Every finding on record at Crystal Care of Coal Grove

Based on record review and staff interview the facility failed to ensure comprehensive care plans to address Post Traumatic Stress Disorder (PTSD) and suicidal ideations were initiated. This affected two Residents (#3 and #4) of 18 resident care plans reviewed. The facility census was 53. Findings include:1.Review of the medical record for Resident #3 revealed an admission date of 02/11/25 and a readmission date of 07/25/25 with diagnoses including Post Traumatic Stress Disorder (PTSD), insomnia, anxiety, depression, diabetes mellitus type two and bilateral above the knee amputations. Review of the five day Medicare minimum data set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact with no behaviors. Resident #3 needed assistance from the staff to complete activities of daily living. Resident #3 had diagnoses of PTSD, anxiety and depression. Review of the plan of care for Resident #3 revealed no plan of care addressing the PTSD cause, resident triggers, resident reaction behaviors and staff interventions. Interview on 09/11/25 at 8:40 A.M. with the Administrator confirmed Resident #3 had diagnosis of PTSD and the care plan did not address the cause of the PTSD, the resident triggers, resident reaction behaviors and staff plan of action or interventions. 2.Review of the medical record for Resident #4 revealed an admission date of 01/03/23 and readmission date of 04/01/25 with diagnoses including senile degeneration of the brain, anxiety, suicidal ideations, seizure disorder, chronic kidney disease stage three, dementia and malignant neoplasm of overlapping sites of rectum, anus and anal canal. Review of the physician orders dated 09/25 revealed Resident #4 received Depakote sprinkles 125 milligrams (mg) by mouth two times daily for suicidal ideations and depression. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 had severe cognitive impairment with inattention, disorganized thinking, hallucination, delusions, verbal behaviors towards others and rejection of care. Resident #4 was dependent on the staff to complete activities of daily living. Resident #4 had diagnoses including dementia, anxiety, depression and suicidal ideations. Resident #4 received antianxiety, antidepressant and anticonvulsant medications. Review of the care plan for Resident #4 revealed there was not a care plan addressing the resident's suicidal ideations. Interview on 09/10/25 at 2:47 P.M. with Certified Nursing Assistant (CNA) #470 stated there was nothing on Resident #4 point of care documentation about the resident having suicidal ideations.Interview on 09/11/25 at 8:40 A.M. with the Administrator confirmed Resident #4 had a diagnosis of suicidal ideations, received medication for suicidal ideations and did not have a plan of care addressing the suicidal ideations.

Based on resident record review and staff interview the facility failed to ensure there were parameters in place for administration of as needed pain medications and non-pharmacological interventions. This affected one resident (#5) of four residents reviewed for pain management. The facility census was 53.Findings include:Review of the medical record for Resident #5 revealed an admission date of 07/25/25 with diagnoses including chronic kidney disease stage three, unspecified psychosis, rheumatoid arthritis, diabetes mellitus and malignant nodule of the lung. Review of the Medication Administration Record (MAR) dated 08/25 and 09/25 revealed Resident #5 received Tylenol 650 milligrams (mg) by mouth every eight hours as needed for pain, Tramadol 50mg by mouth every six hours as needed for pain and no nonpharmacological interventions were ordered. Additionally, no pain level parameters noted of when to administer each medication. Review of the significant change in status Minimum Data Set (MDS) dated [DATE] revealed Resident #5 was cognitively intact with verbal and physical behaviors towards others. Resident #5 was dependent on staff assistance for activities of daily living.Review of the plan of care initiated on 12/22/24 revealed Resident #5 would verbalize adequate relief of pain or the ability to cope with incompletely relieved pain. The goal stated Resident #5 would display a decrease in behaviors of irritability, agitation, restlessness, grimacing, hyperventilation, groaning and crying through the review date. The interventions included: administer medications as ordered, notify the physician as needed, nonpharmacological interventions, observe for side effects of pain medication, observe for signs and symptoms of nonverbal pain and provide therapy as needed. Interview on 09/10/25 at 9:10 A.M. with Resident #5 revealed no expressions or verbalization of pain. Interview on 09/10/25 at 2:55 P.M. with Licensed Practical Nurse (LPN) #200 confirmed Resident #5 did not have nonpharmacological interventions for pain. LPN #200 also stated if a resident had two as needed pain medications, she would administer one or the other based on the resident's pain level.Interview on 09/11/25 at 8:40 A.M. with the Administrator confirmed Resident #5 was ordered and received two different pain medications as needed without directions or parameters of what pain level to administer each one.Review of the Assessment, Intervention of as Needed Medication for Behavior and Pain Policy revised 09/2020 revealed the facility would evaluate and assess the resident's signs and symptoms, identify the specific area and type of pain, and attempt to use non-medication interventions to redirect, stop or reduce the identified pain such as one on one attention, redirection, repositioning and activities.

Based on medical record review, resident and staff interviews, and review of facility policy, the facility failed to provide an adequate plan of care for post-traumatic stress disorder and ensure staff were knowledgeable in the plan of care. This affected one (Resident #20) of three residents reviewed for mood and behavior. The facility census was 53.Findings include:1. Review of the medical record for Resident #20 revealed an admission date of 03/02/25. Diagnoses included PTSD, anxiety disorder, and depression.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 was cognitively intact and was able to make her needs known.Review of the trauma evaluation dated 03/02/25 revealed Resident #20 had experienced emotional abuse from earlier in her life with triggers of being in large crowds. Symptoms due to her PTSD included difficulty sleeping, fear, severe anxiety, and feelings of guilt or shame. Triggers included large groups of people.Review of the care plan dated 05/02/24 revealed Resident #20 did not have a specific plan of care in place that addressed post-traumatic stress disorder. The care plan did not identify any triggers that may help caregivers to not be re-traumatized.Interviews with Certified Nursing Assistants #280 and #410 on 09/10/25 at 2:25 P.M. denied knowledge of specific triggers and care planning involved with post-traumatic stress disorder.Interview with the Administrator on 09/11/25 at 1:02 P.M. confirmed Resident #20's care plan did not include identified triggers that may re-traumatize Resident #20 and acknowledged that staff were not aware of this plan of care.

Based on resident record review, staff interview and review of facility policy the facility failed to implement pharmacy recommendations. This affected two Residents (#5 and #42) of five residents reviewed for unnecessary medications. The facility census was 53. Findings include: 1.Review of the medical record for Resident #5 revealed an admission date of 07/25/25 with diagnoses including chronic kidney disease stage three, unspecified psychosis, rheumatoid arthritis, diabetes mellitus, delusional disorder, schizoaffective disorder, major depressive disorder and malignant nodule of the lung. Review of the Medication Administration Record (MAR) dated 04/25, 05/25, 06/25, 07/25 and 08/25 revealed Resident #5 received Divalproex Sodium Sprinkles 125 milligrams (mg) by mouth, give four capsules to equal 500mg three times daily for schizoaffective disorder.Review of the pharmacy recommendations for Resident #5 dated 04/05/25 revealed Resident #5 was receiving the medication Depakote. The recommendation requested labs of complete blood count and serum Depakote level on next lab day. The physician agreed and signed the recommendation on 04/22/25.There was not a Depakote level noted in Resident #5 medical record during the month of 05/25.An interview on 09/11/25 at 8:40 A.M. with the Administrator confirmed Resident #5 had a pharmacy recommendation that was agreed upon and signed by the physician on 04/22/25 to obtain a complete blood count and a Depakote level. The Administrator confirmed Resident #5 had a complete blood count completed but no evidence of a Depakote level were noted in Resident #5 medical record.2.Review of the medical record for Resident #42 revealed an admission date of 07/23/24 with diagnoses including hypothyroidism, chronic obstructive pulmonary disorder, Atrial fibrillation and schizophrenia.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #42 was cognitively intact. Resident #42 required assistance from the staff to complete activities of daily living. The assessment revealed Resident #42 antipsychotic medications were reviewed on routine basis with no gradual dose reduction and last physician documentation was on 03/25/25.Review of the pharmacy recommendation dated 06/24/25 with a recommendation to attempt a gradual dose reduction of Resident #42 Trazadone medication. The physician agreed to decrease the medication to 75 mg by mouth at bedtime. Review of the current physician orders dated 09/25 revealed Resident #42 had an order written on 05/30/25 for Trazadone 100 milligrams (mg) by mouth at bedtime for schizophrenia. The record did not include any information the medication was reduced as ordered by the physician on 06/24/25. An interview on 09/11/25 at 8:40 A.M. with the Administrator confirmed Resident #42 had a pharmacy recommendation that was agreed upon and signed by the physician on 06/24/25 to decrease the medication Trazadone. The Administrator confirmed Resident #42 medication was not reduced as ordered by the physician.Review of the facility policy titled Consult Pharmacist Reports effective 07/02/2021 revealed the consult pharmacist reviews each resident's medication regimen and clinical record at least monthly. The policy also stated the consultant pharmacist communicated all recommendations to those with authority and or responsibility to implement the recommendations in a timely manner.

Based on record reviews and staff interview, the facility failed to ensure vital signs were monitored as ordered prior to the administration of medication. This affected one resident (#2) out of the five residents reviewed for unnecessary medications. The facility census was 53. Findings include:Record review for Resident #2 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included hypertension, bipolar disorder, and depression.Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/18/25, revealed the resident was assessed to have intact cognition.Review of the active physicians order, dated 11/02/24, revealed the resident was to be administered 25 milligrams of Metoprolol (an anti-hypertensive medication) twice a day for hypertension and to hold medication for pulse below 60. Review of the Medication Administration Record (MAR) and recorded vital signs from 09/01/25 through 09/11/25 revealed no evidence the residents pulse was obtained prior to the administration of Metoprolol. Interview with the Director of Nursing (DON) and Administrator on 09/11/25 at 12:35 P.M. confirmed there was no evidence Resident #2's pulse had been obtained as ordered prior to the administration of Metoprolol.

Based on record review, staff interview, observation, resident interview, and review of facility policy, the facility failed to ensure dependent residents received assistance with incontinence care and eating. This affected three (Residents #23, #47, #53) of 37 facility-identified incontinent residents and affected one (Resident #53) of five facility-identified residents who required physical assistance with meal consumption. The facility census was 52. Findings include: Review of the lists provided by the facility revealed there were 37 residents (#1 #3, #4, #5, #8, #9, #10, #11, #15, #16, #17, #18, #19, #21, #22, #23, #27, #28, #30, #32, #34, #35, #36, #37, #38, #39, #41, #42, #44, #45, #46, #47, #49, #51, and #52) identified as being incontinent of bowel and/or bladder and five residents (#4, #47, #53, #44, and #49) who required physical assistance from staff for eating. 1. Review of the medical record for Resident #53 revealed an admitted [DATE] with diagnoses including depression, hypertension, anxiety, and age-related cognitive decline. Review of the Minimum Data Set (MDS) assessment for Resident #53 dated 01/30/24 revealed the resident was severely cognitively impaired and was always incontinent of bowel and bladder. Review of the care plan for Resident #53 dated 02/16/24 revealed the resident had an activities of daily living (ADL) care deficit related to memory impairment and decreased mobility. Interventions included the staff should provide assistance with toileting and personal hygiene. Observation on 03/25/24 at 8:45 A.M. revealed Resident #53 was lying in bed and was wearing a urine-saturated brief. Interview on 03/25/24 at 8:45 A.M. with STNA #100 confirmed Resident #53 wearing a urine-saturated brief on and had not been provided incontinence care since prior to the beginning of the shift which began at 6:00 A.M. 2. Observation on 03/25/24 at 8:55 A.M. revealed Resident #47 was walking down the hallway with a soiled brief which caused the resident's pants to sag and to be wet with urine. Interview on 03/25/24 at 8:55 A.M. with STNA #100 confirmed Resident #47 was wearing a urine-saturated brief and had not been provided incontinence care since prior to the beginning of the shift which began at 6:00 A.M. 3. Review of the medical record for Resident #23 revealed an admitted [DATE] with diagnoses including Parkinson's disease, muscle weakness, and abnormal posture. Review of the MDS assessment for Resident #23 dated 12/19/23 revealed the resident had mildly impaired cognition and was occasionally incontinent of bowel and bladder. Review of the care plan for Resident #23 dated 12/13/23 revealed the resident was incontinent of bladder. Interventions included staff should check for incontinence as needed and provide peri-care after each incontinence episode. Interview on 03/25/24 at 9:10 A.M with Resident #23 confirmed staff did not consistently provide incontinence care every two hours, and sometimes it was several hours between incontinence changes. Observation on 03/25/24 at 9:20 A.M. revealed STNA #400 entered Resident #23's room to provide incontinence care. STNA #400 pulled Resident #23's gown up which revealed the resident was wearing two incontinence briefs. STNA #400 removed the briefs and there was a large amount of light brown urine on the brief closest to the resident's skin which emitted a strong urine odor. STNA #400 proceeded to cleanse and dry the resident's perineum and buttocks and then placed one clean incontinence brief on the resident. Interview on 03/25/24 at 9:25 A.M. with STNA #400 confirmed Resident #23 had been wearing two incontinence briefs. STNA #400 confirmed residents were only supposed to wear only one incontinence brief at a time. STNA #400 further confirmed her shift had begun at 6:00 A.M. and she had not provided incontinence care to Resident #23 prior to the observation on 03/25/24 at 9:20 A.M. STNA #400 confirmed incontinence care should be provided every two hours. Interview on 03/25/24 at 9:27 A.M with Resident #23 confirmed she had not received incontinence care on 03/25/24 on dayshift until 9:20 A.M. and the shift began at 6:00 A.M. Resident #23 further confirmed night shift staff sometimes applied two incontinence briefs at once but was unsure as to why they did this. 4. Observation on 03/25/24 at 12:27 P.M. revealed the cart containing the residents' lunch meals arrived on the secured unit. At 12:30 P.M. STNA #100 began preparing the meal trays and serve them to residents. Review of the MDS assessment for Resident #53 dated 01/30/24 revealed the resident was severely cognitively impaired and required substantial to moderate assistance of staff with eating. Review of the care plan for Resident #53 dated 02/16/24 revealed the resident had an ADL deficit related to memory impairment and decreased mobility. Interventions included the staff should provide assistance with eating and bed mobility. Observation on 03/25/24 at 12:45 P.M. revealed State tested Nursing Assistant (STNA) #100 set up Resident #53's lunch tray on the resident's overbed table and awakened the resident and raised the head of the bed. STNA #100 then exited the room and left the resident unattended with the lunch meals. Observation on 03/25/24 at 1:01 P.M. revealed STNA #100 removed the last lunch meal tray from the cart and took it to a resident. Observation on 03/25/24 at 1:07 P.M. revealed Resident #53 was slumped over to the left side with her head resting against the wall. The resident held a roll in her hand which she was attempting to eat. The remainder of the resident's lunch meal was on the overbed table but was out of the resident's reach. The resident was unable to reposition herself in the bed. Interview on 03/25/24 at 1:11 P.M. with STNA #100 confirmed Resident #53 was slumped over in bed unable to reach her lunch meal tray as she was unable to reposition herself. STNA #100 further confirmed Resident #53 required assistance with eating and she had not provided assistance to the resident. Review of the facility policy titled Incontinence Management Standard of Care undated revealed the facility would promote intact skin, maintain dryness, and respect the resident's standard and individualized interventions and right to dignity by implementing appropriate interventions. Interventions included routine rounding every two hours with turning and repositioning, provision of personal hygiene and skin care after each incontinence episode, and evaluation for and implementation and the proper use of incontinence products. Review of the facility policy titled Assisting the Resident with In-Room Meals dated December 2013 revealed for meal consumption residents should be positioned so their head and upper body are as upright as possible with the head tipped slightly forward. If the resident was served their meal in bed staff should use wedges and pillows to achieve a nearly upright position. Staff should assist the resident with eating as necessary. This deficiency represents noncompliance investigated under Complaint Number OH00152025.

Based on record review, staff interview, observation, resident interview, and review of facility policy, the facility failed to ensure there were sufficient staff present to provide care and services to residents. This affected three (Residents #23, #47, #53) of 37 facility-identified incontinent residents and affected one (Resident #53) of five facility-identified residents who required physical assistance with meal consumption. The facility census was 52. Findings include: Review of the lists provided by the facility revealed there were 37 residents (#1 #3, #4, #5, #8, #9, #10, #11, #15, #16, #17, #18, #19, #21, #22, #23, #27, #28, #30, #32, #34, #35, #36, #37, #38, #39, #41, #42, #44, #45, #46, #47, #49, #51, and #52) identified as being incontinent of bowel and/or bladder and five residents (#4, #47, #53, #44, and #49) who required physical assistance from staff for eating. Observation on 03/25/24 at 8:25 A.M. revealed there were two licensed nurses and three State tested Nursing Assistants (STNAs) present in the facility to provide care for 52 residents. Interview on 03/25/24 at 8:27 A.M with Registered Nurse (RN) #600 confirmed there were only three STNAs working due to one STNA calling off work for the day. RN #600 confirmed the nurses were busy administering medications to residents and did not have time to help the STNAs provide personal care. RN #600 confirmed it was hard to provide needed care and services to residents present in the facility when there were only three STNAs. Interview on 03/25/23 at 8:35 A.M. with STNA #100 confirmed they were the only employee currently present on the secured unit of the facility. The two nurses and two other STNAs were providing care to the residents outside of the secured unit. STNA #100 confirmed some of the residents on the secured unit required assistance from two staff members with activities of daily living (ADLs) due to behaviors and their physical needs. STNA #100 confirmed some residents on the secured unit were currently soiled with urine as there had not been time to complete incontinence care for any residents on the unit since the shift had begun at 6:00 A.M. on 03/25/24. 1. Review of the medical record for Resident #53 revealed an admitted [DATE] with diagnoses including depression, hypertension, anxiety, and age-related cognitive decline. Review of the Minimum Data Set (MDS) assessment for Resident #53 dated 01/30/24 revealed the resident was severely cognitively impaired and was always incontinent of bowel and bladder. Review of the care plan for Resident #53 dated 02/16/24 revealed the resident had an activities of daily living (ADL) care deficit related to memory impairment and decreased mobility. Interventions included the staff should provide assistance with toileting and personal hygiene. Observation on 03/25/24 at 8:45 A.M. revealed Resident #53 was lying in bed and was wearing a urine-saturated brief. Interview on 03/25/24 at 8:45 A.M. with STNA #100 confirmed Resident #53 wearing a urine-saturated brief on and had not been provided incontinence care since prior to the beginning of the shift which began at 6:00 A.M. because there were not enough staff. 2. Observation on 03/25/24 at 8:55 A.M. revealed Resident #47 was walking down the hallway with a soiled brief which caused the resident's pants to sag and to be wet with urine. Interview on 03/25/24 at 8:55 A.M. with STNA #100 confirmed Resident #47 had not been provided incontinence care since prior to the beginning of the shift which began at 6:00 A.M. because there were not enough staff. Interview on 03/25/24 at 9:05 A.M. with STNA #300 confirmed they were working on the middle unit of the facility (outside of the secured unit) and they were not able to help the STNA on the secured unit because there were not enough staff. 3. Review of the medical record for Resident #23 revealed an admitted [DATE] with diagnoses including Parkinson's disease, muscle weakness, and abnormal posture. Review of the MDS assessment for Resident #23 dated 12/19/23 revealed the resident had mildly impaired cognition and was occasionally incontinent of bowel and bladder. Review of the care plan for Resident #23 dated 12/13/23 revealed the resident was incontinent of bladder. Interventions included staff should check for incontinence as needed and provide peri-care after each incontinence episode. Interview on 03/25/24 at 9:10 A.M with Resident #23 confirmed staff did not consistently provide incontinence care every two hours, and sometimes it was several hours between incontinence changes. Observation on 03/25/24 at 9:20 A.M. revealed STNA #400 entered Resident #23's room to provide incontinence care. STNA #400 pulled Resident #23's gown up which revealed the resident was wearing two incontinence briefs. STNA #400 removed the briefs and there was a large amount of light brown urine on the brief closest to the resident's skin which emitted a strong urine odor. STNA #400 proceeded to cleanse and dry the resident's perineum and buttocks and then placed one clean incontinence brief on the resident. Interview on 03/25/24 at 9:25 A.M. with STNA #400 confirmed Resident #23 had been wearing two incontinence briefs. STNA #400 confirmed residents were only supposed to wear only one incontinence brief at a time. STNA #400 further confirmed her shift had begun at 6:00 A.M. and she had not provided incontinence care to Resident #23 prior to the observation on 03/25/24 at 9:20 A.M. STNA #400 confirmed incontinence care should be provided every two hours. Interview on 03/25/24 at 9:27 A.M with Resident #23 confirmed she had not received incontinence care on 03/25/24 on dayshift until 9:20 A.M. and the shift began at 6:00 A.M. Resident #23 further confirmed night shift staff sometimes applied two incontinence briefs at once but was unsure as to why they did this. Interview with STNA #300 on 03/25/24 at 11:01 A.M. confirmed there were a lot of residents who were incontinent and had behaviors and it was hard to provide care timely when there were only three STNAs present. STNA #300 stated two night shift STNAs had stayed over until approximately 8:30 A.M. and helped pass out breakfast trays but did provide any residents with incontinence care between 6:00 A.M. and 8:30 A.M. before they left. Interview with STNA #200 on 03/25/24 at 12:10 P.M. confirmed incontinence care was to be provided every two hours but there were times when there were not enough staff present to do so. 4. Observation on 03/25/24 at 12:27 P.M. revealed the cart containing the residents' lunch meals arrived on the secured unit. At 12:30 P.M. STNA #100 began preparing the meal trays and serve them to residents. Review of the MDS assessment for Resident #53 dated 01/30/24 revealed the resident required substantial to moderate assistance of staff with eating. Review of the care plan for Resident #53 dated 02/16/24 revealed the resident had an ADL deficit related to memory impairment and decreased mobility. Interventions included the staff should provide assistance with eating and bed mobility. Observation on 03/25/24 at 12:45 P.M. revealed State tested Nursing Assistant (STNA) #100 set up Resident #53's lunch tray on the resident's overbed table and awakened the resident and raised the head of the bed. STNA #100 then exited the room and left the resident unattended with the lunch meals. Observation on 03/25/24 at 1:01 P.M. revealed STNA #100 removed the last lunch meal tray from the cart and took it to a resident. Observation on 03/25/24 at 1:07 P.M. revealed Resident #53 was slumped over to the left side with her head resting against the wall. The resident held a roll in her hand which she was attempting to eat. The remainder of the resident's lunch meal was on the overbed table but was out of the resident's reach. The resident was unable to reposition herself in the bed. Interview on 03/25/24 at 1:11 P.M. with STNA #100 confirmed Resident #53 was slumped over in bed unable to reach her lunch meal tray as she was unable to reposition herself. STNA #100 further confirmed Resident #53 required assistance with eating and she had not provided assistance to the resident. STNA #100 confirmed there was not enough staff available to timely deliver residents' meals and remain with residents who needed assistance with meal consumption. Interview with Licensed Practical Nurse (LPN) #500 on 03/25/24 at 2:10 P.M. confirmed nurses typically did not have time to assist the STNAs in providing resident care due to being busy administering medications and performing other tasks. Interview with Resident #30 on 03/26/24 at 8:25 A.M. confirmed there was often an extended wait time for staff to provide care and assistance and incontinence care was not routinely provided every two hours. Interview with Resident #28 on 03/26/24 at 8:34 A.M. confirmed the facility needed more staff as it sometimes took a long period of time to receive needed care. Review of the facility policy titled Staffing dated 09/202 revealed the facility should provide sufficient and competent staff to meet the care and service needs of all residents. This deficiency represents noncompliance investigated under Complaint Number OH00151811.

Based on closed medical record review, review of the hospital records, review of laboratory test requisitions, review of the facility's laboratory contract, staff interviews, and review of the facility policy, the facility failed to ensure timely and appropriate care and services were provided for Resident #60 following a change in condition. This resulted in Immediate Jeopardy and the potential for serious life-threatening injuries, negative health outcome and/or death on [DATE] at 10:29 A.M. when Resident #60 experienced a decline in condition. Nurse Practitioner (NP) #500 was notified of Resident #60's decline and provided new orders to obtain STAT (urgent) laboratory tests. The ordered laboratory tests were never obtained, and neither the physician nor the NP were notified of the laboratory tests not being obtained. On [DATE] at 8:40 A.M., Resident #60 further declined with pale, clammy skin and diminished breath sounds and the facility did not notify the physician nor the NP of Resident #60's decline in condition. Resident #60's condition was not monitored from 8:40 A.M. until Resident #60 was found deceased at 1:30 P.M. This affected one resident (#60) of the three residents reviewed for care and services following a change in condition. The facility census was 54. On [DATE] at 10:07 A.M., the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at approximately 10:30 A.M. when STAT laboratory tests were ordered for Resident #60 following a change in condition. NP #500 ordered the STAT laboratory tests because the resident had a recent life-threatening potassium level of 9.8 milliequivalents per liter (mEq/L) (normal level is 3.5 to 5.0 mEq/L) requiring admission to the intensive care unit and urgent hemodialysis treatments (ICU) on [DATE]. The laboratory tests were never obtained, and there was no notification to NP #500 or the physician that the laboratory tests were not obtained. Resident #60 continued to decline on [DATE] at 8:40 A.M. when the resident was assessed to have diminished breath sounds with pale, clammy skin and there was no notification to NP #500 or the physician of Resident #60's decline. NP #500 stated she would have transferred Resident #60 to the hospital if she had known the STAT laboratory values were not obtained and if she had been made aware of Resident #60's further decline on [DATE] at 8:40 A.M. There was no evidence the facility monitored Resident #60 from 8:40 A.M. until 1:30 P.M. when Resident #60 was found deceased in her room. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], Regional Director of Clinical Operations (RDCO) #600 provided education to the LNHA and DON on how to correctly enter laboratory tests into the e-med lab system (the electronic entering of physician ordered laboratory tests that goes to the facility's contracted laboratory services), abuse and neglect training, how to complete whole house audits for laboratory values, and for changes in condition. On [DATE], the DON educated all 16 licensed nurses on how to correctly enter laboratory tests into the e-med lab system. The licensed nurses were educated in-person or by telephone. On [DATE], the DON and LNHA educated all 70 staff members on abuse and neglect. All staff were educated in-person or by telephone. On [DATE], the DON completed an audit of all 54 residents currently residing in the facility to ensure all laboratory orders were entered into the e-med lab system correctly. The audit revealed there were no incorrect laboratory tests entered into e-med lab system. On [DATE], the DON completed an audit of all 54 residents to ensure no other residents had changes in condition that were not being addressed by the facility. There were two residents (Residents #1 and #2) observed to have a change in condition during the audit process. Residents #1 and #2 were assessed, the physician was notified, and new physician orders were obtained to treat the changes in conditions. Residents #1 and #2 will be closely monitored and any additional changes will be reported to the physician or NP. On [DATE], RDCO #600 educated the DON on the morning meeting process to ensure all treatments and physician's orders are being covered during the meeting, specifically related to the monitoring of physician's orders and the entering of laboratory tests. On [DATE], an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was completed with the Administrator, DON, and Medical Director #700 to discuss the self-inducted plan of correction (SIPOC) and all the steps taken toward an abatement plan. On [DATE], RDCO #600 educated the LNHA and DON, and Assistant Director of Nursing (ADON) #800 on the process for identifying a change in condition and the timely reporting of a change in condition to the physician. On [DATE], the LNHA and DON educated all 70 staff members to report any residents showing signs and symptoms of a change in condition. All staff were educated in-person or by telephone. On [DATE], the DON educated all 16 licenses nurses on how to address a resident's change in condition and the timely reporting of a change in condition to the physician. All nurses were educated in-person or by telephone. Beginning on [DATE], the DON or designee will complete audits for changes in condition and physician notification. These audits will be completed five times weekly for four weeks. The DON or designee will audit laboratory tests indefinitely. If any concerns are identified, the staff member will be educated at that time. On [DATE], Regional [NAME] President #888 reviewed and modified the facility's policy titled Lab and Diagnostic Test Result to address the procedure to be followed when ordered labs are not drawn, ensuring labs orders are drawn, and how nursing is to monitor the lab draw status and results. On [DATE], RDCO #600 educated the DON on the revised Lab and Diagnostic Test Result policy and change in condition and physician notification policy. On [DATE] at 10:07 A.M., the DON educated all 16 nurses by telephone or in-person on the revised Lab and Diagnostic Test Result policy and all 70 staff members were educated on the responsibility of all staff to report any residents showing signs or symptoms of a change in condition. Although the Immediate Jeopardy was removed on [DATE], 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 in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #60 revealed the resident was admitted to the facility on [DATE]. Resident #60 had diagnoses including atrial fibrillation, muscle weakness, epilepsy, and multiple sclerosis. Review of the hospital records dated [DATE] revealed Resident #60 was under hospice care services for a stroke prior to the hospitalization . Resident #60 improved under hospice care and wanted to receive rehabilitation care so was discharged from hospice services. Resident #60 was discharged from the hospital on [DATE] and admitted to the skilled nursing facility with orders to treat a urinary tract infection with intravenous antibiotics. Review of the nursing progress note, dated [DATE], revealed Resident #60 vomited large amounts of green bile, was diaphoretic (sweating), exhibited increased confusion, had liquid stool in colostomy bag, was lethargic, and slow to respond. The NP was notified with new orders to send Resident #60 to the emergency department for evaluation and treatment. Review of the hospital progress notes, dated [DATE] through [DATE], revealed Resident #60 was admitted to the hospital on [DATE] with a life-threatening potassium level of 9.8 mEq/L requiring admission to the intensive care unit and urgent hemodialysis treatments (ICU) on [DATE]. The resident was stabilized while in the hospital and was transferred back to the facility on [DATE]. Resident #60 exhibited high levels of motivation to participate in rehabilitation and expressed she wanted to walk again. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #60 was assessed to have mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11 (out of 15). Resident #60 was assessed to be dependent upon staff for bed mobility and toileting. Review of the nursing progress notes dated [DATE] through [DATE] revealed no documented evidence staff identified any changes in condition for the resident during this time period. The nursing progress note, dated [DATE] at 10:29 A.M., revealed Resident #60 had a slight increase in confusion, a decrease in appetite, and weight loss. The NP was notified, and new orders were obtained for STAT laboratory testing to be completed. Review of the physician's order, dated [DATE], revealed an order for a Comprehensive Metabolic Panel (CMP), renal panel including Glomerular Filtration Rate (GFR), Complete Blood Count (CBC) with differential, and a B-Natriuretic Peptide (BNP) to be completed STAT due to increased confusion. Review of the requisition for laboratory testing, dated [DATE], revealed orders for a CMP, renal panel including GFR, CBC with differential, and a BNP were entered as routine rather than STAT as ordered by the NP. There were no results of the ordered laboratory tests available for review. There was no evidence the physician or NP were notified the laboratory tests were not completed and no reason was noted in the medical record as to why the laboratory tests were not completed. Record review revealed there were no nursing progress notes completed for Resident #60 between the note on [DATE] at 10:29 A.M. and a note on [DATE] at 8:40 A.M. There was no evidence the resident's overall health status was being monitored or assessed during this time period. The nursing progress note, dated [DATE] at 8:40 A.M., revealed Resident #60 had pale, cool, clammy skin to touch. The resident's breath sounds were diminished in the lower lobes bilaterally. There was no evidence the NP or physician were updated on Resident #60's change in condition at this time. There were no evidence additional assessments or monitoring of the resident completed until 1:30 P.M. The nursing progress note, dated [DATE] at 1:30 P.M., revealed ADON #800 and RN #300 verified Resident #60 had no respirations and no heart rate noted. The physician was notified Resident #60 was deceased . Review of the death certificate revealed Resident #60's immediate cause of death was atrial fibrillation. Interview with the DON on [DATE] at 12:15 P.M. confirmed NP #500 ordered laboratory testing to be completed STAT on [DATE] for Resident #60. The DON verified the STAT laboratory tests were not drawn and therefore there were no results available for review. Telephone interview with NP #500 on [DATE] at 12:53 P.M. confirmed she had ordered STAT laboratory testing to be completed for Resident #60 on [DATE] due to reports of increased confusion and a recent history of critically high potassium levels, which had required hospitalization and were life-threatening. NP #500 stated she would expect STAT laboratory tests to be completed within two to three hours of the physician's order. NP #500 additionally confirmed she had not been notified by the facility the laboratory testing had not been completed for Resident #60 as ordered and had not been notified of the assessment of the resident having diminished breath sounds and cool, clammy, pale skin on [DATE]. NP #500 stated if she had been notified of either situation, she would have ordered the resident be sent to the hospital for evaluation and treatment. Interview with the LNHA and DON on [DATE] at 1:55 P.M. revealed facility management was not aware the STAT laboratory tests had not been obtained for Resident #60 until the morning of [DATE]. The Administrator and DON confirmed the facility did not notify the NP or physician of the ordered laboratory tests not being obtained or of the resident being assessed to have diminished breath sounds and cool, clammy, pale skin on [DATE]. The LNHA and DON stated they were notified during the clinical morning meeting, which was held between 9:00 A.M. and 10:00 A.M. on [DATE], that the laboratory tests were not drawn for Resident #60 because the laboratory company who the facility had a contract with did not have enough staff to come draw the physician ordered laboratory tests. The DON and LNHA stated they did not update the physician or NP of the resident's current condition and the fact the laboratory tests were not drawn because Resident #60 had another change in condition that morning. The Administrator and DON confirmed the facility did not complete an investigation related to the laboratory tests not being drawn for Resident #60 when they were ordered STAT and did not investigate Resident #60's change in condition until [DATE]. Interview with RN #250 on [DATE] at 8:50 A.M. confirmed she had received the order from NP #500 to obtain STAT laboratory tests and had entered the order with the laboratory company the facility contracted with. RN #250 stated she could not recall if she entered the order as STAT or routine. Telephone interview with RN #300 on [DATE] at 9:00 A.M. confirmed Resident #60 did not appear to be well on the morning of [DATE] and had diminished breath sounds and cool, clammy, pale skin. RN #300 stated she did not report the resident's condition to the NP or physician, as she was not familiar with Resident #60 and was told by State tested Nursing Assistants (STNAs) who worked more frequently with the resident she was not acting far from her baseline. RN #300 stated the DON was questioning whether laboratory testing had been ordered for Resident #60 the day before ([DATE]) as the results could not be located. Interview with STNA #133 on [DATE] at 11:40 A.M. confirmed Resident #60 appeared sick on [DATE]. STNA #133 stated she entered the room around lunch time to check on the resident and the resident did not appear to be breathing. STNA #133 stated she informed the nurse who confirmed the resident had expired. STNA #133 stated the resident's death was unexpected. Interview with the DON on [DATE] at 1:28 P.M. confirmed the orders for STAT laboratory testing to be completed for Resident #60 had been entered as routine instead of STAT as ordered. Telephone interview with NP #500 on [DATE] at 1:52 P.M. confirmed the nurse practitioner would have typically expected follow up laboratory tests to be conducted for a resident admitted to the hospital with a potassium level of 9.8 within one week following the resident's return to the facility. NP #500 stated she could not recall the exact discussion she had with facility staff following Resident #60's return or whether she provided orders for the laboratory tests to be drawn. Review of the facility's contract with Laboratory Company #99 dated [DATE] revealed the laboratory company provided 24 hours per day, 365 days per year STAT (life-threatening situation) services. The STAT testing was to be reported within five hours. The facility agreed to provide completed requisitions that reflect a physician or other practitioner's order for the services. The facility shall ensure that all requisitions are completed accurately with all the information needed for the laboratory company. Review of the facility policy titled Lab and Diagnostic Test Results - Clinical Protocol, revised ,d+[DATE], revealed the physician would identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff would process test requisitions and arrange for tests. Staff would use daily logs to ensure lab orders were in place for each shift. The laboratory, diagnostic radiology provider, and or other testing source would report test results to the facility. If a STAT order had not been drawn within four to six hours, physician notification should take place and further direction given. Review of the facility's undated policy titled Change in Condition and Physician Notification Policy revealed the facility was to promptly identify, respond to, and report changes in resident condition to the resident's physician/NP/physician assistant (PA) and resident/resident's representative. A significant change was a major decline or improvement of the resident's status. The nurse would document timely regarding the change in resident's condition, interventions, and notifications. This deficiency represents non-compliance investigated under Complaint Number OH00150811.

Based on interview, record review and facility policy review the facility failed to ensure target behaviors were identified and appropriate indications for use of antipsychotic medications. This affected six residents (#16, #28, #30, #36, #38 and #43) of seven reviewed for unnecessary medications. The facility census was 41. Findings include: 1. Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses including hypertension, psychosis and major depressive disorder. Review of the physician orders for October 2023 revealed Resident #16 was ordered clonazepam (antianxiety medications) 0.5 milligrams (mg) by mouth three times a day for unspecified psychosis, risperidone (antipsychotic medications) four mg by mouth two times daily for unspecified psychosis and citalopram hydrobromide (antidepressant medication) 40 mg by mouth daily for inappropriate sexual behaviors. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #16 was severely cognitively impaired with physical and verbal behaviors directed towards others that interfered with care, rejected care and wandered. Resident #16 received an antipsychotic, antidepressant and antianxiety medications seven of seven days during the look back period. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated August, September, and October 2023 revealed no identified target behaviors were identified for monitoring for the indication of use of the antipsychotic, antidepressant and antianxiety medications. Review of Activities of Daily Living (ADL) documentation for August, September, and October 2023 revealed no identified target behaviors or documentation. Interview on 10/17/23 at 3:17 P.M. with Registered Nurse (RN) #77 revealed behaviors were not identified and monitored each shift. Interview on 10/18/23 at 2:25 P.M. with the Director of Nursing (DON) confirmed target behaviors were not identified for staff to monitor and or document each shift in the electronic medical record. The DON also confirmed the diagnosis for the use of the antianxiety medication clonazepam was not appropriate for Resident #16. 2. Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses including dementia with behavioral disturbances, metabolic encephalopathy, anxiety disorder and major depressive disorder. Review of the physician orders dated October 2023 for Resident #28 revealed Resident #28 was ordered quetiapine fumarate 50 milligrams (mg) by mouth two times daily for vascular dementia with behavioral disturbances, and mirtazapine 15 mg by mouth at bedtime for insomnia. Review of the quarterly MDS dated [DATE] for Resident #28 revealed Resident #28 was severely cognitively impaired with inattention, verbal behaviors towards others, rejection of care and wandered. Resident #28 received the antipsychotic and antidepressant medications seven of seven days of the look back period. The antipsychotic medications were reviewed with no Gradual Dose Reduction (GDR) attempted. The physician documented on 07/14/23 a GDR was contraindicated. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated August, September, October 2023 revealed no identified target behaviors were identified for monitoring for the indication of use of the antipsychotic and antidepressant medications. Review of Activities of Daily Living (ADL) documentation for August, September, and October 2023 revealed no target behaviors or documentation. Interview on 10/17/23 at 3:17 P.M. with Registered Nurse (RN) #77 revealed behaviors were not identified and monitored each shift. Interview on 10/18/23 at 2:25 P.M. with the Director of Nursing (DON) confirmed target behaviors were not identified for staff to monitor and or document each shift in the electronic medical record. The DON also confirmed the diagnosis for the use of the antipsychotic medication quetiapine fumarate and antidepressant medication mirtazapine was not appropriate for Resident #28. 3. Review of the medical record for Resident #30 revealed an admitted [DATE] with diagnoses including bipolar disorder, schizophrenia, schizoaffective disorder, dementia and intellectual disability. Review of the physician orders dated October 2023 for Resident #30 revealed Resident #30 was ordered haloperidol (antipsychotic medication) 1 mg by mouth two times daily for agitation and lorazapam (antianxiety medication) 1 mg by mouth three times daily for agitation. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated August, September, and October 2023 for Resident #30 revealed no identified target behaviors were identified for monitoring for the indication of use of the antipsychotic and antianxiety medications. Review of the significant change MDS dated [DATE] revealed Resident #30 was moderately impaired cognitively impairment. with physical and verbal behaviors directed towards others. Resident #30 required assistance with ADLs. Resident received antipsychotic and antianxiety medication and no GDR attempted. Review of the plan of care for Resident #30 revealed Resident #30 took psychotropic medications and antianxiety medications for anxiety, bipolar disorder and depression. Interventions included medications as ordered, observe for side effects of the the medication, review medications as needed, labs as ordered and psychiatric/counseling services as needed. Review of Activities of Daily Living (ADL) documentation for August, September, and October 2023 revealed no identified target behaviors or documentation. Interview on 10/17/23 at 3:17 P.M. with Registered Nurse (RN) #77 revealed behaviors were not identified and monitored each shift. Interview on 10/18/23 at 2:25 P.M. with the Director of Nursing (DON) confirmed target behaviors were not identified for staff to monitor and or document each shift in the electronic medical record. The DON also confirmed the diagnosis for the use of the antipsychotic and antianxiety medication was not appropriate for Resident #30. 4. Review of the medical record for Resident #36 revealed an admitted [DATE] with diagnoses including alcohol abuse with psychotic disorder, psychoactive substance abuse, type two diabetes mellitus and chronic kidney disease. Review of the physician orders dated October 2023 revealed Resident #36 received risperdal 1 mg by mouth two times daily for polysubstance abuse. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated August, September, October 2023 for Resident #36 revealed no identified target behaviors were identified for monitoring for the indication of use of the antipsychotic medication. Review of the quarterly MDS dated [DATE] revealed Resident #36 was moderately cognitively impaired with rejection of care and wandering. Resident #36 required supervision with activities of daily living. Resident #36 received antipsychotic medication with no GDR attempted. Review of the plan of care dated 12/29/22 revalued Resident #36 received psychotropic medication related to behaviors and history of substance abuse. Interventions included medications as ordered, observe for side effects of antipsychotic medication, medication review as needed, labs as ordered and psychiatric/counseling services as needed. Review of Activities of Daily Living (ADL) documentation for August, September, and October 2023 revealed no identified target behaviors or documentation. Interview on 10/17/23 at 3:17 P.M. with Registered Nurse (RN) #77 revealed behaviors were not identified and monitored each shift. Interview on 10/18/23 at 2:25 P.M. with the Director of Nursing (DON) confirmed target behaviors were not identified for staff to monitor and or document each shift in the electronic medical record. The DON also confirmed the diagnosis for the use of the antipsychotic was not appropriate for Resident #36. 42728 5. Record review for Resident #38 revealed this resident was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia without behavioral disturbances, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/15/23, revealed this resident was assessed to be rarely/never understood evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 99. This resident was assessed to be dependent upon two staff members for transfers and toileting and to require extensive assistance from two staff members for bed mobility. Review of the active physicians order, dated 09/07/23, revealed an order for the administration of 50 milligrams (mg) of Seroquel (an anti-psychotic medication) at bedtime for delirium due to known physiological condition. Review of the pharmacy recommendation, dated 09/29/23, revealed the resident was currently on the drug Quetiapine (the generic name for Seroquel) with the diagnosis of delirium due to known physiological condition. According to new guidelines, appropriate diagnosis for antipsychotic medications in the long term care setting include: Schizophrenia, Psychosis, Bipolar Disorder with Mania, or Dementia with Delusions or Psychosis. Please consider changing to an appropriate diagnosis or titrating off this medication. The recommendation was signed by the physician on 10/07/23 but did not contain a response to the recommendation. Interview with the Director of Nursing (DON) on 10/18/23 at 2:05 P.M. verified Resident #38 continued to be prescribed the medication Seroquel with a diagnosis of delirium due to known physiological condition and that the resident did not have any of the diagnoses listed on the pharmacy recommendation. 6. Record review for Resident #43 revealed this resident was admitted to the facility on [DATE] and had diagnoses including hypertension, abnormal glucose, anxiety disorder, insomnia, and dementia. Review of the admission MDS assessment, dated 08/24/23, revealed this resident had severely impaired cognition evidenced by a BIMS assessment score of 00. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting. Review of the active physicians order, dated 08/19/23, revealed an order for 25 mg of Seroquel to be administered three times a day. The order did not contain a diagnosis or indication for the use of the medication. Review of the pharmacy recommendation, dated 09/05/23, revealed a recommendation to provide a diagnosis for the use of Seroquel (an anti-psychotic medication) or consider titrating off the medication. The pharmacy recommendation did not contain a response by the physician. Interview with the DON on 10/18/23 at 2:05 P.M. verified Resident #43 continued to be prescribed the medication Seroquel without a diagnosis or indication for the use of the medication.

Based on review of the infection/antibiotic stewardship log, interview, and policy review the facility failed to ensure all prescribed antibiotics were appropriate. This had the potential to affect all 41 residents residing in the facility. Findings include: Review of the infection control log dated 01/2023 to 09/2023 revealed there was no evidence in February, March, April, May, June and September 2023 the facility identified the organism of the infection and ensured the antibiotic met the criteria for treatment. Further review of the log revealed in February 2023 there was six urinary tract infections (UTI), two gastrointestinal (GI), one skin, and three lower respiratory infections identified. All the infections were treated with antibiotics and did not meet the criteria for antibiotic treatment. Further review of the log revealed in March 2023 there was two upper respiratory infections (URI), two lower respiratory infection, two GI infections, three skin infections, and five UTI's identified. All the infections were treated with antibiotics and did not meet the criteria for antibiotic treatment. Further review of the log revealed in April 2023 there was two respiratory infections, one UTI and one wound infection identified. All the infections were treated with antibiotics and did not meet the criteria for antibiotic treatment. Further review of the log revealed in May 2023 there was two wound infections, two upper respiratory infections and two UTI's identified. All the infections were treated with antibiotics and did not meet the criteria for antibiotic treatment. Further review of the log revealed in June 2023 there was two upper respiratory infections, two UTI's, two lower respiratory infections and one skin infection denitrified. All the infections were treated with antibiotics and did not meet the criteria for antibiotic treatment. Further review of the log revealed in September 2023 there was five UTI's, one lower respiratory infection, one wound and one skin infection identified. All the infections were treated with antibiotics and did not meet the criteria for antibiotic treatment. Interview on 09/19/23 at 3:45 P.M. with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the infection and antibiotic stewardship log was not comprehensive to include all the organism, and ensuring the antibiotics met the criteria for treatment of the infection. The ADON (the infection preventionist) stated she was not checking the correct criteria for infections. The ADON stated she used the McGreer form provided by the facility and was not aware she needed to have a culture for urine and skin. Review of the facility policy title Antibiotic Stewardship, with no date, revealed it was the policy of the facility to maintain an antibiotic stewardship program with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use.

Based on interview, record review, and review of the facility policy revealed the facility failed to ensure adequate monitoring, screening and offering of pneumonia vaccine. This affected four residents (#28, #29, #30 and #36) of five reviewed for immunizations. The facility census was 41. Findings include: Review of the medical record for Resident #28, #29, #30 and #36 revealed the residents did not receive the appropriate pneumonia vaccination based on the Centers of Disease Control and Prevention (CDC) guidelines. Interview on 10/19/23 at 3:40 P.M. with the Director of Nursing and the Assistant Director of Nursing confirmed Resident #28, #29 #30 and #36 did not receive the appropriate pneumonia vaccination as recommended by the CDC. Review of the facility policy titled Pneumococcal Vaccine, with no date, indicated prior to admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated, will be offered the vaccine series within thirty days of the admission to the facility unless medically contraindicated or the resident has already been vaccinated.

Based on observation, interview and record review the facility failed to ensure the comprehensive plan of care was developed and implemented based on the residents preferences and needs and the plan of care was not person centered. This affected three residents (#28, #29 and #32) of 12 residents reviewed for plan of care. The facility census was 41. Findings include: 1. Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses including dementia with behavioral disturbances, type two diabetes mellitus, metabolic encephalopathy, major depressive disorder and anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #28 had severe cognitive impairment with inattention. Resident #28 required extensive assistance of one person for transfers and supervision with mobility due to unsteady balance and gait. Review of the activity assessment dated [DATE] for Resident #28 revealed Resident #28 preferred self initiated activities in her room such as word search puzzles, activity packs and music. Review of the plan of care revised on 05/24/23 revealed Resident #28 had the potential for activity deficit related to cognitive impairment and decreased mobility. The interventions included to assist Resident #28 to activities, encourage to come to group activities (in common area of the locked unit), provide Resident #28 with access to an activity calendar, staff to provide one on one as needed. Review of the plan of care revised on 03/06/23 revealed Resident #28 had impaired cognition and thought process related to atrophy and vascular dementia with behaviors. The interventions included administer medications as ordered, observe the resident for decline in cognition and notify the physician, staff to anticipate the resident needs, and residents family to come in to the facility and sit with the resident. Observations made on 10/16/23 at 10:10 A.M., 1:07 P.M., on 10/17/23 at 9:14 A.M., 10/18/23 10:05 A.M. found Resident #28 sleeping in her room with no self initiated activities such as word search puzzles, activity packs or music available and no interaction with Resident #28. An interview on 10/19/23 at 2:20 P.M. with the Director of Nursing (DON) confirmed the activity plan of care was not personalized to meet Resident #28 needs. 2. Review of the medical record for Resident #29 revealed an admitted [DATE] with diagnoses including vascular dementia with behavioral disturbances, psychotic disorder with delusions, major depression, anxiety disorder and neuralgia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was severely cognitively impaired with inattention and disorganized thinking. Resident #29 required assistance with activities of daily living. Review of the activity assessment dated [DATE] revealed Resident #29 attended and enjoyed group activities. Resident #29 enjoyed watching television, listening to music, bingo, arts and crafts, seek and find objects, her baby doll, and sitting outside. Review of the plan of care for Resident #29 revealed Resident #29 had the potential for activity deficit related to cognitive impairment, decreased mobility and behavior problems. The interventions included to assist Resident #29 to group activities, provide an activity calendar and provide one on one attention. Observations on 10/16/23 at 12:06 P.M. and on 10/17/23 at 9:18 A.M. of Resident #29 revealed Resident #29 was lying in her bed with eyes closed. An interview on 10/19/23 at 2:20 P.M. with the Director of Nursing (DON) confirmed the activity plan of care was not personalized to meet Resident #29's needs. 42728 3. Record review for Resident #32 revealed this resident was admitted to the facility on [DATE] and had diagnoses including acquired absence of the right leg below the knee, nicotine dependence, and viral hepatitis C. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/05/23, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. This resident was assessed to require supervision for bed mobility, transfers, toileting, and eating. Review of the care plan, most recently revised on 05/10/23, revealed this resident was at risk for impaired skin integrity related to a left below the knee amputation and prosthetic leg left extremity. Interventions included to monitor skin to stump for redness, edema, and abrasions and to inspect skin during routine daily care. Interview with Resident #32 on 10/17/23 at 2:30 P.M. revealed the resident had undergone an amputation of the right leg below the knee. Observation on 10/17/23 at 2:30 P.M. revealed Resident #32 had a right below the knee amputation and had a prosthesis for the right lower extremity. Resident #32 did not have a left leg amputation or prosthetic. Interview with the Director of Nursing (DON) on 10/18/23 at 2:05 P.M. verified Resident #32 had a right below the knee amputation and right lower leg prosthetic and the care plan was incorrect as it identified the resident as having a left below the knee amputation and left leg prothesis.

Based on observations, interviews, and record reviews, the facility failed to ensure monitoring of a resident's skin after post surgical intervention. This affected one resident (#32) of the two residents reviewed for skin conditions during the annual survey. The facility census was 41. Findings include: Record review for Resident #32 revealed this resident was admitted to the facility on [DATE] and had diagnoses including acquired absence of the right leg below the knee, nicotine dependence, and viral hepatitis C. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/05/23, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. This resident was assessed to require supervision for bed mobility, transfers, toileting, and eating. Review of the care plan, most recently revised on 05/10/23, revealed this resident was at risk for impaired skin integrity related to a left below the knee amputation and prosthetic leg left extremity (this was in error as the resident had a right below the knee amputation, not left). Interventions included to monitor skin to stump for redness, edema, and abrasions and to inspect skin during routine daily care. Review of the active physicians order, dated 05/22/23, revealed an order to monitor stump to left leg lower extremity for redness, edema, abrasions, and notify physician. Review of the resident's medical record revealed no documented evidence the resident's skin to the right stump was being monitored for redness, edema, and abrasions. Review of the nurse's progress note, dated 10/18/23, revealed this nurse went to check on the resident. The resident had reddened area to right stump. The Nurse Practitioner was notified and new orders were obtained to change Lidocaine patch to once daily, on for 12 hours then remove, and to change the strength of the Lidocaine patch to four percent. There was no evidence any treatment was ordered and/or provided to the resident's red, irritated skin. Interview with Resident #32 on 10/17/23 at 2:30 P.M. revealed the resident had undergone an amputation of the right leg below the knee and had been asking staff members for cream for the right stump due to irritation. During interview with Resident #32, he stated they were not monitoring the stump at all. Observation on 10/17/23 at 2:30 P.M. revealed Resident #32 had a right below the knee amputation and had a prosthesis for the right lower extremity. The skin to the right stump area was observed to be red and irritated. Interview with the Director of Nursing (DON) on 10/18/23 at 2:05 P.M. verified the order to monitor the skin to the left stump area was incorrect as the resident actually had a right stump and prosthesis following a right below the knee amputation. The DON verified there was no documented evidence the resident's skin at the right stump area was being monitored by staff and the area was red and irritated.

Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure adequate care and services were provided to identify residents at risk for elopement and prevent elopement. This affected two residents (#4 and #43) out of the five residents residents reviewed for accidents during the annual survey. The facility census was 41. Findings include: 1. Record review for Resident #4 revealed this resident was admitted to the facility on [DATE] and had diagnoses including anxiety disorder, schizophrenia, mood disorder, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/14/23, revealed this resident was rarely/never understood evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 99. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and to require supervision for eating. This resident was assessed to use a wander/elopement alarm daily. Review of the care plan, dated 09/15/21, revealed this resident was at risk for elopement. Interventions included wanderguard as ordered and follow facility elopement procedures. Review of the active physician orders for Resident #4 revealed no orders were in place for the monitoring or placement of a wanderguard. Observation on 10/19/23 at 8:30 A.M. revealed Resident #4 was observed lying in bed and had a wanderguard in place to the right ankle. The resident refused to allow observation of the wanderguard for expiration date. Interview with Licensed Practical Nurse (LPN) #84 on 10/19/23 at 8:35 A.M. revealed residents had wanderguard in place as ordered by the physician and the wanderguards were checked for placement and function according to the physicians orders. LPN #84 verified Resident #4 had a wanderguard in place to the right ankle but did not have orders for the wanderguard to be in place or to check the function of the wanderguard. Interview with the Administrator on 10/19/23 at 9:30 A.M. revealed the facility did not have policies or procedures addressing the use and monitoring of wanderguards for residents. Review of the facility policy titled Elopement Prevention, not dated, revealed residents would be assessed for elopement risk and if identified as being at risk, an individualized care plan would be implemented to prevent elopement. The residents care plan would indicate if the resident was at risk for elopement and interventions to promote safety. 2. Record review for Resident #43 revealed this resident was admitted to the facility on [DATE] and had diagnoses including insomnia, dementia, and anxiety disorder. Review of the admission MDS assessment, dated 08/24/23, revealed this resident had severely impaired cognition evidenced by a BIMS assessment score of 00. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, toileting. Review of the care plan, dated 08/28/23, revealed this resident was at risk for elopement related to impaired memory, sits/stands by doors, and exits. Interventions included to apply wanderguard and check per facility policy. Review of the physicians order, dated 08/19/23, revealed an order for a wanderguard to be in place as ordered two times a day for wandering. There were no orders present to check the function or placement of the wanderguard. Observation on 10/18/23 at 10:31 A.M. revealed Resident #43 was observed to have a wanderguard in place to the right ankle with an expiration date of 07/2026. The resident was observed to independently get up from his seat and begin wandering down the hallway. Interview with the DON on 10/18/23 at 2:05 P.M. verified Resident #43 had a wanderguard in place but did not have orders to check the function or placement of the wanderguard. Interview with LPN #84 on 10/19/23 at 8:35 A.M. revealed residents had wanderguards in place as ordered by the physician and the wanderguards were checked for placement and function according to the physicians orders. Interview with the Administrator on 10/19/23 at 9:30 A.M. revealed the facility did not have policies or procedures addressing the use and monitoring of wanderguards for residents. Review of the facility policy titled Elopement Prevention, not dated, revealed residents would be assessed for elopement risk and if identified as being at risk, an individualized care plan would be implemented to prevent elopement. The residents care plan would indicate if the resident was at risk for elopement and interventions to promote safety.

Based on observation, interview, record review and facility policy review revealed the facility failed to implement dietary recommendations timely. This affected one resident (#29) of four residents reviewed for nutrition. The facility census was 41. Findings include: Review of the medical record for Resident #29 revealed an admitted [DATE] with diagnoses including vascular dementia with behavioral disturbances, psychotic disorder with delusions, major depression, anxiety disorder, type two diabetes mellitus, and chronic obstructive pulmonary disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was severely cognitively impaired with inattention disorder, disorganized thinking and problems with appetite. Resident #29 required staff assistance with eating. Resident #29 weighed 159 pounds with no weight loss, or dental problems. Review of the physician orders for October 2023 revealed Resident #29 was on a regular diet, puree texture and thin liquids. Resident #29 did not have an order for a dietary supplement. Review of the dietitian documentation dated 09/07/23 at 11:38 A.M. revealed Resident #29 had experienced a moderate weight loss of seven pound in 90 days with a current weight of 159 pound. Resident #29 remained in the obese class with a BMI of 30. Resident #29 was ordered a regular diet, puree texture, thin liquids and an appetite stimulant. The intake record indicated Resident #29 had been eating 50-75% of meals over the past seven days. The Registered Dietitian (RD) recommended offering a magic cup one time daily. The RD will continue to monitor. Review of the dietitian documentation dated 10/09/23 at 2:11 P.M. revealed Resident #29's weight continued to decline with current body weight of 154 pounds. The weight history indicated Resident #29 had experienced moderate weight loss of five and one half pounds (3.4%) in 30 days. Current body mass index (BMI) was 29.0 and resident was within ideal BMI for her age. Resident #29 received a regular diet, puree texture with thin liquids. Resident #29 received an appetite stimulant. The staff reported Resident #29 oral intake was fair to poor, and she required more assistance with eating her meals. The Registered Dietitian (RD) recommended a magic cup (dietary supplement) daily on 09/07/23 but it was not ordered. RD recommended offering magic cup once daily if available or medpass 2.0 of 60 milliliters (ml) by mouth two times daily if magic cup is not available. The RD will continue to monitor. Review of Resident #29 weights revealed on 06/16/23 weighed 167 pounds, refused weight in 07/23 and 08/23, on 09/04/23 weighed 159 pound, and on 10/04/23 weight 154 pounds. Review of the plan of care revised on 12/02/22 for Resident #29 revealed Resident #29 had a potential for a nutritional problem related to a BMI greater than 30, modified texture, diagnosis of dementia and weight fluctuation related to edema, medications and diagnosis. The interventions included administer medications as ordered, allow the resident to make choices or preferences of food as able, dietary consult as needed, observe the resident for coughing, choking, chewing problems or pocketing food, obtain lab work as ordered, obtain weights as ordered, provide diet as ordered, provide supplements as ordered, and speech therapy screen as needed. Review of the meal intake documentation for October 2023 revealed Resident #29 consumed 75-100% of all meals. Observations on 10/16/23 at 12:50 P.M. and 10/18/23 at 12:40 P.M. of Resident #29 revealed Resident #29 was eating her lunch at bedside. Resident #29 was feeding herself and eating bites from all the food provided. There was not a magic cup provided on the meal tray. An interview on 10/19/23 at 12:53 P.M. with the Director of Nursing (DON) revealed the procedure for the RD recommendations was the DON received the recommendations via email. The DON would then notify the physician for approval, write the order, put the order in the electronic health record, and complete a dietary ticket for the kitchen. The DON confirmed the RD recommendation on 09/07/23 for Resident #29 to receive a magic cup once daily was not confirmed, written or implemented. Review of the facility provided policy titled Dietary: Diet Changes and Reports with no date revealed nursing services was responsible for notifying the dietary department of any changes in the resident's diet.

Based on record reviews, interviews, and review of facility policy, the facility failed to ensure pharmacy recommendations were reviewed and implemented timely. Additionally, the facility failed to ensure the policy for pharmacy recommendations addressed actions to be taken for urgent pharmacy recommendations. This affected three residents (#28, #38, and #43) of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 41. Findings include: 1. Record review for Resident #38 revealed this resident was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia without behavioral disturbances, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/15/23, revealed this resident was assessed to be rarely/never understood evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 99. This resident was assessed to be dependent upon two staff members for transfers and toileting and to require extensive assistance from two staff members for bed mobility. Review of the pharmacy recommendation, dated 03/09/23, revealed a recommendation to consider adding Take apical pulse before giving, if less than 50 beats per minute (bpm), hold and notify prescriber to the residents order for the administration of Metoprolol (an anti-hypertensive medication). The recommendation did not contain a response or signature by the physician. Review of the active physicians order for the administration of Metoprolol, dated 01/12/23, revealed the order did not contain instructions to take apical pulse before giving, and if less than 50 bpm, hold and notify prescriber. Review of the pharmacy recommendation, dated 08/31/23, revealed a recommendation to evaluate the medication Citalopram (an antidepressant medication) for continued use. The recommendation did not contain a response by the physician and was signed and dated 10/07/23 (37 days after the recommendation was made). Review of the active physicians order, dated 01/12/23, revealed an order for 20 milligrams of Citalopram to be administered once daily for generalized anxiety disorder. The order had not been modified since being implemented on 01/12/23. Interview with the Director of Nursing (DON) on 10/18/23 at 2:05 P.M. verified the pharmacy recommendation dated 03/09/23 did not contain a response or signature from the physician and the order for the administration of Metoprolol did not contain the recommendation from the pharmacy. The DON further verified the pharmacy recommendation dated 08/31/23 did not contain a response from the physician and had been signed as being reviewed by the physician on 10/07/23, 37 days after the recommendation had been made. Interview with the Administrator on 10/19/23 at 10:15 A.M. verified the facility policy for addressing pharmacy recommendations did not contain instructions for actions to be taken for urgent pharmacy recommendations. Review of the facility policy titled Pharmacy Recommendations, revised 01/2020, revealed resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented and reported to the Director of Nursing, prescriber, and Medical Director. The Director of Nursing, or Assistant Director of Nursing, will review the recommendations with the Physician and Medical Director as soon as practicable but no later than 30 days. The Director of Nursing will track recommendations and ensure any changes are implemented into the medical record. The policy did not contain instructions for actions to be taken for urgent pharmacy recommendations. 2. Record review for Resident #43 revealed this resident was admitted to the facility on [DATE] and had diagnoses including hypertension, abnormal glucose, anxiety disorder, insomnia, and dementia. Review of the admission MDS assessment, dated 08/24/23, revealed this resident had severely impaired cognition evidenced by a BIMS assessment score of 00. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting. Review of the pharmacy recommendation, dated 09/05/23, revealed a recommendation to provide a diagnosis for the use of Seroquel (an anti-psychotic medication) or consider titrating off the medication. The pharmacy recommendation did not contain a response by the physician and was signed and dated by the physician on 10/13/23 (38 days after the recommendation was made). Review of the active physicians order, dated 08/19/23, revealed an order for 25 mg of Seroquel to be administered three times a day. The order had not been titrated or changed since being implemented on 08/19/23 and continued to not provide a diagnosis as recommended by the pharmacist. Interview with the DON on 10/18/23 at 2:05 P.M. verified the pharmacy recommendation dated 09/05/23 did not contain a response from the physician and had been signed by the physician on 10/13/23, 38 days after the recommendation had been made. Interview with the Administrator on 10/19/23 at 10:15 A.M. verified the facility policy for addressing pharmacy recommendations did not contain instructions for actions to be taken for urgent recommendations. Review of the facility policy titled Pharmacy Recommendations, revised 01/2020, revealed resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented and reported to the Director of Nursing, prescriber, and Medical Director. The Director of Nursing, or Assistant Director of Nursing, will review the recommendations with the Physician and Medical Director as soon as practicable but no later than 30 days. The Director of Nursing will track recommendations and ensure any changes are implemented into the medical record. The policy did not contain instructions for actions to be taken for urgent pharmacy recommendations. 3. Review of the medical record for Resident #28 revealed an admitted [DATE] with diagnoses of dementia with behavioral disturbances, type two diabetes mellitus, metabolic encephalopathy, major depressive disorder, anxiety disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #28 was severely cognitively impaired with inattention, verbal behaviors directed towards others and rejection of care. Resident #28 required extensive assistance of one for activities of daily living. Resident #28 received an antipsychotic, antianxiety and antidepressant medication seven of the seven days in the look back period. Antipsychotic medications were reviewed, however no Gradual Dose Reduction (GDR) had been attempted. On 07/14/23 the physician had documented a GDR was contraindicated. Review of the monthly pharmacy recommendations from 10/01/22 through 09/30/23 for Resident #28 revealed the pharmacist recommendation dated 10/09/22 to evaluate the antipsychotic medication Quetiapine for continued use and the recommendation dated 03/09/23 to reviewed the antidepressant medication Trazadone for reduction were not addressed or implemented timely. Review of the plan of care for Resident #28 revised on 08/14/23 revealed Resident #28 received antipsychotic and antidepressant medications related to dementia with behaviors, anxiety and depression. The interventions included administer medications as ordered, observe for side effects of antianxiety, antidepressant and antipsychotic medications, review medications as needed, notify the physician as needed, labs as needed and psychiatric counseling services as needed. An interview on 10/18/23 at 2:25 P.M. with the Director of Nursing (DON) confirmed the pharmacy recommendations were not reviewed in a timely manner or implemented. Review of the facility policy titled Pharmacy Recommendations, revised 01/2020, revealed resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented and reported to the Director of Nursing, prescriber, and Medical Director. The Director of Nursing, or Assistant Director of Nursing, will review the recommendations with the Physician and Medical Director as soon as practicable but no later than 30 days. The Director of Nursing will track recommendations and ensure any changes are implemented into the medical record. The policy did not contain instructions for actions to be taken for urgent pharmacy recommendations.

Based on record review and staff interview, the facility failed to ensure adequate instructions and indications for the use of topical medications. This affected one resident (#43) out of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 41. Findings include: Record review for Resident #43 revealed this resident was admitted to the facility on [DATE] and had diagnoses including hypertension, abnormal glucose, anxiety disorder, insomnia, and dementia. Review of the admission Minimum Data Set (MDS) assessment, dated 08/24/23, revealed this resident had severely impaired cognition evidenced by a BIMS assessment score of 00. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting. Review of the active physicians order, dated 08/18/23, revealed an order to apply Nystatin External Cream 100,000 units per gram topically to affected areas every eight hours as needed. The order did not contain instructions on where to apply the topical medication, how much of the topical medication to apply, or an indication for the application of the medication. Review of the active physicians order, dated 08/18/23, revealed an order to apply one percent strength Hydrocortisone External Cream topically to affected areas every eight hours as needed. The order did not contain instructions on where to apply the topical medication, how much of the topical medication to apply, or an indication for the application of the medication. Review of the active physicians order, dated 08/18/23, revealed an order to apply 0.44 - 20.6 percent strength Calmoseptine External Ointment topically to affected area two times a day for irritation. The order did not contain instructions on where to apply the topical medication or how much of the topical medication to apply. Interview with the Director of Nursing (DON) on 10/18/23 at 2:05 P.M. verified the orders for the topical application of Calmoseptine External Ointment, Hydrocortisone External Cream, and Nystatin External Cream did not contain information as to where the affected areas were or how much of the medication to apply. The DON further verified the orders for the topical application of Nystatin External Ointment and Hydrocortisone External Cream did not contain an indication for the use of the medication.

Based on record review, facility policy and procedure review and interview the facility failed provide necessary care and services, including dressing changes and antibiotic administration for Resident #41 who had three Stage IV pressure ulcers to promote wound healing. This affected one resident (#41) of two residents reviewed for pressure ulcers. Findings Include: Review of Resident #41's medical record revealed the resident had medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/12/21 revealed the resident had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. The assessment revealed the resident had three Stage IV pressure ulcers that were present at the time of admission. Interventions listed included pressure reducing devices for her chair and bed, turning/repositioning program, nutrition or hydration interventions to manage skin problems, pressure ulcer care, application of nonsurgical dressings, and application of ointments/medications other than to feet. The assessment revealed the resident received intravenous (IV) medications within the last 14 days. Review of the care plan for Resident #41 (initiated 09/27/19) and revised on 11/24/21 revealed the resident had an alteration in skin integrity with pressure ulcers to left gluteal fold, right gluteal fold and coccyx present on admission. Interventions included physical therapy screen as needed for wheelchair mobility, resident to wear brief to contain drainage that leaks from dressing over wounds, specialty mattress to bed as ordered, assess for pain prior to treatment and medicate per physician's orders, consult with dietitian as needed, consults with infectious disease as needed, educate resident and family on importance of turning and repositioning while in bed and wheelchair, encourage fluids as tolerated, encourage resident to comply with dressing changes and explain risks/benefits, encourage resident to turn and reposition frequently, treatment per physician orders, donut cushion to wheelchair for pressure ulcer prevention, encourage resident to limit time in wheelchair as much as possible and offload heels while in bed. Review of the physician's orders for November 2021 revealed Resident #41 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order had a start date of 11/23/21. The resident also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The dressing orders had a start date of 07/13/21. a. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #41 at 9:00 A.M. and 9:00 P.M. with a start date of 11/23/21. The night dose on 11/23/21 was coded as other-see nurse notes. On 11/24/21, the morning dose was marked refused and the night dose was marked as administered. Both doses on 11/25/21 were marked as administered. Both doses on 11/26/21 and 11/27/21 were coded other-see nurse notes. Both doses were administered on 11/28/21 and 11/29/21. The morning dose on 11/30/21 was administered and the night dose were marked as refused. Review of the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 11/26/21 at 11:42 A.M. and 9:02 P.M., and 11/27/21 at 9:41 A.M., [MEDICATION(S)] HCl Solution was not available. On 11/28/21 at 1:01 A.M., [MEDICATION(S)] HCl solution medication was not available. The pharmacy was contacted to send immediately (STAT). On 11/28/21 at 2:13 A.M., a staff person spoke to the pharmacy. The pharmacy stated they did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M. on 11/28/21 and medication was to be sent immediately to the facility. Review of the nurse's notes revealed on 11/16/21 at 8:36 P.M. the resident had an appointment with wound care (scheduled for) 11/22/21. There were no additional notes related to the [MEDICATION(S)] HCl Solution medication, communication with the pharmacy, or communication with the physician related to the medication not being available, administered or delivered to the facility. Review of the pharmacy delivery statement, dated 11/28/21 confirmed [MEDICATION(S)] HCl two gram vial was delivered at 12:50 A.M. On 11/29/21 at 3:33 P.M. interview with Resident #41 revealed the resident was supposed to receive [MEDICATION(S)] antibiotic twice daily to help heal an infection in her wound. The resident stated staff were marking it like it was being given but it wasn't even in the facility. The resident stated she received the first does of the medication on 11/28/21. On 12/02/21 at 1:45 P.M. interview with Assistant Director of Nursing (ADON) #250 confirmed Resident #41 did have an order to start [MEDICATION(S)] antibiotic on 11/23/21. The nurse stated she faxed the order to the pharmacy but the pharmacy stated they did not receive the order. The nurse stated she called the pharmacy each night, requesting the antibiotic order but confirmed there was no documentation of the follow up in the medical record. The order was received by the pharmacy on 11/27/21 and the antibiotic was received at the facility on 11/28/21. The ADON confirmed any doses prior to 11/28/21 that were marked as refused or administered on the MAR must have been done in error because that medication was not in the facility until 11/28/21. Review of the facility policy titled Wound Care, revised 12/2020 revealed it was the policy of this facility to provide therapeutic treatment to heal wounds. Document the assessments, care and treatments administered. b. Review of the Treatment Administration Record (TAR) for November 2021 revealed there were no dressing changes completed for any of the three wounds on 11/15/21, 11/20/21, 11/21/21, 11/25/21, 11/27/21 or 11/30/21. The dressings were changed once a day on 11/09/21, 11/12/21, 11/13/21, 11/14/21, 11/16/21, 11/17/21, 11/22/21, 11/23/21, 11/26/21, 11/28/21, and 11/29/21. There were not any refusals indicated. Review of the nursing progress notes, from 11/01/21 through 11/29/21 revealed there were no notes related to Resident #41's dressing changes not being completed. On 11/29/21 at 3:33 P.M. interview with Resident #41 revealed she was supposed to have wound dressings changed on three separate pressure ulcer areas twice a day but they were often only changed once a day or not changed at all. On 12/02/21 at 12:50 P.M. interview with the Director of Nursing (DON) confirmed Resident #41's dressing changes were not marked as completed on the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . At the time of the interview, the DON revealed she believed it was a documentation issue, not a care issue. And indicated the nurse forgets to go to that TAR. Review of the facility policy titled Wound Care, revised 12/2020 revealed it was the policy of this facility to provide therapeutic treatment to heal wounds. Document the assessments, care and treatments administered.

Based on observation, record review and interview the facility failed to ensure fall interventions were in place as care planned for Resident #16 who had a history of falls and was assessed to be at risk for falls. This affected one resident (#16) of one resident reviewed for falls. Findings Include: Review of the medical record for Resident #16 revealed an admitted [DATE] with medical diagnoses including unspecified dementia with behavioral disturbance, generalized anxiety disorder, abnormalities of gait and mobility, muscle weakness and Alzheimer's Disease. Review of the plan of care, dated 04/19/21 revealed Resident #16 was at risk for falls. Interventions included bed in lowest position except when providing direct care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/04/21 revealed the resident had severely impaired cognition with a Brief Interview of Mental Status (BIMS) score of three. The assessment revealed the resident required limited assistance from one staff with bed mobility, ambulation and transfers. The assessment revealed the resident had not had any falls at the time of the assessment. Review of the nurse's notes from 08/01/21 through current revealed the resident experienced falls on 08/15/21, 11/01/21 and 11/09/21. On 12/01/21 at 10:33 A.M. and 3:15 P.M. observation of Resident #16 revealed the resident was laying in bed in her room. The bed was not in the lowest position and the resident was not receiving any direct care at the times of the observations. Observation and interview on 12/01/21 at 3:21 P.M. with State tested Nursing Assistant (STNA) #266 confirmed Resident #16's bed was not in the lowest position. The STNA used the bed remote control to lower the resident's bed at the time of the observation/interview. Review of the facility policy titled Falls Policy, revised 10/2018 revealed it was the policy of this facility to complete a review of resident fall risk and implementation of interventions to attempt to prevent or reduce falls/accidents and injuries related to falls. Furthermore, current interventions would be reviewed, and a new intervention implemented to reduce the risk of a fall.

Based on record review and staff interview the facility failed to ensure Resident #1, who was identified as having had a significant weight loss, had documented evidence of substitutes being offered when the resident ate less than 50% of her meal as per her plan of care. This affected one resident (#1) of four residents reviewed for nutrition. Findings Include: A review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/09/21 revealed the resident did not have any communication issues and was cognitively intact. No behaviors or rejection of care was noted. The resident required supervision with set up help for eating. Her height was 68 inches and her weight was 209 pounds. She was noted to have had a significant weight loss while not on a physician prescribed weight loss program. A review of Resident #1's care plans revealed she had a care plan in place for an alteration in nutrition related to multiple chronic health issues and weight changes. Interventions included offering the resident a substitution if she ate 50% or less of her meal. A review of Resident #1's nutrition assessment dated [DATE] for a quarterly review revealed the resident's meal intakes were between 25 and 50%. The assessment confirmed she was known to have a loss of 5% or more in the past month or a 10% or more loss in the last 6 months. The resident was reported to have had a 12% or 30 pound loss in six months. A review of Resident #1's current meal intakes on a tracking form revealed the resident was known to eat 50% or less 79 out of 90 meals that were provided. The meal tracking form did not provide any documented evidence of Resident #1 being offered a substitute when she ate 50% or less of her meal. The meal intake tracking form included a space for the staff to document substitutes when offered and the percentage of the substitute taken. The staff were recording fluid amounts in that space instead of documenting a substitute being offered or the percentage taken. On 12/01/21 at 8:21 A.M., an interview with State tested Nursing Assistant (STNA) #262 revealed Resident #1 typically did not eat much for breakfast but did better with lunch and supper. She stated staff were supposed to offer a substitute if the resident ate 50% or less of her meal. She acknowledged the resident's meal intake tracking form had a place to document when substitutes had been offered when the resident ate 50% or less. Staff were to indicate the number offered and percentage taken. She verified the resident's meal intake tracking form was being marked incorrectly as it had fluid amounts recorded in the space where they should be recording the percentage of a substitute that was consumed by the resident. She acknowledged there were multiple days where the resident was noted to eat 50% or less with no documented evidence of a substitute being offered. On 12/01/21 at 2:10 P.M., an interview with the Director of Nursing (DON) confirmed Resident #1 had a significant weight loss over the past six months and was not on a physician prescribed weight loss program. The DON was asked about the meal intake tracking form including fluid amounts where the staff should have been documenting substitutes being offered and the percentage of that substitute that had been accepted. She initially thought the numbers added were the milliliters (mls) of a supplement that had been given as a substitute, but when verifying the amounts entered (as high as 720 ml) she agreed it appeared to be the amount of fluids consumed during the meals. She stated if it was a supplement amount taken it would be either 120 mls or 240 mls. The DON acknowledged, in order for the facility to show adequate monitoring of Resident #1's nutritional status, they should have documented evidence of the percentage of any substitutes that may have been offered when the resident ate 50% or less of her meal. She also acknowledged that documentation was needed to show staff were offering substitutes to help maintain her nutrition when she ate 50% or less of her meal served.

Based on observations, medical record review, and staff interview, the facility failed to monitor the use of a helmet which resulted in harm to Resident #47 when the resident developed a stage two pressure ulcer (Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) on the forehead which had purulent drainage with a foul odor requiring treatment with antibiotics. In addition, the facility failed to do weekly monitoring of stage four pressures ulcers for Resident #24 per facility policy to assess for improvement or decline. This affected two of three residents reviewed for pressure ulcers (Residents #24 and #47). The facility identified two residents in the facility with pressure ulcers (Residents #24 and #44). The facility did not identify Resident #47 as having a pressure ulcer. The facility census was 48. Findings include: 1. Observations on 06/10/19 at 12:48 P.M. revealed Resident #47 had an open area on the center of her forehead with a clear adhesive dressing covering the area. At that time, State tested Nursing Assistant (STNA) #149 said the resident had been wearing a helmet due to repeated falls and the helmet rubbed an area on her forehead. Review of the medical record for Resident #47 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. A Minimum Data Set assessment completed 05/19/19 indicated the resident had long and short term memory problems, required extensive assistance from two staff for dressing and personal hygiene, and had no pressure ulcers. Review of the plan of care dated 11/04/17 revealed the resident was at risk for impaired skin integrity related to poor nutrition and incontinence. The plan of care indicated to pad and protect skin as needed, skin assessments as ordered, and treatments per order. Review of nurses progress notes dated 04/15/19 at 9:05 A.M. revealed the resident fell and hit her head on the floor. The note indicated the resident had two knots to the upper center of the forehead. The physician was notified and new orders were received to monitor the two hematomas for signs and symptoms of infection and swelling and to apply a helmet to the head while out of bed as tolerated. Review of the treatment administration record for (MONTH) 2019 revealed monitoring of the two hematomas continued until 04/30/19. There was no evidence of any monitoring of the hematomas after 04/30/19. The treatment administration record for (MONTH) 2019 had documentation of the helmet being used while out of bed as tolerated. There was no evidence of any monitoring of the skin on the head to assess for rubbing by the helmet. Review of nurses progress notes dated 05/01/19 at 6:30 A.M. revealed the resident was found on the floor and was noted to have a laceration to left side of forehead. A skin grid signed 05/04/19 indicated the resident had a laceration to the left side of the forehead from a fall. Review of a physician progress notes [REDACTED]. The staff reported over the last few days it had appeared to worsen. She did have an order for [REDACTED]. There was some yellow slough (dead tissue) in the wound bed. This wound also had a foul odor when the bandage was removed. An order was given to cleanse the wound and apply wound gel and cover with a dressing. Antibiotics were ordered for five days for possible wound infection. A physician's orders [REDACTED]. However, review of the Medication Administration Record [REDACTED]. Review of the treatment administration record for (MONTH) 2019 revealed the nurses continued to document the helmet to the head while out of bed every day in (MONTH) 2019 even though the physician stated on 05/14/19 that it was being left off so it would not rub the forehead. On 05/15/19 a physician's orders [REDACTED]. Review of the treatment administration record revealed no evidence of a dressing change being done in (MONTH) 2019. Interview with Corporate Registered Nurse #140 on 06/17/19 at 11:12 A.M. confirmed there was no evidence of a treatment being completed to the forehead in (MONTH) 2019. Review of a hospice registered nurse note on 05/16/19 revealed upon arrival, Resident #47 was walking in the hallway with a helmet on. The note stated the helmet had rubbed a sore on her forehead measuring 1.5 centimeters long by 2.5 centimeters wide (The hospice notes were not available at the facility until requested on 06/17/19 per Corporate Registered Nurse #140 on 06/17/19 at 3:30 P.M.). Review of nurses notes on 05/27/19 at 1:36 P.M. revealed the resident had purulent drainage from [MEDICAL CONDITION] with foul odor noted. The physician was notified and an order was received for an antibiotic (Bactrim DS 800/160 milligrams for seven days). Review of the Medication Administration Record [REDACTED]. However, the antibiotic was documented as given once daily from 05/27/19 through 05/30/19. Review of nurses notes on 05/28/19 at 8:06 P.M. revealed the resident was noted on the floor with blood dripping from her face. Laceration to forehead bleeding. The resident was sent to the hospital. Hospital records on 05/28/19 indicated the resident had a two centimeter circular wound to the forehead which appeared to be chronic with eschar (dead hard tissue) formation and an absorbable stitch in place. The resident returned to the facility. There was no further evidence of any monitoring of the wound on the forehead by the facility. The visit notes from the hospice registered nurse received on 06/17/19 did have measurements as follows: 05/30/19 helmet has rubbed a sore on forehead 1.5 centimeters (cm) long and 2.5 cm wide. 06/13/19 helmet has rubbed a sore on forehead 1.5 cm long and 2.5 cm wide and 0.1 cm deep but healing at this time. 06/16/19 wound on forehead 1.5 cm long by 1 cm wide by 0.2 cm deep. Observations on 06/13/19 at 1:45 P.M. revealed Resident #47 had a 1.4 cm long by 2 cm wide by 0.2 cm deep circular open area mid forehead near the scalp. The open area had red tissue in the center of the wound. Interview with Licensed Practical Nurse #118 on 06/13/19 at 2:00 P.M. confirmed there was no evidence of any monitoring or measurements of the open wound on the forehead. She stated the area did not look like a laceration and stated it looked bad. She confirmed there was no evidence of any monitoring for rubbing by the helmet since it was ordered. Interview with Physician #131 on 06/13/19 at 2:30 P.M. revealed the edge of the helmet lined up with the open area on the forehead. He stated, at this point, he could not determine if it was a pressure ulcer or from an infected laceration but helmets did rub. He confirmed the helmet should have been monitored for rubbing. He stated the helmet should be discontinued. Observations on 06/17/19 at 8:53 A.M. and 4:05 P.M. revealed Resident #47 had a helmet on her head. Interview with Corporate Registered Nurse #140 on 06/13/19 at 1:43 PM revealed skin assessments/measurements were to be done and documented weekly. She confirmed the facility did not have a policy regarding this but were to follow CMS guidelines. 2. Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 30 day Minimum Data Set (MDS) 3.0 assessment completed on 04/14/19 revealed no cognitive impairment and no behaviors were identified. The MDS 3.0 assessment identified total dependence with activities of daily living and identified Resident #24 as having a Stage 4 unhealed pressure ulcer with pressure reducing devices for chair and bed, a turning program, and pressure ulcer skin care. Review of physician orders [REDACTED]. 1. Cleanse left lower buttocks with normal saline or wound wash, apply Santyl (enzymatic debrider) and cover with calcium alginate daily. 2. Cleanse right posterior ischial with normal saline or wound wash, apply Dakin's 0.125% soaked gauze and cover with clean dry dressing two times daily. 3. Cleanse coccyx with normal saline or wound wash, apply Dakin's 0.125% soaked gauze and cover with clean dry dressing two times daily. 4. Surgery scheduled on 06/21/19 for debridement bone, drainage wound, acetabuloplasty with resection femoral head (Girdlestone) left perineal. Resident #24 had a physician order [REDACTED]. Review of the Plan of Care (P[NAME]) for Resident #24 revealed a pressure ulcer to the left gluteal fold (left lower buttocks), right gluteal fold (right posterior ischial) and coccyx were present upon admission related to Resident #24's non-compliance with turning, positioning, dressing change and [DIAGNOSES REDACTED]. Moon boots, Roho cushion to wheelchair, pressure reducing mattress to bed and treatments per physician order. Review of the Skin Grid Pressure 3.0 assessment in the electronic record for Resident #24's left lower buttock revealed weekly skin assessment completed on 12/28/18, 04/11/19, 05/15/19, 05/27/19, and 06/09/19. The skin grid pressure 3.0 documentation did not include the date the skin condition was acquired, and the report dated 06/09/19 with depth of 3 centimeter (cm) and 05/27/19 with depth of 2.5 cm identified the area as unstageable although the area was identified as a Stage IV pressure ulcer from 12/28/19 through 05/27/19. No other records were available for review regarding the left lower buttock pressure ulcer. Review of Resident #24's admission nursing assessment dated [DATE] identified the pressure ulcer was present on admission. Review of the Skin Grid Pressure 3.0 assessment in the electronic record for Resident #24's right posterior ischial revealed weekly skin assessment completed on 12/28/19, 05/15/19, 05/27/19 and 06/09/19. The skin grid pressure 3.0 documentation did not include the date the skin condition was acquired. No other records were available for review regarding the right posterior ischial pressure ulcer. Review of Resident #24 admission nursing assessment dated [DATE] identified the pressure ulcer was present on admission. Review of the Skin Grid Pressure 3.0 assessment in the electronic record for Resident #24's coccyx revealed weekly skin assessment completed on 05/15/19, 05/27/19 and 06/09/19. The skin grid pressure 3.0 documentation did not include the date the skin condition was acquired and the report dated 05/15/19 identified a depth of 1.7 cm, the 05/27/19 report identified a depth of 1.2 cm, and the 06/09/19 report identified a depth of 1.5 cm. No other records were available for review regarding the coccyx pressure ulcer. Review of Resident #24's admission nursing assessment dated [DATE] identified the pressure ulcer was present on admission. During observation of dressing change on 06/12/19 from 4:25 P.M. to 5:06 P.M. by Licensed Practical Nurse (LPN) #118, treatments were provided per physician order [REDACTED]. On 06/12/19 at 5:06 P.M. during an interview with LPN #118 she reported Resident #24 would often refuse dressing changes on day shift due to she was awake at night and did not want to be bothered during the day. LPN #118 stated she had worked with Resident #24 since admission and the areas did appear to be improving. LPN #118 reported Resident #24 liked the current wound doctor and had become more compliant with treatments, including staying off her back. LPN #118 reported weekly documentation of measurements, description of wound would be documented on the weekly Skin Grid Pressure 3.0 assessment or in progress notes. On 06/13/19 at 1:43 P.M. during an interview with Registered Nurse (RN) #140 she stated that skin assessments with measurements would be located in the electronic medical record under Skin Grid Pressure 3.0 or in the progress notes. All pressure areas should be assessed and documentation completed on a weekly basis. RN #140 confirmed weekly documentation/measurement of Resident #24's wounds was not present in the medical record. When surveyor requested a policy regarding the weekly monitoring of pressure area, RN #140 reported the facility did not have a written policy however this was a scope of practice and staff were to follow CMS guidelines.

Based on observation, staff interview, policy review, and medical record review the facility failed to ensure residents with limited range of motion (ROM) received services to maintain their range of motion. Actual harm occurred when Resident #20 did not receive services to maintain his ROM and experienced a decline in ROM to his hips and knees and developed limited range of motion to his right shoulder and elbow. This affected two of four sample residents (Resident #12 and #20) reviewed for limited range of motion. The facility census was 48. Findings include: Review of Resident #20's medical record revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #20's Occupational Therapy Assessment discharge summary dated 08/09/18 revealed no upper body contractures. No restorative nursing program was recommended. Review of Resident #20's Physical Therapy discharge summary dated 08/09/18 revealed he had contractures of both hips and knees. No restorative nursing program was recommended. Review of Resident #20's annual Minimum Data Set (MDS) assessment dated [DATE] revealed his speech was unclear, sometimes he understood, sometimes he's understood, and severely impaired decision making. Resident #20 did not reject care. Resident #20 was dependent on two staff for bed mobility, transfers, dressing and dependent on one staff for personal hygiene. Resident #20 had functional limitations on one side of both upper and lower extremities. Review of Resident #20's orders revealed on 06/04/19 Occupational and Physical therapies were ordered as staff reported a decline in Resident #20's functioning. Review of Resident #20's 06/06/19 Occupational Therapy assessment revealed Resident #20 had right shoulder and elbow contracture. Review of Resident #20's 06/06/19 Physical Therapy assessment revealed his hips and knees were more contracted. Review of Resident #20's plan of care revealed no care plan for range of motion. There was no evidence Resident #20 received range of motion. Observation of Resident #20 on 06/11/19 at 4:47 P.M. revealed his hips and knees were contracted. Interview of State tested Nursing Assistant (STNA) #109 on 06/17/19 at 1:45 P.M. revealed Resident #20 use to get out of bed but now he refused because his legs were contracted and he had a lot of pain. Interview of Licensed Practical Nurse (LPN) #102 on 06/17/19 at 1:51 P.M. revealed therapy was ordered for Resident #20 due to contractures. Interview of Certified Occupational Therapist Assistant (COTA) #163 on 06/18/19 at 8:01 A.M. revealed the doctor ordered therapy for Resident #20 because he was getting contracted. She stated the goal for him was to increase right shoulder and elbow ROM. COTA #163 stated Resident #20 had pain before, but now it was worse. On 06/19/19 at 11:30 A.M., COTA #163 stated Resident #20 had declined from when he previously received therapy. COTA #163 stated Resident #20 now had a contracture of his shoulder and elbow that he did not have before. COTA #163 stated they did not refer residents for restorative nursing programs as there was no restorative program and there was not staffing to do the programs. Interview Physical Therapy Assistant (PTA) #161 on 06/18/19 at 8:07 A.M. revealed Resident #20 had contractures of hips and knees. PTA #161 stated he had not tried to get him to sit because Resident #20 was so contracted. PTA #161 stated Resident #20 previously would sit in a chair but not now. On 06/19/19 at 11:31 A.M., PTA #161 stated Resident #20 had a decline in his contractures. PTA #161 stated the contractures were awful. PTA #161 stated Resident #20 was not referred to restorative nursing as there was no restorative program to refer him to. Interview of the Director of Nursing (DON) on 06/19/19 at 11:42 A.M. confirmed there was no evidence Resident #20 received range of motion. 2. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set 3.0 assessment completed on 03/08/19 identified Resident #12 had moderate cognition and impairment of both lower extremities. Review of a physician order [REDACTED].#12 had an order for [REDACTED]. A review of the Plan of Care for Resident #12 identified the resident was at risk for decline in range of motion related to arthritic pain and right foot drop with a goal the resident would show no decline in range of motion. Interventions included therapy to evaluate and treat as ordered. Interview with Occupational Therapy Assistant (OTA) #163 on 06/18/19 at 4:10 P.M. revealed OT had evaluated and treated Resident #12 for wheelchair safety but had not evaluated her for right foot drop or range of motion. Interview with Physical Therapy Assistant (PTA) #161 on 06/19/19 at 7:38 A.M. revealed PT had not seen Resident #12 since she was admitted to the facility. On 06/19/19 at 7:42 A.M. Licensed Practical Nurse (LPN) #118 reported she had informed PTA #161 of the order to evaluate Resident #12 for foot drop when the physician wrote the order. LPN #118 reported the facility did not have a written policy or procedure for notifying therapy when a resident had an order, they just told them and assumed the services were delivered. LPN #118 stated therapy documentation was not in the resident's medical record.

Based on observations, medical record review, staff interview, and policy review, the facility failed to ensure the resident environment remained free of accident hazards and to provide adequate supervision and assistive devices to prevent accidents and injury. This affected eight of 48 residents residing in the facility (Residents #47, #9, #13, #19, #21, #26, #33, and #35) and resulted in harm for Resident #47 who experienced a laceration requiring four sutures, abrasions, a lip laceration with chipped teeth and multiple dental fractures. Findings include: 1. Review of the medical record for Resident #47 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. The resident resided on the secured unit. Review of a fall risk assessment completed 08/20/18 revealed a score of 15, indicating moderate fall risk. Review of a plan of care dated 11/04/18 revealed the resident was at risk for falls and potential injury. Interventions at that time included have commonly used items in easy reach, maintain a clear pathway, provide rest periods, and rehab referral. Review of a Minimum Data Set (MDS) assessment completed 11/05/18 revealed the resident had short and long term memory impairment, had wandering behaviors daily, required extensive assistance from two staff with transfers, required limited assistance from one staff with walking, and had no falls since prior assessment. Review of nurses progress notes revealed on 04/15/19 at 9:05 A.M. the nurse was called to the resident's room. Resident #47 had attempted to get out of bed while wrapped in her blankets and the resident slipped on part of the blanket that was on the floor. The resident fell into the floor and hit her head on the floor. The resident was noted to have two knots to the upper center of her forehead. A physician's orders [REDACTED]. A non skid fall mat was also ordered for the right side of the bed. Review of nurses progress notes revealed on 05/01/19 at 6:30 A.M. the nurse was called to the resident's room by staff on the unit. The resident was found on the floor. The resident was on her hands and knees next to her bed. Blood was noted on her face, clothing, and the floor. The resident had a laceration (2 centimeters (cm) by 0.8 cm by 0.2 cm) on the left side of the forehead, and a small abrasion to the left ear. During neurological checks, the resident was noted to have a change in mental status (lethargy) and the resident was sent to the hospital. Review of hospital records revealed on 05/01/19 Resident #47 was noted to have a laceration to the forehead requiring four sutures. The resident was admitted to the intensive care unit with hypothermia, [MEDICAL CONDITION], dehydration, [MEDICAL CONDITION], and [DIAGNOSES REDACTED] (blood sugar 69). The resident returned to the facility on [DATE]. Review of the fall investigation form for 05/01/19 revealed the resident ambulated/transferred without assistance due to confusion/dementia. A low bed/bed to floor was added as an intervention. Review of a physician progress notes [REDACTED].#47 had functional and cognitive declines. The note indicated she could not safely walk without assistance and had multiple falls. Nurses progress notes on 05/18/19 at 6:53 P.M. revealed the resident was wandering in the hall. On 05/22/19 at 1:46 P.M. the resident was noted to be wandering about the facility. Review of a Significant Change MDS assessment completed 05/19/19 revealed the resident had short and long term memory impairment, had wandering behaviors daily, required extensive assistance from two staff with transfers, required limited assistance from one staff with walking, and had one fall with major injury since the prior assessment. On 05/28/19 at 8:06 P.M. nurses progress notes indicated the nurse was called to the resident's room per staff. Resident on floor on hands and knees with blood on floor and dripping from face. Resident's lip lacerated and teeth appear chipped. Laceration to forehead bleeding. The resident was sent to the hospital for evaluation. Review of hospital records for 05/28/19 revealed Resident #47 was noted to have a lip laceration and multiple dental fractures. The resident returned to the facility. Hipsters (padding sewn into undergarments to prevent [MEDICAL CONDITION]) were added on 05/29/19 as a fall intervention. A fall risk assessment completed on 05/30/19 had a score of 18, indicating high fall risk. The assessment stated the resident was disoriented to person, place, and time at all times, had three or more falls in the past three months, was ambulatory, had poor vision, had balance problems while walking, had decreased muscular coordination, and had jerking or was unstable when making turns. Review of a physician progress notes [REDACTED].#47 was very frail and cachectic in appearance. It stated the resident was very unsteady, had a high risk of falling, and should not be walking independently. Observations on 06/12/19 at 11:42 A.M. revealed Resident #47 walking by herself in her room with the door closed. There were no staff observed. After the surveyor opened the bedroom door, the resident came out of the room and began walking in the hallway unassisted. The resident was not wearing a helmet. Interview with State tested Nursing Assistant (STNA) #154 on 06/12/19 at 1:00 P.M. revealed there were two nursing assistants assigned to care for the 13 residents who resided on the secured unit and the 12 residents who resided on middle hall (a unit outside of the secured unit) at all times. The STNAs worked 6:00 A.M. to 6:00 P.M. and 6:00 P.M. to 6:00 A.M. shifts. STNA #154 said when a STNA had to leave the secured unit to care for a resident on the middle hall, it left one STNA to supervise the 13 residents on the secured unit. STNA #154 said staff could not supervise all of the residents and more staff was needed. Interview with STNA #158 on 06/12/19 at 1:05 P.M. confirmed there were two STNAs to care for the 13 residents on the secured unit and the 12 residents who resided on the middle hall (a unit outside of the secured unit) at all times. She stated it was difficult to supervise the residents on the secured unit. Interview with Licensed Practical Nurse (LPN) #107 on 06/12/19 at 1:24 P.M. revealed she was the nurse for the secured unit (13 residents) and the middle hall (12 residents). She confirmed there were two STNAs from 6:00 A.M. to 6:00 P.M. to provide care for the residents on the secured unit and the middle hall. She stated there were a lot of falls on the secured unit and if there were more staff, they could supervise residents more. The facility identified six residents on the middle hall that required the assistance of two staff with activities of daily living and three residents on the secured unit that required the assistance of two staff with activities of daily living including Resident #47; In addition, the facility identified five residents on the middle hall who required extensive assistance from one staff with activities of daily living and nine residents on the secured unit who required extensive assistance from one staff with activities of daily living. Observations on 06/17/19 at 9:35 A.M. revealed one STNA, STNA #154 providing care for the 13 residents on the secured unit and the 12 residents on the middle hall (outside of the secured unit). STNA #154 confirmed she was the only STNA at that time for the secured unit and the middle hall. She stated she was not supposed to leave the secured unit unless another staff was present. She stated the only other staff present was LPN #107 and she was passing medication on the middle hall. She stated that she could not get Resident #47 to stay in bed and she was walking with her eyes closed and was probably going to face plant soon. On 06/17/19 at 4:00 P.M., STNA #154 confirmed Resident #47 still walked by herself and was doing so at that time. She stated there had been no change in her supervision level since she had fallen. On 06/17/19 at 4:05 P.M. Resident #47 was observed standing in the hallway of the secure unit holding onto the hand rail. The resident's knees were bent, as if she was going down to the floor. Her left foot was bare and she had a gripper sock on the right foot. There were no staff around. Interview with LPN #107 on 06/17/19 at 4:10 P.M. revealed Resident #47 walked by herself. She stated the resident constantly wanted to be on the go and was getting weaker and weaker. This morning she caught her standing with her eyes closed. LPN #107 was worried about her falling. LPN #107 was not aware there was only one STNA for the secured unit and the middle hall this morning; although, she was the nurse for these halls at that time. LPN #107 said she was not aware of the physician's progress note indicating the resident should not be walking independently. She stated unless the resident was 1:1 supervision staff would be unable to keep her from walking alone. Interview with the Director of Nursing (DON) on 06/17/19 at 4:15 P.M. revealed she was not aware there was just one STNA working on the secured unit and the middle hall that morning. She stated she knew additional staff had to be called in but did not know when they arrived. Interview with STNA #111 on 06/17/19 at 4:20 P.M. revealed she worked as a second STNA on the secured unit and middle hall from 6:00 A.M. to 8:00 A.M. but then went back to another unit (front) at 8:00 A.M. She confirmed this left one STNA on the secured unit/middle hall from 8:00 A.M. until another staff came in around 9:40 A.M. Interview with the DON on 06/17/19 at 4:30 P.M. revealed one STNA would not be able to adequately supervise the residents on the secured unit. Observations on 06/19/19 at 9:06 A.M. of the secured unit revealed there were no staff visible on the unit. One STNA and the nurse were off the unit and the second STNA was in the shower room with a resident. Resident #47 was observed walking in the hallway unassisted with no helmet on. 2. Observations on 06/10/19 at 1:00 P.M. revealed Resident #13, who was cognitively impaired, enter the secured unit dining room. Resident #13 grabbed a regular consistency sandwich crust from Resident #14 and put it in her mouth and ate it. There were no staff in the dining room. However, Licensed Practical Nurse (LPN) #113 witnessed Resident #13 to put the crust in her mouth through a window from the hallway. She then asked STNA #104 to check Resident #13's mouth for food as she was on a pureed diet. At that time, STNA #104 stated she checked Resident #13's mouth and there was no food in her mouth. Review of the medical record for Resident #13 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. A Minimum Data Set assessment completed 03/09/19 indicated the resident had short and long term memory problems. The resident had no teeth and required limited assistance from one staff with eating. Further medical record review revealed a physician's orders [REDACTED]. Interview with Speech Therapist #166 on 06/12/19 at 3:45 P.M. revealed she was working with Resident #13 on communication and swallowing. She confirmed the resident was ordered a pureed diet due to pocketing of food. She stated the resident was not safe to have a regular consistency meal. The resident needed to be supervised to ensure she was not taking food from others. Speech Therapist #66 stated she was just working with the resident in the dining room of the secured unit and the resident found Play Doh and was putting it in her mouth. She stated the Play Doh was golf ball size. Speech Therapist #166 confirmed there were no staff in the secured unit dining room where the Play Doh was during the time she worked with Resident #13. Interview with Activity Director #156 on 06/13/19 at 8:10 A.M. revealed she bought the Play Doh yesterday and confirmed it was in the secured unit dining room. Activity Director #156 said she was not aware of which residents on the secured unit that would eat things they should not. Interview with LPN #107 on 06/13/19 at 8:30 A.M. revealed Resident #13 had severe behaviors, wandered, got into everything, and tried to eat things that were not food. She stated it was difficult for staff to supervise the resident when they were trying to pass trays or feed other residents. 3. Review of the medical record for Resident #19 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. A Minimum Data Set assessment completed 06/02/19 indicated the resident had a brief interview for mental status score of 10, indicating moderate cognitive impairment. It further indicated the resident had behaviors of wandering daily. The plan of care dated 12/20/18 indicated the resident was unable to make safe decisions. Review of the medical record for Resident #21 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. A physician progress notes [REDACTED]. A Minimum Data Set assessment completed 03/30/19 indicated the resident had long and short term memory problems and required limited assistance from one staff with walking. Further record review revealed a physician's orders [REDACTED].>Observations on 06/10/19 at 9:25 A.M. revealed the door to the shower room on the secured dementia unit was unlocked, open, and unattended. Resident #21 was observed in the shower room with no staff present. All of the cabinets in the shower room were unlocked; one had a latch but there was no lock. None of the other cabinet doors had a way to lock them. Resident #21 was observed with a white/yellow substance on her hand and around her mouth. State tested Nursing Assistant (STNA) #104 was summoned from the end of the hallway and notified that Resident #21 was in the shower room unattended with a substance on her hands and mouth. STNA #104 stated the substance was eggs. STNA #104 also stated the cabinet with the latch was to be locked but there was no lock available. The door to the shower room was unlocked because no staff had a key to the shower room door. In a cabinet that could not be locked was a 1.12 gallon bottle of Pine Sol cleaner which said eye irritant and if swallowed call poison control center; two bottles of foaming bathroom cleaner with bleach (40 ounce each) with labels indicating if cleaner gets in eyes, flush with water for 15 minutes, if swallowed, contact physician, and a white gallon bottle of liquid with no label. In the cabinet with a latch but no lock there was one bottle of peri wash with a label indicating may cause eye irritation and keep out of reach of children. While the surveyor was checking to see what hazardous items were in the shower room, the staff left the room. Resident #19 then entered the room unattended. She reached up and started to open a cabinet door and reached for the bottle of peri wash. The surveyor asked the resident to wait for staff assistance and summoned staff to assist the resident. Interview with LPN #113 on 06/10/19 at 9:28 A.M. revealed she thought the unlabeled white gallon bottle contained bleach. On 06/10/19 at 9:35 A.M., LPN #118 and Social Service Director (SSD) #146 came and directed staff to take all of the chemicals out of the cabinets. At 9:45 A.M. LPN #118 and SSD #146 stated they were able to locate a key for the shower room door from the maintenance director and it was given to the nurse. They stated the administrator had a second key. SSD #146 confirmed the door was to be locked. She stated the shower room door was replaced about a month ago and they did not realize the floor staff did not have a key. On 06/10/19 at 12:14 P.M. Resident #21 was walking into the unlocked nurses station room on the secured unit. The nurse was in the shower room with another resident and there was no other staff around. There was a bottle of alcohol based hand sanitizer sitting on top of the medication cart in the nurses station. Resident #21 left on her own without staff knowing she was in the room. Additional observations on 06/10/19 at 2:55 P.M. revealed there were two jars of peanut butter and 12 glazed donuts sitting out in the nurses station room. On 06/11/19 at 12:55 P.M., the nurses station room was observed unlocked an unattended. There was a bottle of alcohol based hand sanitizer, two jars of peanut butter, a two liter bottle of Mountain Dew sitting out in the nurses station. On 06/11/19 at 12:59 P.M., LPN #113 stated they tried not to lock the nurses station in case someone needed in. She confirmed there were hazardous items in the nurses station that could be ingested by residents including alcohol based hand sanitizer. She also confirmed there were residents on pureed diets and thickened liquids that should not have access to the peanut butter and Mountain Dew. On 06/12/19 at 10:05 A.M. the nurses station was again observed unlocked and unattended. LPN #107 confirmed the door should be locked because residents could access the area and get into something they shouldn't. She confirmed there were two bottles of surgical hand scrub, two jars of peanut butter and a two liter bottle of Mountain Dew sitting out. 4. Review of Resident #9's medical record revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's smoking assessments dated 11/20/18 and 02/08/19 revealed he did not require supervision. Review of Resident #9's smoking care plan dated 12/04/18 revealed he was at risk for injury related to smoking. The staff were to encourage the resident to express feelings/frustrations. validate concerns. Review of of Resident #9's quarterly Minimum Date Set (MDS) assessment dated [DATE] revealed his speech was clear, he understood, understands, and his cognition was intact. Resident #9 used tobacco. Observation of Resident #9 on 06/11/19 at 4:45 P.M. revealed he was in his room sitting on his bed with cigars and a lighter in his shirt pocket. Resident #9 stated he kept his lighter until the end of the day when he was done smoking then he turned it in. Review of the facility's smoking policy revised dated 09/27/18 revealed lighters would be locked up after smoking breaks. Interview of the Administrator on 06/24/19 at 10:50 A.M. confirmed Resident #9 should not have his lighter all day. 5. Review of Resident #26's medical record revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #26's plan of care dated 01/16/19 revealed he was at risk for injury related to smoking. The staff were to encourage the resident to express feelings/frustrations. validate concerns. Review of Resident #26's quarterly MDS dated [DATE] revealed his speech was clear, he understands was understood, and his cognition was intact. Resident #26 used tobacco. Review of Resident #26's smoking assessment dated [DATE] revealed the resident needed a smoking apron and supervision. Observation of Resident #26 on 06/12/19 at 10:45 A.M. revealed Dietary Aide #145 was supervising him while he smoked. Resident #26 was not wearing a smoking apron and was flicking ashes on the concrete. Dietary Aide #145 was not aware Resident #26 needed to wear a smoking apron. Interview of State tested Nursing Assistant (STNA) #111 on 06/13/19 at 1:04 P.M. revealed Resident #26 required supervision for smoking and he did not use a smoking apron. Observation with and interview of Administrator #151 on 06/13/19 at 1:19 P.M. revealed four of the facility's smoking aprons were threadbare and had holes in them. Administrator #151 confirmed the smoking aprons would not protect the residents. Administrator #151 also confirmed residents flicked ashes on the ground and should be using the appropriate receptacles. 6. Review of Resident #35's medical record revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #35's admission Minimum Data Set assessment dated [DATE] revealed his speech was clear, he understands, was understood, and his cognition was intact. Resident #35 used tobacco. Review of Resident #35's smoking assessment dated [DATE] revealed he was an unsupervised smoker. Observation of Resident #35 on 06/11/19 at 4:49 P.M. revealed he was smoking and flicking ashes on the concrete. On 06/13/19 at 1:19 P.M. Administrator #151 confirmed residents flicked ashes on the ground and should be using the appropriate receptacles. 7. Review of Resident #33's medical record revealed an admission date of [DATE] with the [DIAGNOSES REDACTED]. Review of a document submitted by Resident #33's guardian revealed the resident was permitted to leave the facility when he wanted as long as it was discussed with nursing staff and he signed in and out of the facility. Review of Resident #33's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was alert and orient to person, place, and time with a Brief Interview for Mental Status (BIMS) of 14 indicating intact cognition. Resident #33 was noted to exhibit behaviors such as delusions, verbal behaviors of refusing care and refusing to follow facility's policies and procedures. Review of the facility's Leave of Absence (LOA) log revealed Resident #33 had left the facility grounds on 03/30/19 at 8:57 P.M. and again on 05/11/19 at 7:24 P.M. and had not signed in or out of the facility's LOA log. Interview on 06/12/19 at 1:20 P.M. with Registered Nurse (RN) #140 confirmed Resident #33 did have two occurrences of leaving the facility's grounds without discussing this leave with nursing staff prior or signing in or out of the facility's LOA log.

Based on observations, medical record review, and staff interview, the facility failed to ensure residents who received [MEDICAL CONDITION] drugs had adequate indication for use, non pharmacological interventions attempted prior to use, monitoring of medications for adverse consequences, and gradual dose reductions in an effort to discontinue use. This affected four of five residents reviewed for unnecessary medications (Residents #13, #15, #25, and #47) and resulted in harm to Resident #47 who experienced three falls with injuries including a laceration requiring four sutures, abrasions, a lip laceration with chipped teeth and multiple dental fractures. The facility census was 48. Findings include: 1. Review of the medical record for Resident #47 revealed an admission date of [DATE] and diagnosed including: [DIAGNOSES REDACTED]. The resident resided on secured dementia unit. Review of (MONTH) 2019 physician's orders [REDACTED]. Review of nurses notes on 12/29/18 at 2:41 P.M. revealed the [MEDICATION NAME] 1 mg every hours was started after the resident had a change in mental status. The resident was attempting to bite, chew on objects, grabbing and pulling at anything she could grab a hold of, walking with her eyes closed running into wall and and appearing to be agitated and anxious. There was no documentation to indicate the behavior was causing an immediate risk to the resident or other residents. There was no evidence the resident was evaluated for a possible underlying medical cause of the agitation and anxiety or non pharmalogical interventions being attempted prior to the use of the [MEDICATION NAME]. A physician progress notes [REDACTED]. She continued to pace without any purpose. She would hold hands or grab other residents without aggression but this had been a common behavior for her. She had nonsensical speech. The note indicated she was tolerating her current medications and seemed comfortable. Review of nurses progress notes dated 02/11/19 at 11:31 A.M. revealed the resident had increased agitation and anxiety. The resident was grabbing, tugging, and pulling other residents. The resident was aggressive with staff when redirected and entered the dining room and flipped over a table. The resident was given food and fluids but this did not decrease the agitation. The note indicated the resident was wandering in the hallway at this time and the physician was notified. Review of physician's orders [REDACTED]. Review of nurses notes revealed no other documentation of agitation in the month prior to 02/11/19. There was no documentation to indicate the behavior was causing an immediate risk to the resident or other residents. There was no evidence the resident was evaluated for a possible underlying medical cause of the agitation and anxiety, nor was there evidence of non pharmalogical interventions other than offering food and fluids being attempted prior to the use of the [MEDICATION NAME]. Review of nurses notes on 02/13/19 at 4:33 P.M. revealed the resident was declining. The resident refused to get out of bed all day and refused breakfast and lunch. The physician was notified and a new order was received for [MEDICATION NAME] 1 mg every four hours as needed between the scheduled [MEDICATION NAME]. There was no documentation regarding why the [MEDICATION NAME] was initiated and there were no behaviors documented in the nurses notes. Record review revealed the medication administration records for the as needed [MEDICATION NAME] were not available for February, March, and (MONTH) 2019 to determine how often the medication was given. The as needed [MEDICATION NAME] was discontinued 04/16/19 per pharmacy recommendation due to having an as needed [MEDICAL CONDITION] medication order in place greater than 14 days. Review of nurses progress notes revealed on 04/15/19 at 9:05 A.M. the nurse was called to the resident's room. Resident #47 had attempted to get out of bed while wrapped in her blankets and the resident slipped on part of the blanket that was on the floor. The resident fell into the floor and hit her head on the floor. The resident was noted to have two knots to the upper center of her forehead. Review of nurses progress notes revealed on 05/01/19 at 6:30 A.M. the nurse was called to the resident's room by staff on the unit. The resident was found on the floor. The resident was on her hands and knees next to her bed. Blood was noted on her face, clothing, and the floor. The resident had a laceration measuring 2 centimeters (cm) by 0.8 cm by 0.2 cm on the left side of the forehead, and a small abrasion to the left ear. Nurses notes stated during neuro checks, the resident was noted to have a change in mental status (lethargy) and the resident was sent to the hospital. However, review of the fall investigation dated 05/01/19 revealed an assessment at the time of the fall noted lethargy. Review of hospital records revealed on 05/01/19 Resident #47 was noted to have a laceration to the forehead requiring four sutures. The resident was admitted to the intensive care unit with hypothermia (rectal temperature 94 degrees Fahrenheit), [MEDICAL CONDITION], dehydration, [MEDICAL CONDITION], and [DIAGNOSES REDACTED] (blood sugar 69). The resident returned to the facility on [DATE]. Upon return from the hospital on [DATE], physician's orders [REDACTED]. There was no documentation to indicate why the [MEDICATION NAME] had been increased. Review of a physician's progress note dated 05/08/19 revealed the resident was recently hospitalized and returned to the facility. Initially the patient was sleeping and was difficult to awaken. When the staff came in to feed her she did awaken. She was very thin and frail. She was non verbal at this time. She had not been ambulating since she returned from the hospital. The staff reported she would grab staff and others. She had not been having any behaviors at this time. The resident had functional and cognitive declines. She could not safely ambulate without assistance and had multiple falls. There was no evidence Resident #47's medications were evaluated for contributing to the falls. On 05/08/19 the routine [MEDICATION NAME] was changed to [MEDICATION NAME] 1 mg every 8 hours as needed for [MEDICAL CONDITION] with agitation for 14 days then call for new order. On 05/22/19 (14 days later) a nurses progress note timed 6:49 P.M. indicated the resident was sitting in the dining room with no complaints of pain or discomfort at this time. New order for [MEDICATION NAME] 1 mg twice daily for terminal agitation. On 05/28/19 at 8:06 P.M. nurses progress notes stated the nurse was called to the resident's room per staff. Resident on floor on hands and knees with blood on floor and dripping from face. Resident's lip lacerated and teeth appear chipped. Laceration to forehead bleeding. The resident was sent to the hospital for evaluation. Review of hospital records for 05/28/19 revealed Resident #47 was noted to have a lip laceration and multiple dental fractures. The resident returned to the facility. The fall investigation report on 05/28/19 stated the resident had lethargy at the time of the fall. Record review revealed all medications except [MEDICATION NAME], and [MEDICATION NAME] were discontinued on 05/31/19. Review of a physician progress notes [REDACTED]. She has had a recent decline in her condition. She was at this time unable to swallow her medications. She was taking her comfort care meds, such as [MEDICATION NAME], and [MEDICATION NAME]. Interview with Licensed Practical Nurse #148 on 06/13/19 at 8:54 A.M. revealed he completed the Minimum Data Set (MDS) assessments for all residents of the facility. He stated he also had two other facilities to do MDS assessments for and did not know the residents very well. He stated the social service director was too busy to complete behavior assessments. Interview with Social Service Director #146 on 06/13/19 at 9:35 A.M. revealed she just started working in social services in (MONTH) (YEAR). She stated she had nothing to do with the use of psychoactive medications or monitoring of behaviors for residents. Interview with Corporate Registered Nurse #140 on 06/17/19 at 11:12 A.M. confirmed there was no evidence of an evaluation for what was causing the mental status change for Resident #47 on 12/29/18 when the [MEDICATION NAME] was started. She stated the behavior monitoring sheets for (MONTH) (YEAR) were not dated but did not identify any behaviors exhibited except wandering, pacing, and poor intake. She confirmed there was no indication for use for the [MEDICATION NAME]. She confirmed the resident was already on [MEDICATION NAME], and [MEDICATION NAME], the resident was started on [MEDICATION NAME] routinely on 02/11/19, the resident was started on as needed [MEDICATION NAME] on 02/13/19 with no indication for use, and there were no medication administration records available for February, March, or (MONTH) to determine how often the as needed [MEDICATION NAME] was given. Interview with LPN #118 on 06/17/19 at 2:17 P.M. confirmed Resident #47 came back from the hospital on an increased dose of [MEDICATION NAME] on 05/05/19 without reason. She confirmed there was lethargy documented with the falls on 05/01/19 and 05/28/19 without evidence the medication use was evaluated related to the falls. 2. Review of the medical record for Resident #13 revealed an admission date of [DATE] and diagnosed including: [DIAGNOSES REDACTED]. The resident resided on the secured dementia unit. The resident had a physician's orders [REDACTED]. The resident was also receiving [MEDICATION NAME] 250 mg twice daily. Record review revealed the [MEDICATION NAME] was decreased to 0.5 mg at bedtime on 03/21/19. All other medication dosages remained the same. An admission Minimum Data Set (MDS) assessment completed 03/09/19 indicated the resident had short and long term memory problems. A quarterly MDS assessment completed 06/09/19 indicated the resident had no physical behavior, no verbal behavior, no other behavior directed toward others and no rejection of care. It identified wandering daily. It also indicated the resident had hallucinations and delusions, the resident received antianxiety, antidepressant, and antipsychotic medications and there had been no dose reduction and no physician documentation that a gradual dose reduction was clinically contraindicated. Review of behavior assessments completed 03/02/19 and 06/04/19 revealed physical behaviors toward others (hitting, kicking, pushing), verbal behaviors towards others, other behavioral symptoms, and rejection of care were not exhibited. Both identified wandering daily. The assessments did not indicate the wandering interfered with the resident's functioning. Review of behavior flow records for (MONTH) 2019 revealed monitoring for pacing, exit seeking, putting non food items in mouth, and [MEDICAL CONDITION]. Review of the plan of care revealed the resident had non compliance and physical aggression. The care plan indicated the resident had refusal of medications, personal care, preventative care, and safety measures but no further specifics were given. There was no documentation in the medical record to support the continued use of the [MEDICAL CONDITION] medications. Interview with Licensed Practical Nurse (LPN) #148 on 06/13/19 at 8:54 A.M. revealed he completed the Minimum Data Set (MDS) assessments for all residents of the facility. He stated he had two other facilities to complete MDS assessments for and he did not know the residents at the facility very well. He stated Resident #13 paced a lot but did not cause a lot of issues with other residents. LPN #148 confirmed besides exit seeking and wandering there were no other behaviors monitored or documented for the resident prior to (MONTH) 2019. In (MONTH) 2019, the behavior tracking sheets included pacing, exit seeking, putting non edible food items in mouth, and [MEDICAL CONDITION]. LPN #148 said the social service director was too busy to do any behavior assessments and the staff were terrible about charting behaviors. He said the staff would say residents had terrible behaviors but there was nothing documented to verify it. He confirmed the plan of care did not address what the medications were used for, there was no evidence of any refusals as per the plan of care, there was no documentation of hallucinations or delusions as marked on the MDS, there was no evidence of any assessment of behaviors, there was no evidence of any physical aggression as documented on the plan of care, and there were no behaviors documented to support the use of the [MEDICAL CONDITION] medications. Interview with Social Service Director #146 on 06/13/19 at 9:35 A.M. revealed she just started in social services in (MONTH) (YEAR). She stated she did not have anything to do with the use of [MEDICAL CONDITION] medications or monitoring of behaviors. 3. Review of Resident #15's medical record revealed an original admission date of [DATE] with the latest readmission on 05/06/19 with the admitting diagnoses of [MEDICAL CONDITION] [MEDICAL CONDITION] reflux disease (GERD), diabetes mellitus and malignant neoplasm of the rectum. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, made herself understood and had no cognitive deficit as indicated by a Brief Interview for Mental Status (MDS) of 15. Review of the mood and behavior revealed the resident had indicators of depression and displayed no behaviors. The MDS indicated the resident received insulin, antipsychotic, antianxiety and antidepressant. Review of the resident's plan of care dated 04/28/16 revealed the resident had an alteration in mood and behavior related to depression, anxiety and [MEDICAL CONDITION] disorder. Interventions included, realistically discussing resident's weakness and determine options to improve the resident, social service director one on one as needed and talk with resident about setting realistic self-expectations and goals. Review of the resident's monthly physician's orders [REDACTED]. Review of the resident's monthly behavior and intervention flow record revealed the facility was not monitoring target behaviors associated with the use of the medications [MEDICATION NAME], Trazadone and [MEDICATION NAME]. On 06/18/19 at 2:29 P.M. interview with Registered Nurse (RN) #140 verified the facility had not identified or monitored target behavior to justify the use of the antidepressant and antianxiety medications. 4. Resident #25 was admitted to the facility on [DATE] with diagnoses of metabolic [MEDICAL CONDITIONS], moderate intellectual disabilities, depression, [MEDICAL CONDITION], pseudobulbar affect, [MEDICAL CONDITION], delusional disorders and anxiety. A review of the quarterly Minimum Date Set (MDS) 3.0 assessment dated [DATE] indicated Resident #25 was severely cognitively impaired. The MDS 3.0 assessment also identified Resident #25 as having little interest or pleasure in doing things, feeling or appearing down, depressed or hopeless, trouble falling asleep, and trouble concentrating. No indicators for [MEDICAL CONDITION] was identified. The physician orders [REDACTED].M. and 4:00 P.M., [MEDICATION NAME] 750 mg at bedtime, [MEDICATION NAME] (a medication used to treat anxiety) 2 mg three times daily, and [MEDICATION NAME] 2 mg (a medication for psychotic agitation) two times daily. Review of the physician progress notes [REDACTED].#25 had episodic agitation and yelling behaviors, or scoots around on the floor. A review of the Plan of Care (P[NAME]) for Resident #25 indicated a risk for adverse reactions related to psychoactive medications and to monitor for side effects related to [MEDICAL CONDITION] medications. Resident #25's P[NAME] also identified behavioral symptoms such as hitting, pushing, grabbing, pinching, history of verbal screaming, creating disruptive sounds, hitting walls with hands, hitting walls with feet and hitting head on wall and resident would crawl on the floor to get somewhere due to his inability to see. The behavior/intervention monthly flow record identified behaviors such as aggressive with staff, anxiety, yelling out, putting self on floor, refusal of meals, refusal of medications or treatments. Licensed Practical Nurse (LPN) #102 reported on 06/12/19 at 8:54 A.M. she was familiar with Resident #25. LPN #102 stated most of his behaviors were related to wanting something. Resident #25 was easily redirected and LPN #102 could not identify any psychotic behaviors. When asked if he was receiving antipsychotic medications she stated yes, however was not sure why so the medications must be working. On 06/18/19 at 12:38 P.M. during an interview with State tested Nurse Aide (STNA) #136 she reported caring for Resident #25 on a regular basis. STNA #136 stated Resident #25 was blind and needed extra care. She described Resident #25 as very sweet and easily redirected. When asked if Resident #25 yelled out or hit the door on her shift, STNA #136 reported this happened on a daily basis. STNA #136 stated she did not feel this was a behavior, rather his way to communicate his needs. During an interview with the Director of Nurses (DON) and LPN #118 on 06/18/19 at 1:04 P.M., the DON reported she was unable to determine when a gradual dose reduction for Resident #25 had last been attempted and confirmed no monitoring of antipsychotic behaviors. The DON confirmed Resident #25 had a [DIAGNOSES REDACTED].

Based on observations, medical record review, staff interview, resident interview, and review of the facility policy on skin assessment and documentation guide, the facility failed to ensure that a resident who entered the facility without a pressure ulcer did not develop a pressure ulcer. This resulted in physical harm for Resident #22 when the resident developed an identified deep tissue injury on the right heel that required excisional skin debridement. This affected one of three residents reviewed for pressure ulcers (Resident #22). The facility identified three residents with pressure ulcers. The facility census was 51. Findings include: Review of the medical record for Resident #22 revealed the resident was admitted to the facility 07/13/16 after a hospital stay for a repair of a fractured right leg requiring an [DEVICE] (external fixation is a method of immobilizing bones to allow a fracture to heal. It is accomplished by placing pins or screws into the bone on both sides of the fracture. The pins are then secured together outside the skin with clamps and rods and are known as the external frame). The resident also had [DIAGNOSES REDACTED]. Review of a skin assessment completed on 07/13/16 revealed Resident #22 had an [DEVICE] on the right lower leg with four pins. There was no indication of any pressure ulcers. Review of a pressure ulcer risk assessment completed on 07/13/16 revealed that Resident #22 was low risk for the development of a pressure ulcer. Review of a physician's progress note dated 07/13/16 revealed that Resident #22 fell and broke his leg and required immobilization with external fixation and was admitted to the facility for care and rehab. The progress note stated the resident's skin was warm and dry with no pressure injury. Review of a quarterly Minimum Data Set assessment completed 08/02/16 revealed Resident #22 was not at risk of developing a pressure ulcer and did not have any pressure ulcers. Review of a plan of care dated 07/13/16 revealed Resident #22 was at risk for impaired skin integrity related to surgical site, diabetes, and immobilizer to right foot. The goal was for the surgical site to heal without complications. Interventions on 07/13/16 included inspect skin during routine daily care, pad and protect skin as needed, pressure reduction devices if ordered, skin assessment as ordered, and treatments per order. There was no evidence of an order for [REDACTED]. Interventions on 07/13/16 included monitor/document/report to physician as needed: [MEDICAL CONDITION], bruising/discoloration of skin, skin temperature changes, loss of sensation distal to fracture, presence/absence of pulses distal to fracture, if cast is present, skin breakdown or trauma at cast edges. If orthopedic fixation device or traction is present, follow physician orders for monitoring, maintaining device, and providing skin care. Record review revealed no evidence of any monitoring of the skin on the right leg to determine if the [DEVICE] device/cast was rubbing or causing pressure on the skin. Review of a skin grid tool revealed that on 08/16/16 Resident #22 was noted to have a suspected deep tissue injury pressure ulcer on the right heel measuring 1.8 centimeters (cm) long by 1.2 cm wide. The area was described as non blanchable deep purple area on the heel with skin intact and boggy. The physician was notified and an order obtained on 08/16/16 to apply skin prep to the right heel every shift and encourage the resident to float his heels. Review of the plan of care revealed that on 08/16/16 an intervention was added to encourage resident to elevate heels off of bed. Review of a physician's progress note dated 08/25/16 revealed that Resident #22 was noted with a suspected deep tissue injury on the right heel with black tissue measuring 2.3 cm by 1.0 cm. The note stated the resident was non compliant with efforts to control diabetes with diet and insulin use resulting in elevation of blood glucose levels. Wound healing is delayed with this pattern. Risk of worsening is clear and possibility of amputation a real danger. Resident #22 was seen by a wound care service on 08/26/16 and excisional debridement of the heel was done. The area was noted to measure 5.2 cm long by 3.6 cm wide by 0.1 cm deep. On 08/29/16 the wound care service documented the right heel measured 2 cm long by 1.8 cm wide, and had eschar (thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties and biological activity). and a second area on the right posterior foot measured 4 cm long by 3 cm wide by 0.1 cm deep and excisional debridement was done. On 09/12/16 the wound care service documented the right heel measured 4 cm long by 3.5 cm wide and had eschar and an area on the right posterior foot measured 7 cm long by 4 cm wide with 0.1 cm deep and excisional debridement was done. On 10/24/16 the treatment of [REDACTED]. On 11/15/16 a pressure skin grid stated the blackened skin was removed from the right heel and it now measured 2.4 cm long by 1 cm wide and was 0.1 cm deep. Observations on 11/18/16 at 11:15 A.M. of Resident #22's right heel revealed a 2.8 cm by 1 cm superficial open area with a pink wound bed. No eschar was observed. No other open areas were noted. Review of the facility policy titled skin assessment and documentation guide dated 07/18/03 revealed that a head to toe skin assessment was to be completed by the nurse once per week. The completion of the assessment was to be documented by initialing the treatment administration record and documenting the findings in the nurse's notes or on the weekly skin assessment form. There was no evidence this was completed between the admission skin assessment on 07/13/16 and the area on the heel being identified on 08/16/16. Interview with the Director of Nursing on 11/18/16 at 7:15 A.M. confirmed the current area on Resident #22's heel was caused from the brace/half cast that was on his foot after surgery rubbing the heel. Interview with Resident #22 on 11/18/16 at 7:20 A.M. revealed that he had been unable to feel the half cast type device that was applied to his right leg had been rubbing his heel. He stated that he did not see the staff ever look at his heel prior to the pressure ulcer being identified on his right heel. He stated after the area developed, a wound care specialist began evaluating the area. Interview with the Director of Nursing on 11/18/16 at 2:00 P.M. revealed that Resident #22 had a plastic brace that covered the back of his leg and went down to his foot. Interview with Licensed Practical Nurse #1 on 11/18/16 at 1:05 P.M. confirmed that there was no evidence of a head to toe skin assessment being completed between 07/13/16 (initial skin assessment) and 08/16/16 (when pressure ulcer identified). She further confirmed that there was no evidence that Resident #22's heels were elevated prior to 08/16/16, when the pressure ulcer was identified. This deficiency substantiated Complaint Control Number OH 865.

Based on observation, record review and interview the facility failed to ensure nutritional interventions were in place and provided to prevent a significant weight loss for Resident #38. Harm occurred when Resident #38 was not provided an oral diet as ordered/planned to supplement enteral tube feedings the resident received resulting in a significant 11% weight loss in one month. This affected one resident (Resident #38) of three residents reviewed for nutrition. Findings include: Record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident had a gastrostomy tube in place. Review of the resident's current physician orders [REDACTED]. Review of the weight record for Resident #38 indicated Resident #38 weighed 163 pounds upon admission on 03/11/16, 163 pounds on 04/07/16, 161 pounds on 05/04/16, and 162 pounds on 06/02/16. On 07/07/16 a weight of 145 pounds was obtained which reflected a 17 pound weight loss in one month. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 was cognitively impaired. Resident #38 was identified as having no identified behaviors at the time of the assessment, was totally dependent for all activities of daily living which included one person physical assistance for eating. Resident #38 was assessed to be 71 inches tall with a weight of 162 pounds with no or unknown weight loss. Review of the current plan of care (POC) for Resident #38 identified a potential for alteration in nutrition and hydration related to alternative nutrition via feeding tube. The POC indicated Resident #38 was able to consume pleasure food that were pureed and could have nectar thick liquid. Interventions included on the POC were to assess Resident #38 for signs and symptoms of [MEDICAL CONDITION], honor food preferences as able, monitor consistency of diet served, provide assistance with meals/snacks as required, provide diet as ordered, dietician referral as needed, and weights as ordered. Review of dietary progress notes revealed the following: A note dated 03/11/16 by Dietary Manager (DM) #45 revealed Resident #38 weighed 163 pounds and was 5 feet 11 inches tall. The dietary assessment completed by the Registered Dietician (RD) on 03/16/16 indicated a height was not available for review and no ideal body weight (IBW) was calculated. The assessment revealed the resident's estimated nutritional needs were 1855-2225 kilocalories (kcal), 74-89 grams (g) protein, and 1855-2225 ml of fluids. The initial nutritional assessment identified Resident #38 received the nutritional supplement, Prostat 30 ml twice daily. The RD identified Resident #38 as having a moderately compromised nutritional status with the goal for weight maintenance. A dietary progress note, dated 06/27/16 by the RD indicated labs were reviewed with no significant changes/issues noted, and the current dietary plan provided 1340 kcal and 81 g of protein. No pressure areas noted and RD to follow per protocol. The medical record indicated a weight warning on 07/07/16 at 9:35 AM due to an 11.4% weight loss in four months. The RD visited the facility on 07/12/16 and requested the facility reweigh Resident #38. The resident was reweighed on 07/13/16 and weighed 145 pounds. On 07/14/16 the medical record did not indicate the RD had been notified of the weight obtained on 07/13/16. The medical record indicated a weight warning on 07/07/16 at 9:35 AM due to an 11.4% weight loss in four months. The RD visited the facility on 07/12/16 and requested the facility reweigh Resident #38. The resident was reweighed on 07/13/16 and weighed 145 pounds. Record review revealed no evidence the RD, physician, or family member were notified of the weight obtained on 07/07/16 indicating a 11% weight loss or the weight obtained on 07/13/16 confirming the 11%weight loss. Review of the State tested nursing assistant (STNA) Activity of Daily Living (ADL) tracking forms for May, June and July 2016 revealed the amount of food consumed from the pureed pleasure trays provided by dietary staff at meals was not documented. Documentation on the ADL tracking forms indicated only the amount of fluids Resident #38 consumed was recorded. On 07/13/16 at 12:15 P.M. during an interview with the Director of Nurses (DON) and MDS Nurse #28, the DON reported the facility policy was to immediately notify the physician and family member of any significant change in a resident's condition. The DON and MDS Nurse #28 confirmed an 11% weight loss would be a significant change in a resident's condition and that the facility did not notify the physician, dietician or resident's family. On 07/13/16 at 12:50 P.M., resident meal trays were delivered to the Sunset Hills unit for the noon meal. State tested nursing assistant (STNA) #36 and #39 began passing trays to residents who ate in their room and then served trays to residents in the dining room. Resident #38 was given two glasses of thickened nectar juice from his tray and the covered plate, dessert dish and silverware were left on the cart. STNA #36, #39 and Licensed Practical Nurse (LPN) #20 were observed in the dining room assisting Resident #39 and Resident #53 with their meal while observing other residents eating in the dining room. On 07/13/16 at 1:00 P.M. Resident #38 was observed in bed drinking thickened liquids from a cup by himself. Resident #38 noon pureed tray remained on the hall cart. LPN #20 and STNA #39 began picking up trays from residents who had finished eating in the dining room and who ate in their rooms at 1:30 P.M. on 07/13/16. LPN #20 and STNA #39 were pushing the hall cart towards the door exiting Sunset Hills and confirmed they were taking dirty trays back to the kitchen. When questioned if Resident #38 had received his tray, LPN #20 and STNA #39 stated they had not assisted him with lunch and asked STNA #36 if she assisted Resident #38. STNA #36 stated she had not. STNA #39 stated she had gathered the two empty glasses of liquids from his room but did not remove a tray. LPN #20 stated Resident #38 received pleasure food only and did not know if a tray was sent to him. STNA #39 confirmed that a tray was on the cart with Resident #38's name on it. STNA #39 opened the tray and confirmed it contained pureed food and that the napkin and silverware were adjacent to the plate and had not been moved. STNA #39 took the plate to Resident #38's room and began to assist Resident #38 with his meal. STNA #39 confirmed Resident #38 appeared to be hungry and was aggressively eating his meal. STNA #39 and LPN #20 confirmed they would have sent Resident #38's meal back to the kitchen if the surveyor had not intervened. On 07/13/16 at 3:16 P.M. during an interview with the Director of Nursing (DON), the DON and MDS Nurse #28 reviewed the RD recommendations and had informed the staff of the RD request to re-weigh Resident #38. The DON again confirmed the physician, RD, and Resident #38's family had not been informed of the 11% weight loss. On 07/14/16 at 8:00 A.M. MDS Nurse #28 was observed assisting Resident #38 with breakfast. MDS Nurse #28 reported Resident #38 was eating with little prompting and appeared hungry. On 07/14/16 at 10:25 A.M. STNA # 36 reported she had not fed Resident #38 until dinner on 07/13/16 when he ate 100% of his dinner. STNA #36 reported receiving information regarding the care residents' needed from the previous shift and during her orientation to the Sunset Hills unit. STNA #36 reported she was under the impression Resident #38 received his nutrition through the feeding tube and only took liquids by mouth. STNA #36 confirmed there was no documentation of percentage of meals consumed on the ADL tracking forms, only liquid intake. STNA #36 confirmed she did not receive written documentation on the care the resident needed. On 07/14/16 at 11:15 A.M. during a telephone interview with the RD, she reported not being aware of Resident #38's weight loss until the scheduled visit on 07/12/16. The RD stated she had not been contacted regarding the weight obtained for Resident #38 on 07/13/16, stating she would have made a recommendation to increase the tube feedings to ensure no further weight loss. The RD stated she normally followed up with all re-weigh requests the following week when visiting the facility. The RD stated the reason the 1340 kcal provided from the tube feeding was documented as sufficient was because Resident #38 also received a pleasure feeding pureed diet. When informed of the observation on 07/13/16 revealing Resident #38 had not received the noon tray, she stated if Resident #38 was not consuming the pleasure foods, this could account for the weight loss and she would follow up with the DON. On 07/12/16 at 3:05 P.M. the DON confirmed the RD had called the facility and requested an increase in Resident #38's tube feeding. The DON stated the physician had approved the request and ordered laboratory testing for Resident #38 also. The DON confirmed the needs of the residents were identified on the individualized POC, however the STNAs did not have access to the resident's POC. Review of the facility Clinical Protocol for Dysphagia dated October 2010 indicated residents would receive meals as ordered by physician and staff and physician would monitor the progress of the resident and make any changes as necessary. This deficiency substantiates Complaint Number OH 428.

Based on clinical record review, staff interview, interview with Ohio Certified Paramedic and EMS Instructor, review of the Emergency Transport Team Report, and review of the facility's policies titled "[MEDICATION NAME] Maneuver", "Speech Language Pathologist Notification" , and "Policy Statement," the facility failed to provide a resident with a known risk of swallowing difficulty and choking, the needed services to prevent the resident from choking and resulting death. This resulted in Immediate Jeopardy for one resident (Resident #50) of six sampled residents at risk for choking. The facility identified five residents with swallowing difficulties who were at risk for choking. The census was 49 at the time of the survey. On [DATE] at 4:00 P.M., the Administrator in Training (AIT) and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when Licensed Speech Therapist (LST) #12 discharged Resident #50 from Speech Therapy (ST) and documented Resident #50's difficulty swallowing which presented the resident with a risk for choking. Although LST #12's assessment of Resident #50 documented risks associated with the resident's swallowing abilities, the facility failed to provide safe swallowing interventions for the resident. On [DATE] at approximately 8:20 P.M., State-tested Nurse Aide (STNA) #41 informed Licensed Practical Nurse (LPN) #60 that Resident #50 was choking. LPN #60 walked into Resident #50's room and found her cyanotic with periods of apnea and respiratory status and pulse diminishing. LPN #60 did not initiate the [MEDICATION NAME] maneuver or supervise the procedure which was performed incorrectly by unlicensed staff. Resident #50 was transported to the Emergency Department of a local hospital and pronounced dead. The Immediate Jeopardy was removed and the deficient practice corrected on [DATE] when the facility completed the following corrective actions: *On [DATE], the facility developed and implemented a new policy titled Speech Language Pathologist Notification to ensure dietary and nursing staff received notification from the Speech Language Pathologist related to dietary restrictions, swallowing difficulties, treatment recommendation, or discharge for residents. The policy and procedure identified the Speech Language Pathologist would write out a notification to the Nursing Department and Dietary Department upon discovery during treatment of [REDACTED]. The Nursing staff would notify the physician. *On [DATE], the DON reviewed the new policy titled Speech Language Pathologist Notification with licensed and registered nursing staff, dietary staff, and LST #12. *On [DATE], the surveyor observed the [MEDICATION NAME] maneuver in-service training being completed by a State of Ohio Certified Paramedic and Emergency Medical Services (EMS) Instructor #46. Review of the in-service information presented on [DATE] to all staff to direct the care of a choking person evidenced if a person became unresponsive, the person should be lowered to the ground face up on firm flat surface and begin Cardio-Pulmonary Resuscitation (CPR), starting with compressions. *On [DATE], interviews of three STNAs, two LPNs, and one Registered Nurse (RN) revealed the staff were knowledgeable on the correct technique for initiating and completing the [MEDICATION NAME] maneuver. *On [DATE], interview with the Administrator identified the facility would continue to monitor the corrective action through their QAA committee. *On [DATE], all facility staff were in-serviced on the correct technique for initiating and completing the [MEDICATION NAME] maneuver for a resident who chokes and becomes unconscious. *On [DATE], review of facility documentation revealed all current residents who received speech therapy evaluations or treatment and/or were discharged to nursing services revealed dietary recommendations and appropriate plans of care were in place (Residents #1, #8, #16, #18, and #26). Findings include: Review of the closed clinical record for Resident #50 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a documented full code status in the event of cardiac or [MEDICAL CONDITION]. The resident did sign a refusal of treatment on [DATE] related to therapeutic diet, LCS diabetic; there was no mention of diet texture or risk for aspiration related to oropharyngeal dysphagia. The physician's orders [REDACTED]. Review of the Minimum Data Set Assessment (MDS) completed [DATE] revealed the resident required supervision with set up help only for eating and was cognitively intact. The MDS identified the resident was 61 inches tall and the last weight was 226 pounds. Review of the clinical record revealed a ST evaluation was completed by LST #12 on [DATE] due to a treatment [DIAGNOSES REDACTED]. The reason for the referral was for increased coughing during meals. The bedside swallowing evaluation completed revealed oropharyngeal dysphagia (difficulty swallowing) with complaints of feeling as if food was in her throat. The resident had slightly declined laryngeal strength present. LST#12 identified the resident would benefit from skilled ST to address the oral pharyngeal phase of swallow and to ensure swallow safety. The treatment plan was for ST two times a week for four weeks. Review of the ST Progress Note by LST #12 dated [DATE] revealed Resident #50 refused treatment including oral/laryngeal exercises. The ST Progress Note dated [DATE] revealed the resident refused treatment on this date. The ST Progress Note dated [DATE] revealed the resident refused treatment. The note identified the resident was being discharged from skilled ST due to refusal to participate in therapeutic tasks. There was no documented evidence LST#12 notified nursing staff or dietary staff of Resident #50's swallowing risks. Review of Resident #50's clinical record dietary notes dated [DATE] revealed no reference to the swallowing deficit identified by the ST evaluation on [DATE]. Review of the plan of care for Resident #50 revealed the plan of care did not identify the swallowing deficit and no plan of care was developed to instruct staff to safely monitor oral intake of Resident #50 related to frequent choking. Review of Resident #50's Nurse's Progress Note documented by LPN #60 on [DATE] at 8:20 P.M., revealed the resident yelled out for help due to choking. The resident was eating a peanut butter sandwich. STNA #41 entered the room and summoned LPN #60 to the room. STNA #40 also entered the room. The notes identified the resident was noted to become cyanotic and limp with labored respirations and periods of apnea. The [MEDICATION NAME] maneuver was performed multiple times unsuccessfully by STNA #41. A finger sweep was unsuccessful. The notes revealed the resident's cyanosis was getting worse and respiratory status and pulse diminishing and condition unstable. The [MEDICATION NAME] maneuver continued. LPN #60 called 911 due to a decline in Resident #50's status. A second entry by LPN #60 on [DATE] at 8:25 P.M. in the Nurse's Progress Note for Resident #50, revealed 911 was notified of need for assist. Resident #50's condition worsened and LPN #65 was summoned. CPR with an Ambu bag began due to absence of pulse and respiration. Crash cart on site. Back board placed, CPR per LPN #60 and STNA #41 with no improvement in condition. CPR continued and oxygen connected to Ambu bag. Emergency personnel arrived at 8:30 P.M. and assumed care, CPR continued. At 8:45 P.M., Resident #50 was transported to the emergency room . The facility received a call from the emergency room that Resident #50 expired. Review of the Emergency Transport Team Report dated [DATE] revealed a call was received from the facility at 8:29 P.M. upon the squad's arrival at 8:35 P.M.; CPR was in progress, asystole (no heart beat) was noted on the monitor. The primary impression was airway obstruction. The report further identified the facility staff stated the patient was eating a peanut butter sandwich and began to choke; the [MEDICATION NAME] maneuver was attempted prior to the squad arrival. After the squad's arrival, intubation of Resident #50 was necessary to provide respiratory support. CPR continued, and the monitor continued to identify asystole. The emergency personnel left the facility with Resident #50 at 9:04 P.M. Interview with STNA #40 completed on [DATE] at 10:40 A.M. revealed she could not remember if the nurse left the room on two occasions in reference to the incident with Resident #50 on [DATE]. She confirmed LPN #60 left the room while Resident #50 was unable to breathe and the [MEDICATION NAME] maneuver was in progress. STNA #40 stated Resident #50 choked and made some funny noise from her throat, grabbed her throat and bent over. STNA #40 stated STNA #41 was unable to clear the resident's airway. STNA #40 stated they switched and she tried to do the [MEDICATION NAME] maneuver and clear the resident's airway but was unable to do so. STNA #40 stated she did the [MEDICATION NAME] maneuver 10 to 12 times while standing on the floor with the resident in the bed. STNA #40 verified no one placed the resident on the floor or another hard surface, or tried to straddle the resident and perform abdominal thrusts after the resident became unconscious. Interview with STNA #82 on [DATE] at 12:00 P.M. revealed Resident #50 frequently choked in the dining room, she would eat too fast and choked on her food frequently. STNA #82 stated Resident #50 was always worried she would miss her smoke break. STNA #82 further stated due to Resident #50's choking episodes a new policy was put in place to have staff in the dining room during meals. On [DATE] at 1:00 P.M., interview with the DON revealed the facility did have a policy in place for residents to be supervised when eating in the dining room. Review of the Policy Statement (dated [DATE]) revealed all residents would be encouraged to eat in the dining room with a staff member present. Interview with LST#12 on [DATE] at 12:35 P.M. verified the assessment of Resident #50 was completed but the resident refused to participate in education and was discharged the 2nd week. LST #12 verified notification to nursing staff or dietary staff of residents at risk for choking or aspiration was not a procedure which was followed by the ST department and was not completed upon discharge of Resident #50 from ST services. Interview with STNA #41 on [DATE] at 10:15 A.M. revealed she heard Resident #50 yelling for help as she was choking. The resident was eating a peanut butter sandwich, half was on the table. STNAs #41 and #40 responded to the call. STNA #41 cleaned the resident's mouth out before she gave her a drink and the resident was still talking. The head of the bed was up at a 45 degree angle. STNA #40 left the room to notify LPN #60 who then returned to the resident's room. When LPN #60 came to the room she told STNA #41 to do the [MEDICATION NAME] maneuver, however the resident was still talking. After giving the resident drinks, STNA #41 stated she did the [MEDICATION NAME] maneuver but couldn't get it (the bite of peanut butter sandwich) out. STNA #40 tried the [MEDICATION NAME] maneuver but couldn't get it out. The resident's lips turned blue and she collapsed. STNA #41 was unable to obtain the resident's pulse and left the room to page the nurse "stat" while STNA #40 remained in the room. LPN #60 came to Resident #50's room and instructed STNA #41 to do the [MEDICATION NAME] maneuver. LPN #60 then left the room to get the other nurse and the crash cart. When LPN #60 came back to the room, she and STNA #41 initiated CPR. Interview with LPN #60 on [DATE] at 9:05 A.M. revealed on [DATE] she was called to Resident #50's room by STNA #41. LPN #60 stated STNA #41 was doing the [MEDICATION NAME] maneuver and STNA #40 was helping. LPN #60 stated the resident was cyanotic and having difficulty breathing, choking and giving the sign by holding her hands to her throat. LPN #60 stated she left the room to get the other nurse on duty. LPN #60 verified she left the room and stated STNA #41 was already doing the [MEDICATION NAME] maneuver to Resident #50. LPN #60 stated she summoned the other nurse, got the crash cart and called 911 before returning to the room. Upon return to the room, CPR was initiated. LPN #60 received a call from the hospital at 10:00 P.M. that Resident #50 was deceased . LPN #60 stated she was not aware STNA #41 had given Resident #50 a drink of water when the resident was choking. LPN #60 stated she was new to the facility and this was her second day (referencing [DATE]). LPN #60 stated she did not know where the emergency equipment was kept and all she could think about was she needed to find the equipment and that was why she left the room and to find the other nurse on duty. Interview with LPN #65 on [DATE] at 3:00 P.M. revealed she was approached by LPN #60 on the night of [DATE] at about 8:25 P.M. and returned to Resident #50 ' s room with LPN #60. STNA #41 was doing chest compressions while the resident was in bed without a backboard in place. LPNs #60 and #65 left the room and grabbed the crash cart and called 911. LPN #65 stated STNAs #40 and #41 were doing compressions only and not attempting to provide respiratory support. Interview with the DON on [DATE] at 2:00 P.M., and review of the statements by STNA #41 and LPN #60, confirmed LPN #60 did not follow the facility's policy and maintain supervision in a life threatening emergency. The DON confirmed STNAs #40 and #41 did not perform the [MEDICATION NAME] maneuver procedure per the facility policy for an unconscious person. Interview with Ohio Certified Paramedic and EMS Instructor #46 (who provided the in-service training on the [MEDICATION NAME] Maneuver) at 12:45 P.M. on [DATE], verified the choking Resident #50 should not have been given water to wash down the peanut butter sandwich related to the risk of further occluding the airway and making it more difficult to be expelled by abdominal thrust. Review of the facility's policy the "[MEDICATION NAME] Maneuver" , (revised [DATE]); revealed the [MEDICATION NAME] maneuver was to be initiated upon a resident choking. Care of an unconscious resident was to include the resident be placed on the floor on the back with the arms at the side and perform abdominal thrusts. This certification deficiency substantiates Complaint Number OH 478.

Based on closed medical record review and staff interview, the facility failed to ensure residents did not experience significant unplanned weight loss. This affected one of six sampled residents (Resident #48) of the 49 residents in the facility. Harm occurred to Resident #48 when he had a weight loss of 31.7 pounds (18.2% ) in seven months from January 2011 to August 2011 and a weight loss of 14.3 pounds (9%) in 30 days from July 2011 to August 2011. The facility did not attempt any interventions until 08/11/11 to address the weight loss and attempt to prevent further weight loss. Findings include: Resident #48's closed medical record review revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's physician ordered the resident a low concentrated sweet diet. The quarterly Minimum Data Set (MDS) assessment completed on 06/24/11 identified the resident with short- and long-term memory problems and needed extensive assistance of one staff for eating. The resident's plan of care called for assistance with meals as needed. The care plan did not address the resident's need for extensive assistance for meal intake. The closed record also revealed a note dated 05/12/11 from the resident's family asking for a nurse or nurse aide to feed the resident each meal. Review of the admission dietary assessment completed on 01/18/11 revealed the resident's weight was 174 pounds and the resident was taking in 75 to 100% of his meals. The assessment stated the resident was totally dependent for meals (this area of the assessment was completed by the dietary manager); however, in the dietitian's summary she stated the resident feeds himself. Review of Resident #48's monthly weights revealed in January 2011, the resident's weight was 174 pounds and in August 2011, the resident's weight was 142.3. This represented a 18.2 % weight loss in seven months (31.7 pound weight loss). In July 2011, the resident weighed 156.5 pounds, and on 08/11/11, the resident weighed 142.3 pounds. This was a 9% weight loss in 30 days (14.3 pounds). On 07/29/11, the resident was admitted to Hospice services. The only dietitian progress note after the initial summary of 01/18/11 was on 05/19/11. The note on 05/19/11 revealed the resident's weight was 168.5 pounds and his ideal body weight was 143 pounds. The resident had a pressure area on second toe of right foot. The physician stated the impression was [MEDICAL CONDITION] with probable osteo[DIAGNOSES REDACTED]. The resident was on antibiotic therapy. Recommend to encourage intake of increased protein foods, such as meat, eggs, cheese, and fluids to aid in healing, monitor weight and skin. This was the last progress note from the dietitian. There was no evidence the dietitian had reassessed the resident after the weight loss of 31.7 pounds in August 2011. There was no evidence in the record any interventions had been attempted to prevent the resident from a continual weight loss. There was no evidence the facility had notified the dietitian of the resident's weight loss. On 08/11/11, the physician had ordered health shakes three times a day with meals. The August 2011 resident care flow sheet records did not indicate where the resident had received the health shakes. On 08/21/11, the resident was discharged from the facility. On 08/25/11 at 8:55 A.M., interview with the Director of Nursing confirmed no interventions had been attempted before 08/11/11 to prevent Resident #48 from losing weight. On 08/25/11 at 9:10 A.M., interview with the Administrator stated the facility had not informed the dietitian of the resident's weight loss. She further stated it was the facility's place to inform the dietitian of who they wanted her to assess. This certification deficiency substantiated Complaint Number OH 065.