affected one (#16) of one resident reviewed for tube feedings. The facility census was 85. Findings include: Review of Resident #16's record revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive deficits. She did not display any behaviors no or rejection of care. She required extensive assistance of one person for all activities of daily living. She receives all of her nutrition through enteral feedings through a feeding tube and is able to drink thin liquids orally. Review of the nutritional assessment dated [DATE], indicated Resident #16 received [MEDICATION(S)] 2.0-200 milliners four times a day. She was to have nothing by mouth with the exception of ice chips or clear liquids up to 1500 ml per day. Review of the plan of care dated 04/12/21, the resident was at risk for potential alteration in nutrition and hydration related to alternative nutrition via feeding tube and not having anything by mouth except for ice chips or clear liquid up to 1500 ml per day. The resident has a history of impaired swallowing. The interventions included provide enteral feeding Nutrin 2.0 as ordered, the resident my have clear liquids, and request therapy screening/evaluation as needed. Review of the Speech Discharge Summary dated 11/30/21, revealed the discharge recommendations indicated Speech Therapy will schedule a modified [MEDICATION(S)] swallow (MBS) (swallowing study) to be performed on the resident On 07/12/21 at 4:40 P.M., Resident #16 stated she received a tube feeding due to difficulty swallowing. She stated the facility would not do a swallow study to see if she could eat pudding or yogurt because her insurance would not pay for it. She stated she really wants to eat pudding and yogurt. She stated she can drink water and has no problem with it. The resident has a water pitcher with water at bedside and can drink thin liquids. Interview with Dietician #300 on 07/15/21 at 12:00 P.M., stated she has talked to the resident several times and she has not expressed wanting to try to eat again or wanting a swallow study. Interview with Speech Therapist #505 on 07/15/21 at 2:00 P.M., verified she wrote for speech therapy to schedule an MBS and she thought she remembered that insurance stated it was too soon to repeat the MBS in November 2020. She stated she would need a referral from the physician to see the resident now. Interview with Resident #16 on 07/15/21 at 2:15 P.M., revealed Resident #16 stated adamantly she wanted a swallow study to see if she could safely eat pudding and yogurt. She stated the dietician has never talked with her recently. She said the dietician met with her when she was first admitted . She stated in the winter she was told by speech therapy she could not have a swallow evaluation due to non payment from insurance. She stated at the time she was eating puree foods with speech therapy without any concerns.

Based on record review, observations, staff interview, and review of the facility policy, the facility failed to ensure oxygen tubing was dated or documented as changed; oxygen concentrators were cleaned weekly and comprehensive respiratory assessments were completed as ordered. This affected three (#82, #41 and #25) of three residents reviewed for oxygen. A total of nine residents receive oxygen services. The facility census was 85. Finding include: 1. Review of medical record for Resident #82, revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #82's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #82 had a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #82 was cognitively intact. Resident #82 required extensive assistance with one person for bed mobility, transfers, toileting; limited assistance with one person assist for dressing, personal hygiene, and bathing. Review of the physician orders dated 07/2021, revealed oxygen per nasal cannula to maintain saturation above 90 percent as needed secondary to Asthma, nurse to perform comprehensive respiratory assessment which included respiratory assessment monitoring, and set and or removal of equipment related to asthma three times a day, change oxygen tubing/cannula/ mask weekly and clean filter on oxygen concentrator weekly. Review of the Treatment Administration Record (TAR) for Resident #82, revealed oxygen tubing was not changed and the concentrator filter was not cleaned on 04/25/21, 05/02/21, 06/14/21, 06/27/21. Comprehensive respiratory assessments were not completed on the second shift of 04/07/21, 04/19/21, 05/08/21, and 07/05/21; and third shift on 05/27/21, 05/29/21, 07/01/21, and 07/09/21. 2. Review of medical record for Resident #41, revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #41's quarterly Minimum Data Set assessment (MDS) dated [DATE], revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #41 was cognitively intact. Resident #41 required limited assistance with one person assist for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Review of the physician orders dated 07/2021, revealed oxygen continuous per nasal cannula at three liters per minute to maintain saturation above 92 percent, clean filter on oxygen concentrators weekly, change oxygen cannula weekly, and comprehensive respiratory assessment which included respiratory assessment, monitoring and setup/removal of equipment related to [CONDITION(S)]. Review of the Treatment Administration Record (TAR) for Resident #41, revealed oxygen tubing was not changed and the concentrator filter was not cleaned on 06/13/21, and 07/11/21. Comprehensive respiratory assessments were not completed on third shift of 05/27/21. Observation on 07/12/21 at 1150 A.M., revealed oxygen tubing was not labeled for Resident #82. Interview on 07/12/21 at 11:59 A.M. with State tested Nurse Aide (STNA) #306, revealed oxygen tubing was changed weekly and labeled. She further verified there was no label on the oxygen tubing for Resident #82. Interview on 07/12/21 at 4:00 P.M. with Licensed Practical Nurse (LPN) #200, revealed oxygen tubing was changed weekly and the tubes labeled on night shift. Interview on 07/13/21 at 10:30 A.M. with the Director of Nursing (DON), revealed documentation on oxygen tube changing was located in the TAR. 3. Review of the medical record for Resident #25 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly minimum data set (MDS) assessment dated [DATE], revealed a brief interview of mental status score (BIMS) of four, indicating impaired cognition. The MDS revealed shortness of breath or trouble breathing when lying flat. Receives oxygen therapy. Required extensive assistance with bed mobility, transfers, dressing, toilet use and total dependence for personal hygiene and locomotion on unit. Review of the current physician orders revealed orders were in place to change oxygen tubing, nasal cannula and water every night shift every Tuesday with a start date 12/31/19. Observations on 07/12/21 at 10:19 A.M. through 1:55 P.M. of Resident #25, revealed no date on the oxygen tubing for the nasal cannula. Interview on 07/12/21 at 1:55 P.M. with State tested Nursing Assistant (STNA) #406, revealed once a week the oxygen tubing was changed on Sunday. STNA #406 revealed typically night shift changes tubing and water if needed and yes it should be dated. STNA #406 verified no date on the oxygen tubing. Observation on 07/13/21 at 9:18 A.M., revealed Resident #25's oxygen tubing was dated 07/12/21. Interview on 07/15/21 at 2:35 P.M. with Registered Nurse Manager of Clinical Care Operations, verified the oxygen tubing orders for Resident #25, change oxygen tubing, nasal cannula and water every night shift every Tuesday start date 12/30/19. Review of the facility policy titled, Infection Control Policy/Procedure Manual Subject Infection Control: Respiratory- Oxygen Equipment, Cleaning/Disinfecting:, revised 07/2012, revealed procedures included oxygen tubing/masks/nasal cannula's change tubing weekly and prn (as needed).

Based on record review, observations, resident and staff interviews, and review of the facility policy, the facility failed to provide fluids in between meals for one resident. This affected one (#7) of 24 residents observed and interviewed during Stage I of the annual survey. The facility census was 85. Findings include: Review of the record for Resident #27 revealed the resident was admitted to the facility on [DATE]. Diagnoses included [CONDITION(S)] following cerebral infarct, chronic pain syndrome, hypertension, and depression. Review of the physician orders initiated on 03/08/21, indicated Resident #16 was to receive a regular diet with regular texture and thin liquids. On 05/04/21, there was a physician order to encourage extra fluids. Review of the quarterly Minimum Data Set ( MDS) assessment dated [DATE], revealed the resident scored a 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. She had no behaviors or rejection of care. She required total assistance of two staff for transfers and toileting, was non ambulatory and feeds herself with set up. Review of the plan of care dated 05/07/21, revealed the resident was at risk for potential for alteration in nutrition and hydration. The interventions included to monitor the resident's eating ability; provide assistance with meals/snacks as necessary; and drinks were to be served in handled lidded cups. Observation on 07/12/21 at 12:20 P.M., revealed there was no water pitcher or any fluids in the residents room. Interview with Resident #27 verified she had no water pitcher in her room. She stated she has never had a water pitcher in her room since she was admitted to the facility. She verified she did not get any fluids to drink in between meals. She stated she would really like a cold glass of water. She stated she gets water on her meal tray but it was not cold. Observations on 07/13/21 at 8:00 A.M., 10:30 A.M., 12:30 P.M., and 3:30 P.M., revealed the resident was up in the recliner in her room. There was no water pitcher or cups in her room On 07/13/21 at 4:00 P.M. during an interview with Licensed Practical Nurse (LPN) #200, verified Resident #27 did not have a water pitcher or anything to drink in her room. She looked in her medical e-chart and verified Resident #27 was on a regular diet with thin liquids. She stated all of the residents who were able to drink thin liquids without choking were to have a water pitcher at their bedside. LPN #200 entered the residents room verifying she did not have a water pitcher or anything to drink. She asked Resident #27 what happened to her water pitcher and the resident stated, I have never had a water pitcher since I have been here. LPN #200 stated she would get her a water pitcher with ice water. Resident #27 smiled and stated that would be great. Interviews with State tested Nursing Assistants (STNA's) #300, #302, and #304 on 03/13/21 between 4:15 P.M. to 4:30 P.M., verified the staff pass fresh ice water each shift, sometimes several times a shift. They verified they did not know Resident #27 did not have a water pitcher. They stated if there was not a water pitcher at the bedside they assumed the resident was not allowed to have thin liquids. Review of the undated, Hydration Cart / Water Pitcher Policy, revealed the STNA was to deliver fluids daily and as requested by the residents. The night shift STNA will fill and replace the water cup at the bedside by the end of the shift. Nursing was to distribute all water cups to current and new residents.

Based on record review, observations and staff interview, the facility failed to accurately document the use of alarms and fall mats for one resident. This affected one (#49) of 23 records reviewed. The facility census was 85. Findings include: Review of the record for Resident #49 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual minimum data set (MDS) assessment dated [DATE], revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS) due to short and long memory deficits. She did not display behaviors or rejection of care and was non ambulatory requiring extensive assistance with all activities of daily living. She was totally dependent on staff for eating via a tube feeding. She did not experience any fall since the last assessment. Review of the plan of care initiated 05/23/19, with a target date of 08/26/21, revealed the resident was at risk for falls with interventions including a sounding alarm to chair to alert staff of the resident attempting to get up and a tabs alarm when in bed. The plan of care did not mention fall mats to be placed by a low bed as a fall intervention. Review of the June and July 2021 Treatment Administration Records (TAR), revealed the nurses had signed the TAR indicating the alarms to the resident's chair and bed were in place everyday. There was not mention of the use of fall mats in the medical record. Observation on 07/13/21 at 2:21 P.M., revealed Resident #49 was lying in bed with fall mats on each side of the bed. No bed or chair alarms were in place . Observation on 07/14/21 at 8:45 A.M., revealed Resident #49 was up in a chair in the common area with other residents and a staff member. There was no alarm on the chair. Observation on 07/14/21 at 10:30 P.M., revealed Resident #49 was in a low bed with bilateral fall mats by the bed. There were no alarms on the bed or the chair which were in the room. Observation on 07/14/21 at 12:30 P.M., revealed Resident #49 was up in a chair out in the common area with no alarm on the chair. Observation on 07/14/21 at 2:30 P.M., revealed Resident #49 was in a low bed with bilateral mats by bed. No alarms were on the bed. On 07/15/21 at 8:45 A.M., Licensed Practical Nurse (LPN) #420, verified there were no alarms on the the residents chair or bed. She stated they had not used alarms for quite some time. She stated when the resident was first admitted she was very restless and needed alarms as a fall intervention, however, she does not need them anymore. She verified there were fall mats the staff put by her low bed as fall interventions. On 07/15/21 at 9:00 A.M. with LPN #425, verified the current plan of care had alarms to the bed and chair as current fall interventions to the bed and chair. She stated the resident has not required alarms on her bed and chair for Resident #49 for quite some time and they had not been using alarms. She verified the nurses were signing the June and July 2021 TAR's indicating the bed and chair alarms were in place each shift. Interview with MDS Coordinator Registered Nurse (RN) #425, verified she had completed and updated the plan of care for Resident #49. She stated no one had told her the resident no longer needed alarms and was using fall mats as fall interventions.

Based on record review, observations, staff interviews, and review of the facility policy, the facility failed to follow infection control practices regarding proper hand hygiene and failed to ensure one resident's family was wearing proper Personal Protective Equipment (PPE) for a resident who was on contact isolation. This affected three (#76, #18 and #288) residents reviewed for infection control practices. The facility census was 85. Findings include: 1. Observation on 07/12/21 at 12:36 P.M. during lunch service, revealed Activities #400 was feeding Resident #19 and #76 at the same time. She was sitting in between both residents on a rotating chair. She was witnessed wiping Resident #19's face and turning around and feeding Resident #76. She then wiped Resident #76's face and then turned around and feed Resident #19. At no time was she observed to use hand sanitizer after wiping the residents face. Interview on 07/12/21 at 12:45 with Activities #400, verified she was feeding both residents and had wiped their mouths and did not use hand sanitizer after wiping their mouths. She furthermore stated she was unaware of the hand washing policy. Review of the facility policy titled, Hand Washing, dated 11/28/17, revealed staff perform hand hygiene (even if gloves were used) in the following situations: before and after contact with the resident; after contact with blood, body fluids, or visible contaminated surfaced or other objects and surfaces in the resident's environment; after removing protective equipment (e.g., gloves, gown, facemask); and before performing a procedure. Review of the facility policy titled, Infection Prevention and Control Program, dated 11/28/17, revealed hand washing protocol all staff shall perform hand hygiene before and after performing resident care procedures and per facility established hand hygiene procedure. 2. Review of the medical record for Resident #288 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #288's admission Minimum Data Set Assessment (MDS) dated [DATE], revealed Resident #288 had a Brief Interview for Mental Status (BIMS) score of 12, indicating she was cognitively intact. Resident #288 required extensive assistance with two people for bed mobility, transfers, toileting; extensive assistance one person for dressing; and limited assistance with one person for personal hygiene and bathing. Review of the physician orders for 07/2021, revealed the resident was on contact isolation due to C-diff. Review of the baseline care plan dated 06/19/21, revealed the resident had a current infection and was placed on droplet precautions. Review of the care plan dated 06/20/21, revealed the resident was at risk for infection related to C-diff. Interventions included to give antibiotic therapy as ordered and isolation per order. Review of the Skilled Progress Note dated 06/19/21 at 5:40 P.M., revealed the resident had loose stools. She had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was on [MEDICATION(S)] until 08/05/21, and [NAME] for five days. Review of the Admission Assessment and Baseline Care plan dated 06/19/21 revealed the resident had [CONDITION(S)] and had a current infection and was on droplet precautions. Review of the nursing progress note dated 07/12/21 at 7:04 P.M., revealed the Director of Nursing (DON) was notified by a nurse regarding Resident #288's son was non-compliance with donning/doffing of PPE for contact precautions. The son acknowledged he was aware he was to don/doff PPE according to isolation precaution signage that was present on the resident's door and facility screening station. The son confirmed the resident had an isolation donning station outside of her room with available PPE. The son was notified window visits remain an option if he prefers not to wear PPE and was provided education related to infection prevention/control and appropriate PPE for visitation with acknowledgement received. Observation on 07/12/21 at 4:00 P.M., revealed Resident #288's family was into visit the resident with no PPE on. Outside of the resident's door there was a PPE bin with gowns, gloves, and masks. There was signs on the door referring what PPE was to be worn in the resident's room. Interview on 07/12/21 at 4:05 P.M. with Licensed Practical Nurse (LPN) #202, revealed Resident #288 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She further verified the family was in the room and was not wearing PPE. Observation on 07/14/21 at 12:31 P.M., revealed Resident #288's door was closed. Signage on door remains related to contact precautions and required PPE to use to enter. The PPE bin was still located outside the resident's door. Upon entrance of the room, the son was sitting in a chair with his gown hanging over the back of the chair while Resident #288 was sitting in her chair. Interview on 07/14/21 at 12:41 P.M. with the DON, revealed the signage was from the Centers for Disease Control (CDC) and Prevention and referred to staff. He verified he had a conversation with the son regarding proper PPE to wear. The DON stated he Cannot police resident families regarding PPE. Interview on 07/15/21 at 10:00 A.M. with the DON, revealed he spoke with Resident #288's son yesterday and was informed he did not have his PPE on as he was using the resident's restroom. Review of the facility policy titled, Infection Prevention and Control Program, dated 11/28/17, revealed isolation signs were used to alert staff, family members, and visitors to speak with the nurse regarding isolation precautions. Review of the facility policy titled, Standard and Transmission-based precautions, dated 01/23/19, revealed transmission-based precautions (also known as Isolation Precautions) refers to the actions (precautions) implemented, in addition to standard precautions, that were based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections. The facility will apply Transmission-based precautions, in addition to standard precautions, to residents who develop signs and symptoms of a transmissible infection, arrive with symptoms of an infection (pending laboratory confirmation), or have a laboratory confirmed infection and were at risk for transmitting the infection to other residents. Information regarding the precaution to be utilized will be communicated through verbal reports, written in-house communication forms, or signage.

Based on review of the daily staffing, staff interview, and observation, the facility failed to post the nursing staff information with the number of Registered Nurses, Licensed Practical Nurses, and State tested Nurse Aides directly responsible for resident care per shift. This had the potential to affect 85 of 85 residents who reside in the facility. Findings include: Review of the daily staffing sheets from 06/01/21 to 07/14/21, revealed the sheet did not include how many Registered Nurses, Licensed Practical Nurses, and State tested Nurse Aides were working for each day. The daily staffing sheet only had the numbers of hours worked each day. Observation on 07/15/21 at 8:45 A.M., revealed the 07/15/21 daily staffing posting did not include how many Registered Nurses, Licensed Practical Nurses, and State tested Nurse Aides were working for that day. Interview with the Administrator on 07/15/21 at 9:45 A.M., verified the daily staffing sheets from 06/01/21 to 07/15/21, did not include how many Registered Nurses, Licensed Practical Nurses, and State tested Nurse Aides were working for each day.

Based on observations, record review, staff interview, review of facility policies, and review of the guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to follow professional standards of practice when room doors were left open where signage was posted for droplet precautions. This affected four (#93, #95, #102 and #107) of four residents whose rooms were observed regarding signage for droplet precautions. The total facility census was 104. Findings include: Review of the medical record for Resident #93 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of the medical record for Resident #95 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of skilled progress notes dated 12/06/20 to 12/09/20, revealed transmission-based precautions were maintained by staff. The resident remained in the room and all services were brought to the resident. Review of the medical record for Resident #107, revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of the medical record for Resident #102, revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Observations on 12/07/20 at 12:46 P.M., revealed signage posted for droplet and contact precautions, personal protective equipment (PPE) in plastic bins outside of resident rooms, and Residents #93, #95, #102, #107's doors were left open. Interview on 12/07/20 at 1:00 P.M. with State tested Nurse Aide (STNA) #112, revealed this employee usually works this unit. STNA #112 confirmed room doors should be closed for anyone on droplet precautions. STNA #112 verified droplet precautions signage, personal protective equipment cart, and room door open for Resident #93, #95, #102, and #107. STNA #112 further verified droplet precautions signage, personal protective equipment cart, and an open personal door for the room of Resident #102, who shared an open common space outer door to the suite. Interview on 12/07/20 at 1:06 P.M. with the DON, revealed doors can be open for droplet and contact precautions. Interview on 12/07/20 at 2:05 P.M. with RN #117, revealed room doors should be closed for anyone on droplet precautions unless there was a physician ordered exception to allow the door to remain open. Interview on 12/07/20 at 2:10 P.M. with the DON revealed acknowledgement of room doors should remain closed for residents on droplet precautions referencing the professional resource. Review of facility policy titled, Nursing Policy/Procedure Manual Standard and Transmission-based Precautions, dated 05/05/17, revision date 11/28/17, revealed the facility had a policy in place related to droplet precautions. The policy defined Transmission-Based precautions (a.k.a. Isolation Precautions) as the actions (precautions) implemented, in addition to standard precautions, that are based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections. The policy defined droplet precautions as actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. The policy defined isolation as the practices employed to reduce the spread of an infectious agent and/or minimize the transmission of infection. The policy included the facility would use standard approaches, as defined by the CDC, for Transmission-based Precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions would determine the type of personal protective equipment to be used. The category of and duration of transmission-based precaution (isolation) would depend upon the infectious agent or organism involved. Policy further included reference to the Centers of Disease Control (CDC) recommendations titled, Type and Duration of Precautions Recommended for Selected Infections and Conditions and Clinical Syndromes or Conditions Warranting Empiric Transmission Based Precautions in Addition to Standard Precautions as attached to this policy. Review of facility policy titled, Foundations Health Solutions Infection Control Policy/Procedure Manual Infection Prevention and Control Program (IPCP), dated 08/18/10, revision 11/28/17, revealed the facility had a policy in place for transmission-based precautions. The policy listed an Isolation Protocol which included a resident with an infection or communicable disease shall be placed on Transmission-based precautions (a.k.a. Isolation precautions) as recommended by current CDC Guidelines for Isolation Precautions. Review of guidance titled, Centers for Disease Control Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 11/04/20, revealed section titled, Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. Section included patient placement. If admitted , place a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection in a single-person room with the door closed.

Based on observation, staff interview and policy review, the facility failed to ensure expired and undated medications were not stored in the medication cart. This affected two (100 hall and 200 hall) of five carts observed. Additionally, the facility failed to ensure expired medications were not stored in the medication storage refrigerator. This affected one (400/500 hall) of two storage rooms observed. The facility census was 111. Findings include: 1. Observation of the 400/500 hall medication storage room on 03/13/19 at 12:05 P.M., revealed there was an opened vial of Influenza vaccine 5 milliliter (ml) vial with an opened date of 02/11/19 located in the fridge. Interview with Licensed Practical Nurse (LPN) #35 on 03/13/19 at 12:07 P.M. confirmed the vial had an opened date of 02/11/19 and once opened it was only good for 28 days. LPN #35 confirmed the Influenza vaccine was expired. Review of the manufacturer's recommendations for the Influenza vaccine revealed once the [MEDICATION NAME] of the multi-dose vial has been pierced, the vial must be discarded within 28 days. 2. Observation of the 100 hall medication cart with LPN #128 on 03/13/19 at 1:06 P.M. revealed there was an opened and undated bottle of [MEDICATION NAME] HCl Solution (eye drops for [MEDICAL CONDITION]) 1% eye drops for Resident #93. Additionally, there was a bottle Travoprost Solution (eye drops for [MEDICAL CONDITION]) 0.004% eye drops for Resident #18 that was opened and undated. Interview with LPN #128 on 03/13/19 at 1:10 P.M. confirmed the above eye drops were opened and undated. 3. Observation of the 200 hall medication cart with LPN #92, on 03/13/19 at 1:25 P.M. revealed an opened bottle of Olopatadine ([MEDICATION NAME] eye drops) 0.2% eye drops for Resident #63 with an opened date of 01/20/19. Interview with LPN #92 at 1:26 P.M. voiced once eye drops are opened they are good for 30 days. She confirmed these eye drops were expired. Review of the facility policy titled Medication Storage dated 06/21/17 revealed outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the Pharmacy, if replacements are needed.

Based on medical record review, staff interview and policy review, the facility failed to ensure the physician's order for a resident's code status (level of medical interventions a patient wishes to have started if their heart or breathing stops) matched the State of Ohio DNR document. This affected one (#53) of one residents reviewed for advance directives. Additionally, the facility failed to ensure accurate advance directives were in the medical record for one (#39) of two residents reviewed for advance directives. The facility census was 111. Findings include: 1. Review of Resident #53's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the State of Ohio Do Not Resuscitate Comfort Care form identified the resident as being a Do Not Resuscitate Comfort Care-Arrest (DNRCC-A). This was signed by the physician on 08/20/18. Review of the order summary report revealed the resident was a full code. This order was initiated on 08/31/18. Review of the quarterly minimum data set (MDS) assessment dated [DATE] identified the resident as being cognitively intact as indicated by a brief interview for mental status (BIMS) score of 15. Interview with Licensed Practical Nurse (LPN) #130 on 03/12/19 at 1:19 P.M.,. confirmed the residents physician order identified the resident as being a full code. Additionally, she confirmed the resident had a signed DNRCC-A form. 2. Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of five which indicated Resident #39 had severe cognitive impairment. His functional status was listed as extensive one to two person assist for all activities of daily living and total assist for eating. Review of the care plan dated 01/10/19 revealed a plan in place for advanced care planning reviewed with Resident/Responsible Party; code status was full code and resident had a living will. The wife was next of kin and was working on a guardianship application. Review of the medical record revealed Resident #39's code status as do not resuscitate comfort care and his face sheet and electronic medical record indicated a full code. Interview with the Licensed Practical Nurse (LPN) #113 at 1:10 P.M., confirmed the do not resuscitate comfort care was the wrong code status for Resident #39 and also confirmed the resident was a full code. She also revealed, in an emergency, she would look in the medical record to see the Resident's code status or in the electronic medical record. Review of the facility policy titled Residents' Rights: Treatment and Advance Directives dated 11/22/16 revealed no concerns.

Based on medical record review, review of the Skilled Nursing Facility Beneficiary Protection Notification Review, staff interview and admission agreement review, the facility failed to ensure a resident was issued the correct forms when cut from Medicare Part A services. This affected two (#310 and #19) of three residents reviewed. The facility census was 111. Findings include: 1. Review of Resident #310's medical record revealed an admission date of [DATE] and a discharge date of [DATE]. Review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review revealed the resident's last covered day of Medicare Part A services was on 02/06/19, and was a facility/provider initiated discharge. It indicated the resident was not issued an Skilled Nursing Facility Notice of Non-coverage (SNFABN) (a form that provides information to the beneficiary so that they can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. 2. Review of Resident #19's medical record revealed an admission date of [DATE] and the resident currently remained in the facility. Review of the SNF Beneficiary Protection Notification Review revealed the residents last covered day of Medicare Part A services was on 12/17/19, and was a facility' provider initiated discharge. It indicated the resident was not issued an SNFABN. Interview with Social Service Designee (SS) #10 on 03/13/19 at 10:16 A.M. confirmed both Resident #310 and Resident #19 both remained in the facility after they were cut from Medicare Part A services. She confirmed neither of the residents were issued an SNFABN and they should have been. Review of the facility Admission Agreement for Medicare covered services and charges indicated that you may be cut from Medicare any time during the 100 days based of your condition/progress in which the responsible party will be notified in writing.

Based on observation, staff interview and policy review, the facility failed to ensure proper infection control was followed for the storage of a urinary catheter bag. This affected one (#53) of four residents reviewed. The facility census was 111. Findings include: Review of Resident #53's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Review of the quarterly minimum data set (MDS) assessment dated [DATE] identified the resident as being cognitively intact as indicated by a brief interview for mental status score of 15. It identified the resident as requiring an extensive two person assist with toilet use. Observation on 03/12/19 at 8:11 A.M. revealed Resident #53's urinary catheter bag was lying on the floor. Additional observation on 03/12/19 at 3:33 P.M. revealed Resident #53's urinary catheter bag was lying on the floor. Interview with Licensed Practical Nurse (LPN) #130 on 03/12/19 at 3:35 P.M. voiced a catheter bag should be hung below the level of the bladder, on the side of the bed. LPN #130 voiced a catheter bag should not be lying on the floor. Observation and interview with LPN #130 on 03/12/19 at 3:38 P.M. confirmed Resident #53's urinary catheter bag was lying on the floor. Review of the facility policy titled Foley Catherization dated 03/07/15 indicated to secure the drainage tubing to the bottom bed sheet with the clip from the drainage set.

Based on observation, record review, and staff interview, the facility failed to revise a care plan to accurately reflect the current mobility needs of one (#10) out of three residents reviewed for care plans. The facility census was 115. Findings include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of health status note dated 10/13/17 at 5:10 A.M. revealed the resident had become combative during a transfer from the bed to the wheelchair, suffering a laceration to the left calf which required sutures. Review of the skilled nurses note dated 10/18/17 revealed Resident #10 was to begin utilizing a mechanical lift for transfer with two assistance to ensure safety. Review of occupational therapy note dated 10/20/17 revealed Resident #10 was to utilize a mechanical lift for transfers and would benefit from the use of a geriatric (geri) chair for seating . Review of State tested Nurse Aide (STNA) care plan book revealed revealed a care plan cover sheet dated 09/18/16 indicating the Resident #10 required one to two assistance with bed mobility and transfers. On 12/19/16 it was updated to use two assistance with direct care when she is anxious and agitated, use of wheel chair with padded areas to wheelchair, dermasavers to bilateral extremities, and apply foam edge to dining room table. There was no interventions for the mechanical lift or geri chair. Review of the current plan of care for self care deficit revealed SR required assistance related to severe cognitive deficits, impaired mobility, impaired balance, non-ambulatory secondary to dementia, Alzheimer's dementia, and general weakness. There was no interventions listed for use of mechanical lift or geri chair. Interviews on 10/25/17 at 9:13 A.M. with STNA #76 and at 9:16 A.M. with STNA #70 revealed resident care needs are on every resident's care plan face sheet. This will note if they require a mechanical lift for transfers. Interview on 10/25/17 at 11:25 A.M., STNA #71 stated individualized resident care needs are on the resident care plan face sheets, which are updated frequently with changes. She stated Resident #10 was recently identified to require a mechanical lift for transfers due to hard time with pivoting transfers. Interview with Director of Nursing (DON) on 10/25/17 at 2:54 P.M. verified Resident #10 was now using a mechanical lift transfer since 10/20/17. The DON verified Resident #10's care plan and the STNA care plan cover page should have been updated to reflect Resident #10's use of a mechanical lift with two staff assistance for transfers and the use of the geri chair. This is an incidental citation discovered during the investigation for Complaint Number OH 088.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based medical record record review, hospital documentation review, in-servicing review, audit/monitoring review, and staff interviews, the facility failed to ensure a resident was removed from the bedpan prior to being transported to the hospital. This affected one (#72) of three residents reviewed for care and treatment. The facility census was 112. Findings include: Review of Resident #72's medical record revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #72's comprehensive assessment dated [DATE] revealed the resident was alert and oriented, could make her needs known and was totally dependent on two staff for bed mobility, transfers and toilet use. Review of Resident #72's nurse's notes dated 10/05/17 at 10:34 P.M. revealed this nurse was called to resident room by staff. Upon entering resident room decreased level of consciousness was noted. Vital signs: Blood pressure (B/P) 86/68, oxygen saturations (SPO2) 92%, pulse (P) 155, temperature (T) 100, Respiration (R) 24. Certified Nurse Practitioner (CNP) notified, new order obtained to send to emergency room (ER) for evaluation. Power of Attorney (POA) made aware. Review of Resident #72's hospital progress notes dated 10/06/17 at 12:30 P.M. revealed patient admitted septic yesterday. Resident has been bed-bound for the last several months and is at an extended care facility (ECF). Apparently, emergency room staff found patient on bedpan from the ECF. Interview with the Director of Nursing (DON) on 10/12/17 at 1:30 P.M. revealed the facility received a call from the hospital on [DATE] around 3:00 P.M., informing the facility the resident had been left on the bed pan when she left the facility. The DON stated the facility was unaware of this and immediately started an investigation and in-servicing staff on the facility's bedpan protocol. Interview with the Administrator on 10/18/17 at 3:30 P.M. verified Resident #72 did utilize a metal bed pan. Although the facility completed a thorough investigation, it could not be determined who placed the resident on the bed pan. The resident's bed pan was missing from the facility. During the facility investigation, a facility nurse had observed the resident being lifted utilizing lift sheets by the emergency squad onto the stretcher the day she was transported to the hospital. Prior to the 10/12/17 complaint survey the facility implemented the following corrective action: · On 10/06/17, investigation began when allegation of Resident #72 was left on a bed pan when she left the facility. · On 10/06/17, all residents who utilize the bed pan was assessed and reviewed for the use of a bed pan. · On 10/06/17 at 3:00 P.M. through 10/11/17 6:00 P.M., all nursing staff including nurses and State tested Nurse Aides where in-serviced by the DON on the facility Bed Pan Protocol. · On 10/12/17, review of weekly audits revealed the DON was auditing three times a week the residents utilizing the bed pan and residents being discharged from the facility. · On 10/12/17, review of two additional residents (#17 and #32) medical record reviewed revealed no concerns. This deficiency substantiates the allegations contained in Complaint Number OH 917.

Based on observation and staff interview, the facility failed to properly handle clean kitchen equipment during transportation from the kitchen through hallways of residents' room, to the dining room. The facility identified nineteen residents who attend the dining room (Resident #24, #25, #36, #42, #65, #67, #90, #92, #98, #104, #127, #130, #135, #140, #145, #153, #191, #192, and #193). The facility census was 109. Findings include: Observation of transportation of the breakfast meal from the kitchen to the Autumn Court dining room on 08/05/15 at 7:40 A.M., revealed Dietary Staff (DS) #20 had an insulated cart with four clean serving utensils and two clean tongs uncovered on the top of the insulated cart. The DS had another open cart with four clean water pitchers, all which were uncovered. Both the insulated cart and open cart came from the main kitchen through 200 and part of 400 hallways of residents rooms to the kitchenette located on Autumn Court. Interview with DS #20 on 08/05/15 at 8:06 A.M. confirmed she did not have the four clean serving utensils, two clean tongs, and four clean water pitchers covered while transporting down the hallways and stated she should have probably covered them. Interview with the Administrator on 08/05/15 at 10:59 A.M. stated there was no facility policy regarding handling of utensils and said staff are to use best practice and that is to cover them when going down the hallway.

Based on observation, record review and staff interview, the facility failed to review and revise plans of care for two (Resident #181, Resident #138) of 44 residents reviewed for the plans of care. The facility census was 109 residents. Findings include: 1. Review of Resident #181's clinical record revealed the resident was admitted to the facility with [MEDICAL CONDITION], dysphagia, [MEDICAL CONDITION] of the anus and dementia. Review of Resident #181's physician order [REDACTED]. Review of Resident #181's plan of care dated 05/28/15 revealed the resident had the potential for alteration in nutrition and hydration related to: [MEDICAL CONDITION], altered mental status, risk for impaired swallowing/history of pocketing. Interventions included: assess for signs and symptoms of aspiration. Provide assistance with meals/snacks as necessary and provide diet as ordered. Review of Resident #181's speech evaluation dated 05/29/15 revealed the resident was evaluated for pocketing/fatigue with regular textured food. According to the evaluation,. the resident demonstrated severe cognitive deficits and had minimal progression with the cognitive goals resident #181 had a speech goal to safely consume least restrictive diet with no overt signs or symptoms of dysphagia, using compensatory strategies as trained by the speech pathologist at 100% accuracy. Resident #181 continued to require maximum verbal and visual cues to perform cognitive tasks at 30 to 40% accuracy. At the time of discharge from speech therapy resident #181 was was maintaining an 80% (percent) accuracy rate toward the identified goal. Recommendation by the speech therapist at the time of discharge included: mechanical soft diet/chopped meats with alternating bites and sips and close supervision. With continued use of verbal and visual cues in order to decrease risk of further decline and cognitive abilities. Interview with Unit Manager (UM) #26 on 08/05/15 at 10:48 A.M. revealed she was unaware of the speech recommendations to be prompted to alternate bites of food with sips of liquids. UM #26 verified as of 08/04/15, there was not plan of care developed for the speech therapist recommendation for close supervision during meals and for the resident to be cues to alternate bites of food with sips of liquids. 2. Medical record review revealed Resident #138 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's progress notes revealed on 06/29/15 revealed the resident was reported to have increased agitation and different medications were discussed with a family member. On 07/13/15, Licensed Practical Nurse (LPN) #17 stated the physician was in the facility and discussed resident behavioral outbursts and received new orders for [MEDICATION NAME] 125 mg. No other behaviors were noted in the progress notes from 06/10/15 to 08/04/15. Review of physician orders [REDACTED]. Review of the plan of care (POC) for mood and/or behavioral updated on 08/01/15 revealed, the resident had a [DIAGNOSES REDACTED]. Review of the POC for psychoactive medications updated on 08/01/15 revealed the resident was at risk for adverse effects due to depression and anxiety. The POCs did not include the reported behaviors of increased agitation and behavioral outbursts nor the use of a mood stabilizer. Interview with LPN #17 on 08/15/15 at 4:20 P.M. confirmed the behavior and mood POC and the psychoactive medication POC did not reflect the resident being on a mood stabilizer and the reported behaviors by the resident were not noted on the POC.

Based on observation, record review and staff interview, the facility failed to provide proper wheelchair positioning for one (#7) of one residents reviewed for positioning. The facility census was 109 residents. Findings include: Review of Resident #7's clinical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #7's comprehensive minimum data set (MDS) assessment, dated 06/12/15, revealed the resident required extensive assist of two persons for bed mobility and transfers, and the assistance of one person for dressing, eating and personal hygiene. Review of Resident #7's plan of care (POC) revealed the resident had altered health maintenance related to progressive physical and mental status due to [MEDICAL CONDITIONS], and lower extremity [MEDICAL CONDITION]. Interventions included staff to assist the resident with turning and repositioning as needed. Observation of Resident #7's wheelchair positioning on 08/03/15 at 12:42 P.M. revealed the resident's feet were not positioned properly on the wheelchair footrests. Resident #7's left leg was hanging in between the gap of the two wheelchair footrests. The position of the leg caused Resident #7's left hip to turn in toward the right and caused the left knee to be arched in an upward direction Interview on 08/03/15 at 12:43 P.M. with Registered Nurse (RN) #29 and Unit Manager (UM) #26, verified Resident #7's left leg was hanging in between the gap of the two wheelchair footrests, with the left hip turned in toward the right, and the left knee arched in an upward direction. Interview with Physical Therapist (PT) #30 on 08/04/15 at 2:20 P.M., revealed Resident #7's hips were to be up against the wheelchair backrest at a 90 degree angle. PT #30 stated the back should be no more than four fingers width from the backrest. Resident #7's knees should not be farther than two finger widths from the back of the knee to the edge of the wheelchair seat. The resident's feet should be flush to the wheelchair footrest. If the feet ere too tight the left knee may arch. PT #30 stated the left leg should be straight and not turned in toward the right.

Based on observation, record review and staff interview, the facility failed to provide supervision during meals and to provide interventions to prevent falls. This affected two(Resident #98, #181) of five residents reviewed for accidents/supervision. The facility census was 109 residents. Findings include: 1. Review of Resident #181's clinical record revealed the resident was admitted to the facility with [DIAGNOSES REDACTED], dysphagia, [DIAGNOSES REDACTED] of the anus and dementia. Review of Resident #181's plan of care dated 05/28/15 revealed the resident had the potential for alteration in nutrition and hydration related to:[DIAGNOSES REDACTED], altered mental status, risk for impaired swallow/history of pocketing. Interventions included: Assess for sings and symptoms of aspiration. Provide assistance with meals/snacks as necessary. Provide diet as ordered. Review of Resident #181's speech evaluation dated 05/29/15 revealed the resident was evaluated for pocketing/fatigue with regular textured food. According to the evaluation, the resident demonstrated severe cognitive deficits and had minimal progression with the cognitive goals resident #181 had a speech goal to safely consume least restrictive diet with no overt signs or symptoms of dysphagia, using compensatory strategies as trained by the speech pathologist at 100% accuracy. Resident #181 continued to require maximum verbal and visual cues to perform cognitive tasks at 30 to 40% accuracy. At the time of discharge from speech therapy resident #181 was maintaining an 80-% accuracy rate toward the identified goal. Recommendation by the speech therapist at the time of discharge included: mechanical soft diet/chopped meats with alternating bites and sips and close supervision. With continued use of verbal and visual cues in order to decrease risk of further decline and cognitive abilities. Review of Resident #181's comprehensive assessment dated [DATE] revealed the resident was limited supervision for bed mobility, transfer and eating. Resident #181 was an extensive assist of one person for dressing and personal hygiene. Review of Resident #181's dietary assessment dated [DATE] revealed the resident remained at moderate risk for nutrition/hydration due to [DIAGNOSES REDACTED], altered mental status, impaired swallowing, mechanically altered diet, no mixed consistency foods, double portions and chopped meats. Observation of Resident #181 on 08/03/15 at 11:48 A.M. revealed the resident was seated at a table unsupervised with a napkin torn up and rolled in her potatoes. Resident #181 was eating around the potatoes which had small pieces of paper napkin on the potato. No staff were observed to be supervising or monitoring Resident #181. At 11:53 A.M. Resident #181 was observed eating potatoes with the torn up napkin still on her plate. At 11:55 A.M.,. Resident #181 was asleep at the table with her napkin wrapped up in her plate. The observation was verified with the Register Nurse (RN) #27 at 11:54 A.M. Interview with Registered Nurse (RN) #27 on 08/05/15 at 10:30 A.M. verified she was unaware Resident #181 had speech recommendations to be closely supervised and to alternate bites of food with sips of liquids. Interview with Unit Manager (UM) #26 on 08/05/15 at 10:48 A.M. revealed she was unaware of the speech recommendations to be prompted to alternate bites of food with sips of liquids. 2. Medical record review revealed Resident #98 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital records dated 06/08/15 revealed the resident had a history of [REDACTED]. She presented to the hospital with status [REDACTED]. Review of the Care Plan Cover form dated 06/10/15 did not include any safety interventions in place and the admission care plan dated 06/10/15 stated the resident was at risk for falls due to history and weakness and interventions included were to place the resident close to the nursing station, call light within reach, and glasses on when out of bed. Review of fall risk assessment dated [DATE] revealed the resident was at risk for falls. Review of Resident #98's fall plan of care (POC) dated 06/18/15 revealed the resident had a history of [REDACTED]. Goals included for the resident to have no falls and sustain no injury from falls. Interventions included low bed for fall prevention, provide assistance with one to two with all transfers, have commonly used articles within reach, reinforce need to call for assistance, resident education, and to wear proper and non-slip footwear. The POC was updated on 07/02/15 to include a call light sensor pad and later was discontinued without a date specified. On 07/09/15 the resident was moved closer to the nurse's station and the call light sensor pad would be discontinued. The POC was further updated on 07/12/15 to re-instate the call light sensor pad to the bed and chair and later was also discontinued without a date specified. Review of the resident's progress notes dated 07/02/15 revealed the resident was found on the floor and was found sitting on her bottom in front of the toilet. A skin tear was noted to the left elbow measuring 0.5 centimeters (cm) by 0.5 cm. and the skin tear was cleansed with normal saline, patted dry, triple antibiotic ointment applied and a band aid. The new intervention was for an alarm to wheelchair to notify the staff if the resident attempts to transfer without assistance. Review of the Fall Investigation form dated 07/02/15 revealed the resident's current plan of care included a low bed and the resident had a fall from a chair and the resident was noncompliant at the time of the fall. Observations of the time of all included no shoes on and the resident's wheelchair was out of reach. The Fall Investigation form under observations stated if non slip socks were on or off and this was not marked either one. New fall interventions included chair alarm and a call sensor pad to bed. Review of physician orders [REDACTED]. The resident's progress dated 07/09/15 noted the resident was lethargic and had periods of confusion. Further review of the physician orders [REDACTED]. Review of the resident's progress notes revealed on 07/12/15 at 4:00 A.M. the resident was sitting in her recliner and her wheelchair was beside her recliner and within reach. The resident tried to transfer from her recliner to her wheelchair and lost her balance and fell in front of the recliner chair. The resident did not use her call light. The resident was found laying on her right side and the resident was bleeding from her left hand and above her right side of her eye brow. The skin tear on her left hand measured 1 cm by 0.5 cm and the raised area over her right eyebrow in the center of the raised area was a laceration measuring 1 cm. by 0.5 cm with depth of 0.3 cm. and surrounding the raised areas was dark purple and swelling. New interventions were to apply bed alarm and chair alarm. Another note on 07/12/15 at 6:00 A.M. revealed the laceration above the right eyebrow was actively bleeding and more depth noted the first assessment and notified the physician and the physician ordered for the resident to be sent to the hospital. Review of the emergency room progress noted on 07/12/15 revealed the right side of the resident's forehead and the wound on her left hand was cleansed and irrigated. Steri strips were applied to the wound on the left hand and glue was applied to the wound on the forehead. Review of the Fall Investigation dated 07/12/15 revealed there was an unknown history of previous falls and unknown previous history of fall with injury. Observations at time of fall included the resident had no shoes on and did not include if the non-slip socks were on or off. The new interventions was for a bed and chair alarm. Observation of Resident #98 on 08/05/15 at 8:12 A.M. revealed the resident was leaning forward in her wheelchair in her room unsupervised and her eyes were closed head was nodding back and forth and her call light was not within reach. Unit Manager (UM) #17 entered Resident #98 room and offered to take the resident to the dining room for breakfast. Further observation with the UM revealed the call light was attached to behind the recliner and was not near the resident's wheelchair. Interview with UM #17 on 08/05/15 at 8:15 A.M. verified the call light was not within reach. Interview with the Director of Nursing (DON) on 08/06/15 at 8:30 A.M. verified the fall investigation on 07/02/15 did not indicate whether the residents non-slip socks were on or off and the fall POC stated for the resident to have proper, non-slip footwear. The fall investigation also documented the resident's wheelchair was not within reach and the fall POC stated to keep commonly used items within reach. The DON also verified the fall investigation on 07/12/15 stated fall history and fall history with injury was unknown and it did not state if the non-slip socks were on or off. Interview with UM #17 and the DON on 08/06/15 at 8:45 A.M. verified the resident was started on an antibiotic on 07/08/15 and was noted to have increased confusion and the wheelchair alarm was discontinued on 07/09/15. The UM stated they moved her closer to the nurse's station and that is why they discontinued the wheelchair alarm.

Based on medical record review, staff interviews, review of facility policy and procedures, review of hospital laboratory results, review of facility laboratory results and review of Web MD.com "Drugs and Medication", the facility failed to monitor therapeutic blood levels for one resident (#1) of 13 sampled residents who received [MEDICATION NAME], an oral anticoagulant (blood thinning) medication. This resulted in Immediate Jeopardy for Resident #1 who received anticoagulant medication for ten (10) days without any laboratory tests completed to monitor for therapeutic blood levels. The facility identified 13 of 110 residents currently residing in the facility who were receiving anticoagulant therapy. On 05/24/13 at 5:30 P.M., the Administrator, Director of Nursing (DON), Corporate Director of Operations (CDOO) #1, Assistant Director of Nursing (ADON) #2 , and Skilled Unit Manager Licensed Practical Nurse (LPN) #3 were notified that Immediate Jeopardy began on 05/13/13, when the facility failed to implement a physician order to monitor Resident #1's [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) blood levels twice a week, every Monday and Thursday, since admission to the facility on [DATE]. Resident #1 continued to receive the anticoagulant medication [MEDICATION NAME] 10 milligrams (mg), daily for six days without PT/INR blood monitoring. On 05/19/13 at 7:53 A.M., the resident was found to be confused, lethargic and incontinent of urine. The resident stated, at this time, he felt like his brain was not working with his body. At 10:42 A.M., the resident remained confused, lethargic and again was incontinent of urine. At approximately 12:36 P.M., the resident was transferred to the emergency department where he was found to have a critical elevation of his bleeding time, (PT/INR) with [MEDICATION NAME] Time measuring 98.8 (normal 11.8 to 14.3), and an INR of 14.1 (normal 2.0 to 3.0). The resident was given two doses of Vitamin K, and two units of packed red blood cells to bring the PT/INR down to a safe level. The resident was admitted to the hospital with [REDACTED]. The Immediate Jeopardy was removed and the deficiency was corrected on 05/23/13 at 9:45 P.M., when the facility implemented the following corrective actions: ? On 05/23/13, the DON, ADON #2 and CDOO #1, audited the medical records of all residents to ensure every resident on anticoagulant therapy had current physician and laboratory orders, including PT/INR, and the laboratory blood work results were being obtained as ordered and the physician was notified of the results. Audits were completed at 2:00 P.M., for all 13 residents currently receiving [MEDICATION NAME] therapy. ? On 05/23/13 at 2:30 P.M., the DON, ADON #2 and CDOO #1, verified all 13 residents who were on anticoagulant therapy, had a current "PT/INR Flow Sheet " placed in their Medication Administration Record (MAR). There were no other residents identified who were not receiving their anticoagulant therapy and PT/INR blood levels as ordered. ? On 05/23/13, the facility in-serviced all licensed nursing staff beginning at 3:00 P.M., on [MEDICATION NAME] administration, PT/INR monitoring, the laboratory ordering procedure with a new process initiated and in effect 05/23/13, and monitoring residents for a change in condition. The in-services were completed on 05/23/13 at 9:45 P.M. ? On 05/24/13 from 5:10 P.M. through 5:35 P.M., LPNs #5 and #6 and RNs #4 and #6 were interviewed and verbalized knowledge of the facility's new laboratory procedure, [MEDICATION NAME] administration, the PT/INR monitoring process, and monitoring residents for change in condition. ? On 05/24/13 at 5:00 P.M. through 5:40 P.M., the PT/INR flow sheets were reviewed for all 13 residents (#28, #14, #4, #27, #35, #56, #25, #101, #88, #86, #91, #93 and #89) currently receiving [MEDICATION NAME] therapy to verify residents were receiving PT/INR monitoring as ordered by the physician, and results were monitored and reported to the physician. All 13 residents were found to have current PT/INR results and proper notification as ordered by the physician. Findings include: Review of Resident #1's medical record revealed an admitted to the facility on [DATE] following a left total knee replacement. The resident had [DIAGNOSES REDACTED]. Admission physician orders dated 05/09/13, revealed Resident #1 was to receive [MEDICATION NAME] 10 mg daily. The 05/09/13 physician's orders included an order for [REDACTED]. Review of the admission minimum data set (MDS) assessment dated [DATE], indicated the resident was alert and oriented with good short and long term memory and was always continent of bladder. Review of Resident #1's May 2013 MAR, revealed the resident received [MEDICATION NAME] 10 mg daily from 05/09/13 through 05/18/13, for ten (10) daily doses. According to Web MD.com, "Drugs and Medication", [MEDICATION NAME] is used to decrease the blood clotting time and can cause very serious (possibly fatal) bleeding. This is more likely to occur when [MEDICATION NAME] is first started or if too much [MEDICATION NAME] is taken. To decrease the risk for bleeding, the health care provider will monitor closely and check laboratory results (INR test) to make sure the individual is not taking too much [MEDICATION NAME]. Review of the laboratory results revealed no PT/INR's were completed for the resident, and [MEDICATION NAME] 10 mg continued to be given daily to the resident. Review of nursing notes dated 05/19/13 at 7:53 A.M., documented by night shift nurse LPN #7, revealed LPN #7 entered the resident's room and noted the resident was confused, lethargic and incontinent of urine. Staff attempted to transfer the resident to a wheelchair but they were unsuccessful due to the resident's lethargy. The resident stated he feels like "my brain is not working with my body." Further review of the notes revealed the day shift nurse was aware and will continue to monitor the resident and notify the physician if the resident's condition does not improve. Nursing notes dated 05/19/13 at 10:46 A.M., documented by day shift Registered Nurse (RN) #8, revealed the resident continued to be confused and was incontinent of urine. The resident was sweating profusely and pale although all vitals were within normal limits. The physician was notified of the change in condition and ordered the resident to be transferred to the hospital for evaluation. Review of the hospital "History and Physical" dated 05/19/13, included laboratory results which indicated Resident #1 was found to have a critical elevation of his bleeding time (PT/INR), with [MEDICATION NAME] Time being 98.8 (normal 11.8 to 14.3), and an INR of 14.1 (normal 2.0 to 3.0). The resident was given two doses of Vitamin K, and two units of packed red blood cells to bring the PT/INR down to a safe level. The resident was admitted to the hospital with [REDACTED]. Interview with CDOO #1 on 05/23/13 at 5:00 P.M., revealed on 05/23/13 at 10:39 A.M, LPN #3 informed her Resident #1 had not had any PT/INR blood tests drawn from the time of admission to the facility on [DATE] through the time of discharge to the hospital on [DATE]. Interview with LPN #3 on 05/24/13 at 4:45 P.M., verified Resident #1's admitting physician orders dated 05/09/13, indicated the resident was to have a PT/INR blood test twice a week. She stated all PT/INR blood tests were completed on Mondays and Thursdays unless otherwise specified by the physician. LPN #3 further verified Resident #1's PT/INR blood test should have been drawn on 05/13/13 and 05/16/13 and that no PT/INR blood tests were drawn while the resident was residing in the facility. LPN #3 also verified Resident #1 did not have a "PT/INR Flow Sheet" in the MAR. Review of the facility policy entitled, "[MEDICATION NAME] Best Practice", dated 04/17/13, revealed on admission to the facility, residents on [MEDICATION NAME] should have an initial PT/INR drawn on the first available lab day following admission to obtain a baseline for the resident. The policy also indicated [MEDICATION NAME] administration will be given after 4:00 P.M. to assure PT/INR results are received prior to the dose given. A PT/INR Flow Sheet will be placed in the residents MAR and copied on brightly colored card stock. This deficiency substantiates Complaint Number OH 294.

Based on medical record review, staff interview, and review of hospital records, the facility failed to implement physician orders accurately and in a timely manner for one resident which delayed care and treatment. This affected one resident (#100) of four residents reviewed for care and treatment and following physician orders. This resulted in actual harm when laboratory tests and x-rays were not completed as ordered by the physician and Resident #100 suffered respiratory distress and required hospitalization for treatment. The facility census was 110. Findings include: Review of Resident # 100 medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission physician orders dated 05/13/13 revealed the resident was to be provided a skilled level of care. The physician orders include blood sugar check before meals and at bedtime with a sliding scale of insulin for coverage of elevated blood sugars. On 05/17/13 a physician order to change the insulin sliding scale to obtaining blood sugars before meals and at bedtime and administering [MEDICATION NAME] regular insulin as follows: four units regular insulin for blood sugars between 200 - 249; six units regular insulin for blood sugar between 250 - 299; eight units of regular insulin for blood sugars between 300- 349; ten units regular insulin for blood sugars between 350-399; twelve units regular insulin for blood sugars between 400 - 449; and for any blood sugars 450 or higher the physician was to be notified. Review of the May 2013 Medication Administration Record, [REDACTED].M., Resident's #100 blood sugar was 471 and fifteen units of regular insulin was given. Review of the physician telephone orders revealed no physician order for [REDACTED]. Review of the nursing progress notes and skilled nursing notes dated 05/19/13 at 4:00 P.M,. revealed no documentation of the resident's elevated blood sugar of 471 or physician notification. Further review of the May 2013 MAR indicated [REDACTED].M., Resident #100's blood sugar was 469, and twelve units of regular insulin was administered. Review of the physician telephone orders revealed no physician order for [REDACTED]. Review of the nursing progress notes and skilled nursing notes dated 05/22/13 at 11:00 A.M., revealed no documentation of the resident's elevated blood sugar of 469 or physician notification. On 05/24/13 at 11:54 A.M. the Director of Nursing (DON) verified that there was no physician order to give the fifteen units of regular insulin on 05/19/13 at 4:00 P.M., or twelve units regular insulin on 05/22/13 at 11:00 A.M. Review of physician progress notes [REDACTED]. The resident has Diabetes Type II verses [DIAGNOSES REDACTED]. The plan is stated to include laboratory blood test including blood cultures and to adjust the resident's insulin dosage. Review of the physician orders revealed an order written [REDACTED].M., requesting laboratory blood work including a complete blood count, renal panel, glucose, blood culture and urinalysis with a culture and sensitivity and a posterior, anterior and lateral view chest x-ray due to Resident #100 experiencing coughing, shortness of breath and fever. The order specified that the laboratory blood work and chest x-ray was to rule out pneumonia [MEDICAL CONDITION]. Review of the nursing progress notes dated 05/22/13 at 11:08 A.M., written by Registered Nurse (RN) #8, states that a laboratory blood work including a complete blood count, renal panel, glucose, blood culture and urinalysis with a culture and sensitivity was ordered to be drawn due Resident #100 having increased lethargy and fever. Review of the chest x-ray results dated 05/22/13 at 10:26 P.M., stated that a single view of the frontal chest was done the results stated that the lungs were free of infiltrates and local consolidations. There was no evidence of the posterior and lateral chest x-rays were completed. Review of the laboratory blood tests results revealed that the blood tests were not completed on 05/22/13. Review of nursing notes dated 05/23/13 at 6:30 A.M., states that Resident #100 was having difficulty breathing and appeared to be in respiratory distress. The resident's oxygen saturation level was 63% on room air. Oxygen was applied to the resident per nasal cannula which brought the residents oxygen saturations up to 89 %. The resident's breathing remained labored. The physician was notified and the resident was transported to the hospital emergency room . Review of the hospital,"History and Physical" dated 05/23/13, stated under "History of Present Illness", that Resident #100 was brought to the emergency room by emergency squad with hypoxemia (deficiency of oxygen in arterial blood) and decreased alertness. Records of his oxygen saturation level reveal his levels were as low as 50 -60%. It was noted that he had been getting weaker with confusion over the past three days at the nursing home. Review of the hospital chest x-ray posterior, anterior, and lateral views dated 05/23/13 at 10:25 A.M., states there are small pleural effusions. The resident was admitted to the hospital with [REDACTED]. On 05/24/13 at 11:54 A.M., during an interview with the DON, she verified that the laboratory blood work ordered on [DATE] at approximately 11:00 A.M., was not drawn by the laboratory until 6:00 A.M. on 05/23/13, prior to the resident going to the hospital. She verified that the chest x-ray completed on 05/22/13, was a frontal view only and that the physician order stated that an anterior, posterior and lateral view chest x-ray was to be done. She stated that it was her expectation that the laboratory blood work would have been completed on 05/22/13, based on the condition of the resident. This deficiency substantiates Complaint Number OH 294