Every finding on record at Cypress Pointe Health Campus

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on closed medical record review, review of facility investigation, review of facility's timeline of events, review of the incident log, staff interviews, and policy review, the facility failed to ensure residents were free from significant medication errors when one (Resident #87) who was moderately cognitively impaired and dependent on staff for medication administration, received another resident's (Resident #102) morning medications. This resulted in Actual Harm for Resident #87 when the resident was administered medications in error on 11/11/25 at 6:15 A.M. and at 6:40 A.M., the resident became acutely symptomatic with dizziness and low blood pressure. The on-call Nurse Practitioner (NP) was contacted and ordered for the resident to receive midodrine (medication to elevated blood pressure) five milligram (mg) and vital signs to be monitored every 15 minutes. At 7:00 A.M, the resident's blood pressure was still low (73/44 millimeters of mercury [mmHg]) and the NP ordered another dose of midodrine five mgs and a bolus of intravenous (IV) fluids. From 7:15 A.M. through 8:15 A.M, the resident's blood pressure remained low and at 9:20 A.M. and Resident #87 started receiving IV fluids. The resident had two additional low blood pressure readings requiring midodrine five mg at 2:37 P.M. and again at 9:00 P.M. This affected one (Resident #87) of the three residents reviewed for medication administration. The facility census was 66.Findings include: Review of the closed medical record for Resident #87 revealed an admission date of 11/03/25 and discharged on 11/13/25. Diagnoses included fractured left femur, acute post hemorrhagic anemia, dementia, type two diabetes, hypertension, heart failure, and atherosclerotic heart disease. Review of the Incident log from 09/01/25 through 12/11/25 revealed a medication error on 11/11/25 at 6:55 A.M. involving Resident #87. Review of the Minimum Data Set (MDS) assessment for Resident #87 dated 11/10/25, revealed the resident was moderately cognitively impaired and dependent on staff for medication administration. Review of the blood pressure readings for Resident #87 on 11/11/25 revealed the residents blood pressure was 88/56 mmHg at 7:00 A.M, 80/50 mmHg at 7:15 A.M., 73/44 mmHg at 7:19 A.M., 88/51 mmHg at 7:38 A.M., 94/57 mmHg at 7:49 P.M., 97/59 mmHg at 8:04 A.M., 97/60 mmHg at 8:21 A.M., 102/60 mmHg at 8:37 A.M., 90/52 mmHg at 8:51 A.M., 98/59 mmHg at 9:15 A.M., 97/54 mmHg at 9:47 A.M., 90/52 mmHg at 10:05 A.M., 91/52 mmHg at 10:15 A.M, 79/38 mmHg at 11:07 A.M., 92/54 mmHg at 1:00 P.M., 88/56 mmHg at 1:45 P.M., 76/40 mmHg at 2:00 P.M., 75/48 mmHg at 2:15 P.M., 90/52 mmHg at 2:30 P.M. and 90/57 mmHg at 9:00 P.M.Review of the medication error investigation documents revealed on 11/11/25 at 6:55 A.M., Resident #87 was administered Resident #102's medication in error which included: Aspirin EC 81 mg, Coreg (slows heart rate) 25 mg, Clonidine (treats hypertension) 0.1 mg, Plavix (antiplatelet) 75 mg, Aricept (treats dementia caused by Alzheimer's disease ) 5 mg, Losartan (treats hypertension) 100 mg, Namenda (treats dementia caused by Alzheimer's disease) 10 mg, Vitamin B complex tablet, and Hydralazine (treat hypertension) 50 mg. Review of the Investigation Timeline of Events revealed on 11/11/25 at 6:15 A.M., Resident #87 was administered medication that was due to be administered to Resident #102. At 6:40 A.M., Resident #87 alerted staff that he was feeling dizzy, and LPN #62 realized a medication error had occurred. At 6:42 A.M., Resident #87 was ordered to receive midodrine five mg, vital signs every 15 minutes and hold his normal medications. At 7:00 A.M., resident #87's blood pressure was still low, and Nurse Practitioner (NP) was contacted and ordered another midodrine 5 mg and a 500 milliliter (mL) bolus of normal saline via intravenous (IV) fluids. At 9: 20 A.M. the resident's daughter called the facility after the resident called her to tell her about the medication error. An IV line was established, and the NP was notified of an IV line in place with fluids running. The last documented entry was at 4:00 P.M. which noted the resident was going to be monitored every hour through the night. Review of the progress note dated 11/11/25 at 7:08 A.M., revealed Resident #87 received the wrong medication and the resident had a hypotensive event. New orders were received for midodrine five mgs, monitor vital signs every 15 minutes until the resident's blood pressure stabilizes and place the resident in Trendelenburg position (head lower than feet to increase blood pressure). Review of an occurrence note dated 11/11/25 at 1:17 P.M., revealed at 6:15 A.M., Resident #87 received the wrong medications. Resident #87 received the following medications Aspirin EC 81 mg, Coreg 25 mg, Clonidine 0.1 mg, Plavix 75 mg, Aricept 5 mg, Losartan 100 mg, Namenda 10 mg, Vitamin B complex tablet, and Hydralazine 50 mg. Review of the Interdisciplinary Team (IDT) note dated 11/11/25 at 1:21 P.M., revealed Resident #87 received the wrong medications during the morning medication administration. The on-call provider was contacted and ordered for all the resident's normal morning medications be held, give midodrine five mg one dose to help raise the resident's blood pressure and check vital signs every 15 minutes. The resident's blood pressure was still low, so the NP was notified and ordered another dose of midodrine five mg and start IV fluids. Resident #87 continued to complain of dizziness. Review of progress note dated 11/11/25 at 1:45 P.M., revealed Resident #87's was in up in a recliner and his blood pressure dropped. The resident was encouraged to get back in bed and elevate his legs. The NP was made aware and another as needed midodrine was administered for low blood pressure. Review of progress note dated 11/11/25 at 2:15 P.M., revealed Resident #87 continued to present with hypotension. The NP was made aware and another dose of midodrine was ordered to be given. Review of November 2025 Medication Administration Record (MAR) revealed Resident #87 received an as needed midodrine five mg on 11/11/25 at 2:37 P.M. due to blood pressure being below 100 mmHg systolic and again on 11/12/25 charted at 12:04 A.M. but given at 9:00 P.M. due to low blood pressure. The MAR indicated Resident #87 had a blood pressure of 88/56 mmHg at 7:00 A.M., 73/44 mmHg at 7:15 A.M., 88/51 mmHg at 7:30 A.M., 94/57 mmHg at 7:45 A.M. and 97/59 mmHg at 8:15 A.M. On 11/11/25 at 8:52 A.M. an Intravenous (IV) line to administer fluids for low blood pressure was attempted but could not be initiated. Interview on 12/11/25 at 10:51 A.M., Licensed Practical Nurse (LPN) #33 stated at the time of the incident she was being trained by LPN #62. LPN #33 stated LPN #62 was running behind on her medication pass and LPN #33 offered her assistance. LPN #62 gave LPN #33 a cup of medications and asked her to administer the medications to Resident #87. LPN #33 stated she did not check what medications were in the cup or verify the physician orders prior to giving the medications to Resident #87. LPN #33 verified Resident #87 received the wrong medications in error. Interview on 12/11/25 at 12:37 P.M., LPN #62 stated the medication error incident occurred towards the end of her shift (7:00 A.M.) and she was running behind on her medication pass. LPN #33 offered to assist her with medications. LPN #62 verified that she pulled the medication for Resident #102, gave the medication to LPN #33 and incorrectly instructed LPN #33 to give the medication to Resident #87. Review of the facility policy titled, Medication Administration, General Guidelines dated November 2018, revealed the five rights (right resident, right drug, right dose, right route, and right time) are applied for each medication being administered. The deficient practice was corrected on 11/18/25 when the facility implemented the following corrective actions: On 11/11/25 at 6:42 A.M., LPN #62 contacted the on-call provider. New orders of midodrine five mg and vital checks every 15 minutes were ordered for Resident #87. On 11/11/25 at 7:00 A.M., LPN #62 notified the NP. New orders for additional dose of midodrine five mg and 500 milliliters of bolus fluids IV for Resident #87. On 11/11/25, all residents on the 100-hall where LPN #33 and LPN #62 were assigned to, were audited for medication errors. No additional medication errors were identified. On 11/11/25, all staff received education on medication administration and medication error reporting guidelines. On 11/12/25, LPN #33 and LPN #62 received disciplinary action forms. On 11/12/25, LPN #33 and LPN #62 completed the training course Medication Administration in Acute Care On 11/12/25, LPN #33 and LPN #62 were observed during medication administration and no errors occurred. On 11/18/25, the Director of Nursing (DON) began conducting medication administration observations of two nurses per week for four weeks and then monthly for one quarter. There were concerns identified. The audits will be presented in Quality Assurance Performance Improvement (QAPI) once completed. This deficiency represents non-compliance investigated under Complaint Number 2674268.

Based on interview, record review, review of internal investigation log, and policy review, the facility failed to notify a resident's power-of-attorney (POA) following a significant medication error. This affected one (Resident #87) of four residents reviewed for notification after a change in condition. The facility census was 66.Findings include:Review of the closed medical record for Resident #87 revealed an admission date of 11/03/25 and discharged on 11/13/25. Diagnoses included fractured left femur, acute post hemorrhagic anemia, dementia, type two diabetes, hypertension, heart failure, and atherosclerotic heart disease. Review of the Incident log from 09/01/25 through 12/11/25 revealed a medication error on 11/11/25 at 6:55 A.M. involving Resident #87. Review of the Minimum Data Set (MDS) assessment for Resident #87 dated 11/10/25, revealed the resident was moderately cognitively impaired and dependent on staff for medication administration. Review of the blood pressure readings for Resident #87 on 11/11/25 revealed the residents blood pressure was 88/56 millimeters of mercury (mmHg) at 7:00 A.M, 80/50 mmHg at 7:15 A.M., 73/44 mmHg at 7:19 A.M., 88/51 mmHg at 7:38 A.M., 94/57 mmHg at 7:49 P.M., 97/59 mmHg at 8:04 A.M., 97/60 mmHg at 8:21 A.M., 102/60 mmHg at 8:37 A.M., 90/52 mmHg at 8:51 A.M., 98/59 mmHg at 9:15 A.M., 97/54 mmHg at 9:47 A.M., 90/52 mmHg at 10:05 A.M., 91/52 mmHg at 10:15 A.M, 79/38 mmHg at 11:07 A.M., 92/54 mmHg at 1:00 P.M., 88/56 mmHg at 1:45 P.M., 76/40 mmHg at 2:00 P.M., 75/48 mmHg at 2:15 P.M., 90/52 mmHg at 2:30 P.M. and 90/57 mmHg at 9:00 P.M.Review of the medication error investigation documents revealed on 11/11/25 at 6:55 A.M., Resident #87 was administered Resident #102's medication in error which included: Aspirin (anti-coagulant) EC 81 milligrams (mg), Coreg (slows heart rate) 25 mg, Clonidine (treats hypertension) 0.1 mg, Plavix (antiplatelet) 75 mg, Aricept (treats dementia caused by Alzheimer's disease ) 5 mg, Losartan (treats hypertension) 100 mg, Namenda (treats dementia caused by Alzheimer's disease) 10 mg, Vitamin B complex tablet, and Hydralazine (treat hypertension) 50 mg. Review of the Investigation Timeline of Events revealed on 11/11/25 at 6:15 A.M., Resident #87 was administered medication that was due to be administered to Resident #102. At 6:40 A.M., Resident #87 alerted staff that he was feeling dizzy, and LPN #62 realized a medication error had occurred. At 6:42 A.M., Resident #87 was ordered to receive midodrine five mg, vital signs every 15 minutes and hold his normal medications. At 7:00 A.M., resident #87's blood pressure was still low, and Nurse Practitioner (NP) was contacted and ordered another midodrine 5 mg and a 500 milliliter (mL) bolus of normal saline via intravenous (IV) fluids. At 9: 20 A.M. the resident's daughter called the facility after the resident called her to tell her about the medication error. The Director of Nursing (DON) went to investigate what was going on with the resident. The DON established an IV, and the NP was notified of an IV line in place with fluids running. The last documented entry was at 4:00 P.M. which noted the resident was going to be monitored every hour through the night. Review of the progress note dated 11/11/25 at 7:08 A.M., revealed Resident #87 received the wrong medication and the resident had a hypotensive event. New orders were received for midodrine five mgs, monitor vital signs every 15 minutes until the resident's blood pressure stabilizes and place the resident in Trendelenburg position (head lower than feet to increase blood pressure). There was no documented evidence of the resident's POA being notified. Review of an occurrence note dated 11/11/25 at 1:17 P.M., revealed at 6:15 A.M., Resident #87 received the wrong medications. Resident #87 received the following medications Aspirin EC 81 mg, Coreg 25 mg, Clonidine 0.1 mg, Plavix 75 mg, Aricept 5 mg, Losartan 100 mg, Namenda 10 mg, Vitamin B complex tablet, and Hydralazine 50 mg. Review of the Interdisciplinary Team (IDT) note dated 11/11/25 at 1:21 P.M., revealed Resident #87 received the wrong medications during the morning medication administration. The on-call provider was contacted and ordered for all the resident's normal morning medications be held, give midodrine five mg one dose to help raise the resident's blood pressure and check vital signs every 15 minutes. The resident's blood pressure was still low, so the NP was notified and ordered another dose of midodrine five mg and start IV fluids. Resident #87 continued to complain of dizziness. Review of progress note dated 11/11/25 at 1:45 P.M., revealed Resident #87's was in up in a recliner and his blood pressure dropped. The resident was encouraged to get back in bed and elevate his legs. The NP was made aware and another as needed midodrine was administered for low blood pressure. There was no documented evidence that the resident's POA was contacted. Review of progress note dated 11/11/25 at 2:15 P.M., revealed Resident #87 continued to present with hypotension. The NP was made aware and another dose of midodrine was ordered to be given. There was no documented evidence that the resident's POA was contacted.Review of November 2025 Medication Administration Record (MAR) revealed Resident #87 received an as needed midodrine five mg on 11/11/25 at 2:37 P.M. due to blood pressure being below 100 mmHg systolic and again on 11/12/25 charted at 12:04 A.M. but given at 9:00 P.M. due to low blood pressure. The MAR indicated Resident #87 had a blood pressure of 88/56 mmHg at 7:00 A.M., 73/44 mmHg at 7:15 A.M., 88/51 mmHg at 7:30 A.M., 94/57 mmHg at 7:45 A.M. and 97/59 mmHg at 8:15 A.M. On 11/11/25 at 8:52 A.M. an Intravenous (IV) line to administer fluids for low blood pressure was attempted but could not be initiated. Interview on 12/11/25 at 10:30 A.M., Clinical Support Registered Nurse (CSRN) #130, verified the facility did not timely notify Residents #87's POA after the medication error incident on 11/11/25 at 6:15 A.M CSRN #130 verified the resident contacted his POA about the incident and the POA contacted the facility to discuss the incident. Interview on 12/11/25 at 10:51 A.M., Licensed Practical Nurse (LPN) #33 stated at the time of the incident she was being trained by LPN #62. LPN #33 stated LPN #62 was running behind on her medication pass and LPN #33 offered her assistance. LPN #62 gave LPN #33 a cup of medications and asked her to administer the medications to Resident #87. LPN #33 stated she did not check what medications were in the cup or verify the physician orders prior to giving the medications to Resident #87. LPN #33 verified Resident #87 received the wrong medications in error. Interview on 12/11/25 at 12:37 P.M., LPN #62 stated the medication error incident occurred towards the end of her shift (7:00 A.M.) and she was running behind on her medication pass. LPN #33 offered to assist her with medications. LPN #62 verified that she pulled the medication for Resident #102, gave the medication to LPN #33 and incorrectly instructed LPN #33 to give the medication to Resident #87. Review of the facility policy titled Notification of Change in Condition dated 12/17/24, revealed the resident representative should be notified of change in condition in a timely manner. This deficiency represents non-compliance investigated under Complaint Number 2674268.

Based on medical record review, observation, staff interview, review of the facility policy, the facility failed to ensure proper hygiene was completed during wound care. This affected one (Resident #24) of three residents reviewed for pressure sores. The facility census was 66 residents. Findings include: Review of the medical record for Resident #24 revealed an admitted [DATE] with diagnoses including type two diabetes mellitus, chronic kidney disease, and congestive heart failure. Review of the physician's orders for Resident #24 revealed an order dated 07/10/24 to cleanse the wound to the right foot/ankle with wound cleanser or normal saline, apply calcium alginate, and cover with dressing every day or as needed. Observation of wound care for Resident #24 per Licensed Practical Nurse (LPN) #20 on 07/22/24 at 3:59 P.M. revealed the nurse performed hand hygiene prior to starting the wound treatment and donned gloves. During wound care, LPN #20 removed the old dressing and cleansed the wound without changing her gloves and performing hand hygiene. LPN #20 continued to complete the dressing change with the same pair of gloves throughout the entire treatment. LPN #20 removed her gloves and performed hand hygiene after completion. Interview on 07/22/24 at 4:18 P.M. with LPN #20 confirmed she did not change her gloves or perform hand hygiene during the dressing change for Resident #24. Review of the facility policy titled Guideline for Handwashing/Hand Hygiene dated 12/31/23 revealed handwashing was the single most important factor in preventing transmission of infection. All health care workers should utilize hand hygiene frequently and appropriately.

Based on resident and staff interviews, and record review, the facility failed to ensure medications were supplied by the pharmacy to be administered per physician order. This affected one (Resident #1) of three residents reviewed for medications. The facility census was 67. Findings include: Record review for Resident #1 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #1 included intervertebral disc disorder, arthritis, asthma, and chronic pain. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition. Review of Resident #1's care plans dated 07/2023 revealed a focus for resident exhibiting a verbal difficulty with compliance of medication administration. Interventions included assessing for unmet needs, assist the resident with comprehension of policies and regulations, determine cause for behaviors, and observe for triggers to behaviors. Review of the physician orders revealed on 06/30/23, Resident #1 was ordered to receive Humira (immunosuppressive) 40 milligrams (mg) per 0.8 milliliter (ml) subcutaneous injection once a day every two weeks on Friday. Review of the Medication Administration Records (MAR) dated 06/2023 revealed Resident #1 received the Humira shot on 06/30/23 per physician order. On 07/14/23, Resident #1 received one dose of the Humira shot. On 07/28/23, Resident #1 did not receive the Humira shot for the reason charted as 'drug item unavailable, pharmacy to send'. On the 08/11/23, Resident #1 did not receive the Humira shot for the reason documented as 'drug unavailable, pharmacy notified of need to supply-resident to supply'. On 8/25/23, the Humira shot was not administered for the reason documented 'drug unavailable'. On 09/08/23, Resident #1 received the Humira shot per physician order. On 09/22/23, Resident #1 did not receive the Humira shot scheduled for the reason documented 'drug unavailable'. On 10/06/23, Resident #1 did not receive the Humira shot scheduled for the reason documented as 'drug unavailable'. Resident #1 received Humira three times out of eight opportunities. Interview on 10/11/23 at 2:30 P.M. with Resident #1 revealed the resident admitted to having medications from her personal pharmacy brought into the facility. Resident #1 stated she was upset because every time her Humira shot was due, the nurses would tell her it was unavailable. Resident #1 stated she did have her family bring her a Humira shot to her, and she was caught by the nurse with the medication. Resident #1 stated she only was taking the medication herself because she did not believe the facility would supply her with her medication. Resident #1 verified prior to 06/2023, her medications were being supplied as ordered. Interview on 10/16/23 at 11:30 A.M. with the Director of Nursing (DON) revealed Resident #1 often refused medications and would have her family bring in medications from home for her to administer to herself. The DON stated the facility staff educated the resident frequently on how important it was to only take the medications from the facility per order. The DON stated the resident was found to be administering the Humira shot herself at times. The DON stated the resident's personal pharmacy had supplied some of the Humira medications. The DON verified there was missing scheduled doses of the Humira on the reviewed MARs for Resident #1. Interview on 10/16/23 at 3:00 P.M. with the Regional Support (RS) #400 stated he was able to get a pharmacy invoice for Resident #1's Humira medications from her personal pharmacy. The resident's pharmacy had supplied the Humira medications since 11/2022, upon the resident's admission. RS #400 stated he was unsure of how Resident #1 would have gotten the Humira shot to administer to herself unless her family was bringing in the medications and giving them to the resident. RS #400 stated there were no facility pharmacy invoices for Resident #1's Humira medication and there was no evidence the facility pharmacy had supplied any of the Humira while the resident was residing in the facility. RS #400 stated Resident #1 was non-compliant with medications and would often have her family bring in medications not on her medications lists and she would take the medications as she wanted. RS #400 stated the facility staff tried to educate the resident on the importance of not taking medications herself. RS #400 verified there was documentation on the 06/2023, 07/2023, 08/2023, 09/2023, and 10/2023 MARS that the Humira shot was administered and not available for administration. RS #400 verified the only documentation of the resident giving herself the medication was the nursing progress note dated 08/01/23. This deficiency represents non-compliance investigated under Complaint Number OH00146459.

Based on medical record review, staff and resident interviews, and review of facility policy, the facility failed to have care conferences for residents. The facility also failed to ensure interdisciplinary team members (IDT) were present at care conferences. This affected four (#12, #18, #20, and #30) of four reviewed for care plans. The census was 60. Findings include: 1. Review of Resident #12's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Minimum Data Set (MDS) assessments revealed an annual assessment was completed on 07/13/22. Further review of Resident #12's medical record revealed no evidence of a care conference being completed from 07/13/22 to 10/12/22. Review of care conference documentation dated 01/07/22 and 04/05/22 revealed the only staff member present during care conferences was the Social Service Director (SSD) #89. Interview with SSD #89 on 10/12/22 at 2:58 P.M. confirmed there was no care conference held for Resident #12 after the annual MDS dated [DATE]. SSD #89 confirmed care conferences should be held at least quarterly. SSD #89 also confirmed she was the only staff member present during care conferences held on 01/07/22 and 04/05/22 for Resident #12. 2. Record review for Resident #30 revealed an admitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 08/09/22, revealed he had intact cognition. Further review of the MDS assessment revealed he required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #30 required supervision from staff with eating. Review of the care conference notes for Resident #30 reveled he had a meeting with the SSD #89 on 09/07/22, 06/24/22, 04/04/22, and 01/05/22 to discuss his plan of care. However, no other IDT members were present. Interview on 10/11/22 at 9:19 A.M. with Resident #30 revealed he has never attended a care conference meeting with members of the IDT team. Interview on 10/12/22 at 3:42 P.M. with SSD #89 confirmed the facility has not provided an IDT team meeting or care conference for Resident #30 in the past year. 3. Medical record review for Resident #18 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE] revealed the resident had moderately impaired cognition and received hospice services. Review of the care conference documentation revealed evidence of a phone care conference on 07/13/22 conducted with the resident, her responsible party and SSD #89. There was no evidence other team members were included in the phone conferences to discuss the resident's care. Interview with SSD #89 on 10/13/22 at 10:45 A.M. verified no other facility team members were part of the phone initial care conference on 07/13/22 she conducted with the resident and her responsible party. SSD #89 verified there was no staff from nursing, administration, dietary or activities participating in the care conference conducted with the resident. 4. Medical record review for Resident #20 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment dated [DATE] revealed the resident had severely impaired cognition with her daughter as the responsible party. Review of the care conference documentation revealed evidence of phone care conferences on 02/11/22, 05/06/22 and 09/01/22 conducted with the resident, her daughter and SSD #89. There was no evidence other team members were included in the phone conferences to discuss the resident's care. Interview with SSD #89 on 10/13/22 at 10:45 A.M. verified no other facility team members were part of the phone care conferences on 02/11/22, 05/06/22 and 09/01/22 she conducted with the resident and her daughter. SSD #89 verified there was no staff from nursing, administration, dietary or activities participating in the care conferences. Review of the policy titled Resident's First Meeting Guidelines revised 09/03/21 revealed care conference meetings were to facilitate communication regarding the care plan, medical condition and care needs between the resident, resident representative and staff providing care. The meetings should be attended by a nursing designee, Administrator if applicable, SSD, dietary and activity staff. Each staff reviewed their respective care plans with the resident and resident representative with encouraged participation.

Based on observations, review of the facility census, review of a list of diet orders, staff interview and policy review, the facility failed to ensure the legacy kitchen was free from expired food items and a food item was stored in a sanitary manner in the 200 unit nutritional freezer. This had the potential to affect 10 (#14, #15, #25, #33, #35, #36, #37, #38, #45, and #55) out of ten residents that resided on the Legacy unit and 13 (#1, #2, #3, #5, #6, #8, #9, #13, #16, #17, #46, #48, and #57) out of 13 residents that resided on the 200 unit. The facility census was 60. Findings include: 1. Observation of the Legacy kitchen on [DATE] at 7:55 A.M. revealed there were two gallons of expired whole milk that were half empty dated [DATE] and one full gallon of expired whole milk dated [DATE] in the reach in refrigerator. Interview on [DATE] at 7:55 A.M. with Cook #6 verified there were two gallons of expired whole milk that were half empty dated [DATE] and one full gallon of expired whole milk dated [DATE] in the Legacy unit kitchen refrigerator. Review of the facility census dated [DATE] revealed Resident #14, #15, #25, #33, #35, #36, #37, #38, #45, and #55 resided in the Legacy unit. Further review of a list of diet order for the Legacy unit dated [DATE] revealed no residents received no food by mouth. 2. Observation of the 200 unit nourishment and supplement freezer on [DATE] at 10:35 A.M. revealed there to be a milkshake cup with a lid and straw in it that was not labeled or dated. The straw was uncovered and open to air in the freezer. Interview with Licensed Practical Nurse (LPN) #32 on [DATE] at 10:35 A.M. verified there to be a milkshake cup with a lid and straw in it that was not labeled or dated. The straw was uncovered and open to air in the freezer. Review of the facility census revealed Resident #1, #2, #3, #5, #6, #8, #9, #13, #16, #17, #46, #48, and #57 resided on the 200 unit. Further review of a list of diet order for the 200 unit dated [DATE] revealed no residents received no food by mouth. Review of the facility's food labeling and dating policy dated [DATE] revealed all food items must be properly covered and not exposed to air prior to being labeled and dated.

Based on record review, review of the resident fund accounts, staff interviews and policy review, the facility failed to ensure a personal funds account authorization was in place before managing a residents funds. This affected one (#36) of four fund accounts reviewed. The census was 60. Findings include: Medical record review for Resident #36 revealed an admitted [DATE] and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's son was her responsible party. Review of the resident fund accounts revealed Resident #36 had $1,932.09 in a fund account with no evidence of an authorization for the account. There was evidence of social security deposits into the account each month and withdraws from the resident's account. Interview on 10/12/22 at 11:30 A.M. with the Business Office Manager (BOM) #1 verified there was no authorization for the fund account for Resident #36 with a current balance of $1,932.09 because the resident's son did not return the authorization form mailed to him on 12/04/20 and emailed on 02/22/22. BOM #1 stated she had not attempted to contact the resident's son by phone at any time to receive the authorization signature for the fund account. BOM #1 stated the facility was representative payee for the resident's fund account initiated on 12/04/20 and the resident's son regularly obtained funds from the fund account to make purchases. Review of the policy titled Resident Trust Fund Management dated 01/2020 revealed the resident trust fund authorization form must be completed when funds were received to open an account.

Based on medical record review, staff interview and policy review, the facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner. This affected two (#24 and #49) of five residents reviewed for to unnecessary medications. The facility census was 60. Findings include: 1. Review of the Resident #24's chart revealed Resident #24 admitted to the facility on [DATE] with diagnoses including cerebral atherosclerosis, difficulty in walking, muscle weakness, cognitive communication deficit, dysphagia, type two diabetes mellitus with diabetic [CONDITION(S)], retention of urine, [CONDITION(S)], major depressive disorder, unspecified cataract, heart failure, [CONDITION(S)], hallucinations, and unspecified dementia with behavioral disturbance. Review of Resident #24's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and Resident #24 required extensive assistance with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Resident #24 also received insulin, antipsychotic, antianxiety, antidepressant, diuretic, and opioid medications during the assessment review period. Review of Resident #24's pharmacy recommendation dated 04/30/22 revealed Resident #24 was on [MEDICATION(S)] one milligrams (mg) twice a day, [MEDICATION(S)] 10 mg daily, and [MEDICATION(S)] 25 mg twice a day. Per Centers for Medicare and Medicaid Services (CMS) guidelines, please consider a gradual dose reduction or document the need for the current dose. Further review of the pharmacy recommendation revealed Resident #24's physician was notified of the pharmacy recommendation on 08/10/22. Resident #24's physician did not respond to Resident #24's pharmacy recommendation. Interview on 10/12/22 at 2:07 P.M. with Corporate Registered Nurse (CRN) #800 verified Resident #24's physician was not notified of Resident #24's pharmacy recommendation dated 04/30/22, until 08/10/22 and Resident #24's physician did not address the pharmacy recommendation. 2. Review of the Resident #49's chart revealed Resident #49 admitted to the facility on [DATE] with diagnoses including fracture of unspecified part of neck of left femur, acute respiratory failure with [CONDITION(S)], cerebral atherosclerosis, [CONDITION(S)], dehydration, Alzheimer's disease, unspecified dementia, anxiety disorder, [CONDITION(S)], low back pain, constipation, other amnesia, and history of falling. Review of Resident #49's quarterly MDS assessment dated [DATE] revealed the resident to be severely cognitively impaired and Resident #49 required extensive assistance with bed mobility, transfers, and dressing. Resident #39 was also totally dependent on staff for toileting, and personal hygiene. Resident #49 received antipsychotic, antianxiety, antidepressant and opioid medications during the review period. Review of Resident #49's pharmacy recommendation dated 04/18/22 revealed to consider reducing Resident #49's [MEDICATION(S)]. Further review of the pharmacy recommendation revealed Resident #49's physician was notified of the pharmacy recommendation on 08/17/22. Resident 49's physician did not respond to Resident #49's pharmacy recommendation. Review of Resident #49's pharmacy recommendation dated 08/29/22 revealed the physician should consider a gradual dose reduction on Resident #49's [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. Further review of the pharmacy recommendation revealed Resident #49's physician was notified of the pharmacy recommendation on 09/16/22. Resident 49's physician did not respond to Resident #49's pharmacy recommendation. Interview on 10/13/22 at 11:30 A.M. with the Director of Nursing (DON) verified Resident #49's physician was not notified of Resident #49's pharmacy recommendation dated 04/18/22 until 08/17/22 and Resident #49's physician did not address the pharmacy recommendation dated 04/18/22. The DON also verified Resident #49's physician was not notified of Resident #49's pharmacy recommendation dated 08/29/22 until 09/16/22 and physician did not address the pharmacy recommendation dated 08/29/22. Review of the facility's medication regimen review policy dated November 2018 revealed recommendations will be acted upon and documented by the facility personnel or prescriber. The prescriber accepts and acts upon suggestions or rejects and provides an explanation for disagreeing.

Based on medical record review, observation, staff interview, review of facility policy, and review of manufacturer guidelines, the facility failed to ensure staff primed an insulin pen devices before administration resulting in a significant medication error. This affected one (#24) of four residents observed for medication administration. The census was 60. Findings include: Review of Resident #24's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #24 was assessed as being severely cognitively impaired and requiring extensive assistance in a significant change Minimum Data Set (MDS) assessment dated [DATE]. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 08/21/21 was for [MEDICATION(S)] [MEDICATION(S)] (insulin pen) 100 units/ml per sliding scale SQ before meals. Observation on 10/13/22 at 7:47 A.M. revealed Licensed Practical Nurse (LPN) #16 preparing insulin pens for Resident #24. LPN #16 prepared a [MEDICATION(S)] [MEDICATION(S)] by connecting a new needle and dialing the insulin pen to four units. LPN #16 did not prime the pen needle. LPN #16 also prepared a [MEDICATION(S)] Kwikpen by connecting a new needle and dialing the insulin pen to 15 units. LPN #16 did not prime the pen needle. Observation on 10/13/22 at 7:52 A.M. revealed LPN #16 administered the [MEDICATION(S)] [MEDICATION(S)] four units and [MEDICATION(S)] Kwikpen 15 units to Resident #24. Interview with LPN #16 on 10/13/22 at 7:58 A.M. confirmed she had not primed Resident #24's [MEDICATION(S)] [MEDICATION(S)] needle or [MEDICATION(S)] Kwikpen needle before dialing up the required dose of insulin. Review of the facility's policy titled Specific Medication Administration Procedures dated revised January 2018 revealed for insulin pen devices staff should dial dose as instructed by pen manufacturer. Review of manufacturer instructions for the [MEDICATION(S)] [MEDICATION(S)] before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing, turn the dose selector to select 2. Hold your [MEDICATION(S)] [MEDICATION(S)] with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge . Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times. If you do not see a drop of insulin after six times, do not use the [MEDICATION(S)] [MEDICATION(S)] and contact the manufacturer. A small air bubble may remain at the needle tip, but it will not be injected. Review of manufacturer instructions for use for [MEDICATION(S)] Kwikpen revealed priming means removing the air from the needle and cartridge that may collect during normal use. It is important to prime your pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat the priming steps, but not more than four times. If you still do not see insulin, change the needle and repeat the priming steps.

Based on medical record review, staff interview, and family interview, the facility failed to notify a family member of a resident's scheduled outside appointment. This affected one resident (#54) of three reviewed for appointments. The facility census was 63. Findings include: Review of the medical record for Resident #54 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #54's quarterly Minimum Data Set (MDS) assessment, dated 05/03/21, revealed the resident had impaired cognition. Review of Resident #54's nurse progress note dated 05/10/21 revealed the facility received a call from the doctor's office stating Resident #04's appointment had been moved to 05/19/21 at 11:00 A.M. There was no evidence the resident's son was notified of the change in appointment. Interview on 05/25/21 at 12:45 P.M., with the Administrator and Registered Nurse (RN) #320 revealed on 05/19/21 at approximately 10:00 A.M., Resident #54 left the facility, via a transport company, to go to a doctor's appointment. At approximately 12:00 P.M., the facility received a phone call from the local police department indicating Resident #54 had been found in the elevator of the doctor's office building. The Administrator stated Resident #54's son was immediately notified of the incident and the son stated he was not aware his mother had an appointment that day (05/19/21). He stated the last he had heard was the appointment needed to be rescheduled. RN #320 reported she immediately went with the Director of Plant Operations (DPO) #325 to pick up Resident #54 from the doctor's office. Interview on 05/25/21 at 12:57 P.M., with Licensed Practical Nurse (LPN) #300 confirmed on 05/19/21 she gave the transport driver the paperwork for Resident #54 prior to leaving for her appointment. LPN #300 confirmed Resident #54's son normally accompanied her to her appointments. Interview on 05/25/21 at 1:08 P.M. with Resident #54's son stated he was not aware his mother had an appointment on 05/19/21. Resident #54's son stated the last he knew, the appointment needed to be rescheduled. He revealed he normally goes with his mother to her appointments and would have gone to the appointment if he had known about it. Interview on 05/25/21 at 1:50 P.M., with LPN #310 confirmed she received a phone call from Resident #54's doctor's office on 05/10/21 stating the resident's appointment was rescheduled for 05/19/21 at 11:00 A.M. LPN #310 confirmed she did not call the resident's son to notify him of the appointment. Interview on 05/25/21 at 3:07 P.M., with Clinical Support Nurse (RN) #330 confirmed the progress notes were silent for notifying the son of Resident #54's appointment being rescheduled. This deficiency substantiates complaint number OH 649.

Based on record review and staff interview, the facility failed to ensure the residents had regular bowel movements. This affected two (#5 and #15) of three residents reviewed for regular bowel movements. The facility census was 71. Findings include: 1. Review of Resident #5 medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/27/19, revealed the resident had short term and long memory problems. The resident had no delusions, hallucinations or behaviors coded during the review period. The resident required extensive assistance from one staff for toileting, was always incontinent of bowel and bladder and was not on a toileting program. Review of the physician orders [REDACTED]. Review of the bowel movement records from 11/19/19- 12/16/19 revealed the resident did not have a bowel movement (BM) from 11/26/19-11/30/19 for a total of five days and additionally from 12/10/19 through 12/15/19 for a total of six days with no bowel movement. Review of Medication Administration Record [REDACTED].M. 2. Review of Resident #15 medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 11/22/19, revealed the resident was cognitively impaired and required extensive assistance from one staff for toileting. Review of the physician's orders [REDACTED]. Review of the bowel movement record revealed the resident had no documented bowel movement from 12/11/19 through 12/14/19 for a total of four days without a bowel movement. Review of the medical record revealed there was no documented abdominal assessment during this time frame and there were no doses of [MEDICATION NAME] administered or refused during this time frame and the progress notes were silent to physician notification of the resident not having a bowel movement. Interview with the Director of Nursing (DON) on 12/16/19 at 4:12 P.M. verified Resident #5 and Resident #15's bowel records and Medication Administration Records had consecutive days with no documented bowel movement, no documented administration of ordered bowel medications, no documented refusals of medications by the resident and no documented notification of the lack of bowel moment to the physician in the medical record. The DON confirmed the facility does not have a bowel protocol and they follow the medical director's instructions. The medical director wants the staff to use the resident's physician ordered medications or call the physician if the resident does not have bowel medications ordered, and if the resident was not having bowel movements. This deficiency substantiates Complaint Number OH 685.

Based on medical record review, observations and staff interview, the facility failed to ensure that all wound interventions were available and implemented upon admission. This affected one (#218) out of three reviewed for skin breakdown. The facility census was 68. Findings include: Medical record review for Resident #218 revealed an admitted on 10/09/19 with [DIAGNOSES REDACTED]. Review of Resident #218's hospital discharge orders dated 10/09/19 revealed an order for [REDACTED].#218's admitting physicians orders revealed the order for the waffle boot was not on the document. Review of Minimum Data Set (MDS) assessment dated [DATE] for Resident #218 revealed the assessment was not completed at this time. Medical record supported resident abilities as extensive assist with bed mobility, transfers, toileting. Resident was independent with eating. Review of plan of care for Resident #218 was not completed at this time. Observation on 10/16/19 at 11:39 [NAME]M. revealed Resident #218 was resting in bed without a waffle boot on left lower leg. Interview with Licensed Practical Nurse #25 on 10/16/19 at 12:33 P.M. verified the boot was not on his foot at this time. Further interview verified the physician's orders did not contain an order for [REDACTED]. Interview with Director of Health Care Services on 10/16/19 at 1:29 P.M., verified the waffle boot was ordered on [DATE]. Facility staff was going to pick it up today 10/16/19. Director of Health Care Services further stated the nurse missed the order for the waffle boot and did not work again until 10/15/19 when it was ordered for the supplier.

Based on review of medical records, interviews with facility staff, a hospice nurse, the fire fighter, and a representative from the oxygen company, review of the Nursing Home Fire Report, review of the local Fire Department Report, review of facility in-service training, review of the facility policy for the Administration of Oxygen, and review of the facility Emergency Operations Plan, the facility failed to ensure a resident's environment remained free of accident hazards when the regulator on an E-Cylinder oxygen tank was not functioning properly, began to spark flames and smoke, and was left on the resident continuing to flow oxygen via the non-rebreather mask on the resident's face. This resulted in Immediate Jeopardy and the potential for serious injury and life-threatening harm when the regulator to an E-Cylinder oxygen tank was turned on by Certified Resident Care Associate (CRCA) #03 and was noted to be making a hissing sound. Licensed Practical Nurse (LPN) #01 attempted to turn off the regulator when the E-Cylinder oxygen tank sparked flames and smoke. Subsequently, the resident was left alone in the smoke-filled room and staff shut the door with the sparking, smoking E-Cylinder oxygen tank continuing to flow via the non-rebreather mask on the resident's face. This affected one (#01) of three residents reviewed for accident hazards and placed the other 21 residents (#35, #36, #37, #38, #40, #66, #41, #42, #43, #02, #03, #04, #05, #06, #07, #08, #09, #10, #11, #12, #13) on the affected hall at risk for the likelihood of serious impairment or injury. Additionally, the facility identified thirteen (#02, #08, #19, #20, #32, #34, #35, #38, #66, #44, #45, #46, and #50) residents currently utilizing oxygen in the facility. The facility census was 66. On 12/26/18 at 4:51 P.M., the Administrator, Division Vice President (DVP) #140, Director of Health Services (DHS) #20, Campus Support of Clinical Services (CSCS) #102, Registered Nurse (RN) #139, and Assistant Director of Health Services (ADHS) #69 were notified Immediate Jeopardy began on 12/09/18 at approximately 1:52 P.M. when the regulator to an E-Cylinder oxygen tank was turned on by CRCA #03 and was noted to be making a hissing sound. LPN #01 then attempted to turn off the regulator when the oxygen cylinder sparked flames and smoke. Staff and family members were evacuated from the room. The resident was left alone with the door shut to the smoke-filled room, with the sparking, smoking oxygen cylinder continuing to flow via the non-rebreather mask on the resident's face. The Immediate Jeopardy was removed on 12/12/18 at 10:00 A.M. when the facility assessed all residents residing on the same hall as Resident #01, education on oxygen safety and fire was implemented, oxygen equipment and regulators were checked for safety and all staff were in-serviced regarding the facility's Emergency Disaster Plan including Rescue, Alarm, Confine and Evacuate (R.A.C.E.) and Fire Safety. Although the Immediate Jeopardy was removed on 12/12/18, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on 01/14/19, when the facility implemented the following corrective actions: · On 12/09/18, all residents on the same hall were assessed for any respiratory distress and monitoring of vital signs continued throughout second and third shifts by RN #36 and Medical Records Clerk (MRC) #27, who is also a nurse. · Beginning 12/10/18, an all department staff education on fire safety including evacuation and oxygen handling was conducted on all three shifts by CSCS #102, Corporate Support of Plant Operations (CSPO) #138, and Respiratory Therapist (RT) #135. Training concluded on 12/11/18 at 4:30 P.M. of all staff; however, the facility could not provide documentation of this in-service training. · On 12/10/18, at approximately 9:00 A.M. and again at 5:30 P.M., the local Oxygen Company Provider came to the facility to check all oxygen equipment for safety. · On 12/10/18, all new regulators for oxygen cylinders were ordered through the local Oxygen Company. · On 12/11/18, RT #135 came to the facility and made rounds with DHS #20, rechecking all regulators and providing education to staff regarding oxygen precautions, and removing and replacing regulators on portable oxygen cylinders. · Beginning 12/12/18, Fire and Evacuation Drills began with staff and continued drills were conducted on 12/13/18, 12/14/18, 12/18/18, 12/20/18 and 12/22/18. Review of the staff signature sheets verified participation. · On 12/12/18, facility audits began and will be completed by monitoring residents with E cylinder (portable oxygen) in use for properly fitting regulators. Audits will be conducted on three residents weekly, times one month. Information will be taken to the Quality Assurance (QA) committee and further audits will be determined. · On 12/24/18 to 12/27/18, nurses and CRCAs were provided with training on Oxygen including: Only a nurse can place a regulator on the E tank and adjust the oxygen flow; CRCAs may obtain tanks and transport to resident room via appropriate carrier; and prior to placing the regulator on the oxygen tank, ensure ring is in place. An Oxygen Precaution Handout was provided. Review of signature sheets verified the training was completed. · On 12/26/18 at 2:12 P.M. to 12/27/18 at 12:06 P.M., random interviews with RNs #116, #69, #36, LPNs #01 and #02, CRCAs #96 and #03, revealed they had attended current in-service training for safe handling of oxygen, fire safety including R.A.C.E. with evacuations. All the staff interviewed were able to verbalize the policy and procedures for safe handling of oxygen and the R.A.C.E. procedure. · Beginning on 12/26/18, the facility will conduct three fire drills for the next three months. The facility will conduct a first shift, second shift, and third shift drill each month. After 03/2019, the facility will proceed with standard operating procedures and conduct one drill per month and alternate shifts each month. · On 01/22/19, the facility will conduct mandatory annual fire safety education for all staff to maintain compliance. · By 01/31/19, all nursing staff will complete oxygen safety on-line training for reeducation to maintain continued compliance. Findings include: Review of the closed medical record revealed Resident #01 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #01 was admitted to local Hospice services on 12/07/18 with the [DIAGNOSES REDACTED]. Comprehensive review of the medical record revealed there was no documentation of an incident of fire and/or respiratory distress incident on 12/09/18. The resident passed away at the facility on 12/17/18 from terminal [MEDICAL CONDITION]. Review of the Nursing Home Fire Report documented on 12/10/18 at 4:03 P.M. revealed on 12/09/18 at 2:00 P.M., a staff member reported one oxygen cylinder was leaking with the presence of sparks, inside a resident room. Furthermore, the report noted one staff member was injured and the resident was not evacuated from the room. The report indicated a manual pull station was used to activate the fire alarm system. Review of the local Fire Department Report dated 12/09/18 at 1:53 P.M. revealed the fire department was dispatched to the facility for a hyperoxidized spark from an oxygen cylinder without perforation to the cylinder. The remarks included Engine 99 (E99), arriving on location at 1:56 P.M., to find Resident #01 not evacuated nor staged behind the fire doors. The room was reported to be found hazy with smoke and the resident was still in the room. The resident was observed to be wearing a non-rebreather oxygen mask with burnt away oxygen tubing two feet from the mask. In addition, the report documented LPN #01 was injured. Resident #01 was removed and placed in another room and a positive pressure ventilation fan was used to clear smoke from Resident #01's room. Medic #84 was then dispatched for LPN #01's injuries, who was in the room when the event occurred. LPN #02 and Resident #01 were noted not to be injured. LPN # 02 and Resident #01's power of attorney and family member signed refusals of care and transport. The fire report also documented the fire alarm pull alarm box, next to the exit door, was activated. Interview with LPN #01 on 12/24/18 at 10:31 A.M. revealed she was providing resident care to Resident #01 on 12/09/18. LPN #01 stated while suctioning the resident, she checked his oxygen saturation and it was dropping, so she asked CRCA #03 to obtain an oxygen cylinder from storage. After she completed suctioning Resident #01 she turned off the suction machine, and she could hear the oxygen cylinder had been turned on and was making a hissing sound. LPN #01 stated she went to turn the cylinder off to replace the regulator, and when she touched the cylinder she heard a pop and sparks were coming from it. LPN #01 stated she turned her back to the cylinder and it continued having sparks and smoke coming from it. LPN #01 stated she maintained her body between the oxygen cylinder and the resident. She stated she then instructed LPN #02 to pull the fire alarm and CRCA #03 to call 911. LPN #01 stated she did not feel she could get the resident out safely so everyone left the room and shut the door behind them, leaving the resident in the room with the flaming oxygen cylinder. The occupants of the room were evacuated. The occupants included: LPN #01, LPN #02, CRCA #03, Hospice Nurse (HN) #137, and two-family members. The resident was not evacuated. LPN #01 stated we closed the door to the resident's room and have no idea if he was still connected to the cylinder, but the cylinder was still on. LPN #01 stated there was smoke coming from the room, but there was no smoke in the hall. LPN #02 then began closing other resident rooms doors in the 300-hall smoke compartment. LPN #01 stated a few minutes later, a female police officer from the police department arrived and removed the oxygen cylinder from Resident #01's room and moved the cylinder out the back door outside. LPN #01 remembers nursing staff, which responded to the fire alarm, evacuated Resident #01 while the fire department was on scene but could not recall who evacuated the resident. LPN #01 was treated on the scene by the local Emergency Medical Services (EMS) and transported to the hospital. LPN #01 stated she received [MEDICAL CONDITION] the face, ear and singed hair. Interview with LPN #02 on 12/24/18 at 10:45 A.M. revealed she was assisting LPN #01 giving resident care inside Resident #01's room when the resident appeared to be in respiratory distress. Resident #01's oxygen level was checked and noted to be in the 60's, so CRCA #03 was instructed to get an oxygen cylinder while LPN #01 and LPN #02 continued with suctioning. While the suction machine was turned on, the machine was loud in the room. When LPN #01 turned off the suction machine, an audible hissing could be heard from the oxygen cylinder leaking. LPN #01 then touched the regulator on the oxygen cylinder. LPN #02 stated she heard a loud boom and observed a fire ball about the size of a basketball, followed by sparks and smoke in the room. Everyone left the room except for the resident and someone closed the door. LPN #02 stated she did not know if the oxygen was removed from the resident before leaving the room or who closed the door. She stated residents in the adjacent rooms to Resident #01's room were not evacuated; however, the resident room doors were closed. Interview with CRCA #03 on 12/24/18 at 10:53 A.M. revealed she was assisting LPN #01 suctioning Resident #01 and was instructed by LPN #01 to go to the oxygen storage room and retrieve an oxygen cylinder. Once inside the oxygen storage room, CRCA #03 located a full oxygen cylinder, removed a regulator from an empty cylinder and placed it on the new cylinder. CRCA #03 stated the new oxygen cylinder did contain a white seal around the stem of the cylinder; however, she was not sure if a regulator seal was on at the regulator connection. Once she returned to the resident's room with the full oxygen cylinder and regulator on, she turned on the regulator valve and heard a hissing sound. CRCA #03 stated she told LPN #01 and LPN #02 the cylinder was hissing, but she does not think they heard her. CRCA #03 stated she told them it was the only regulator in the oxygen room and she was in a hurry to get the cylinder back to the resident's room, so she didn ' t have time to search for another one. CRCA #03 stated when someone reached down and touched the cylinder, she heard a big boom and there were sparks like a roman candle that just kept coming up. She stated LPN #01 moved and placed herself between the resident and the cylinder. She stated family members were in the room during the event and were evacuated from the room. CRCA #03 stated she left the room to get more help and LPN #01 yelled for her to call 911. CRCA #03 stated she was unsure what happened in the room after that. She stated someone activated the alarm system and shut all the residents room doors. CRCA #03 verified she has been provided training on fire evacuation and fire safety and has participated in fire drills. She also was trained in the fire safety procedures when hired in 2013. CRCA #03 stated she has not had any training in the safe handling of oxygen cylinders, including the removal and installation of oxygen cylinder regulators prior to 12/09/18. CRCA #03 stated her job duties allowed her to handle the oxygen cylinders, including changing of the oxygen cylinder regulators. Interview with Oxygen Company Representative ([NAME]R) #134 on 12/24/18 at 11:30 A.M. revealed the company has a contract with the facility to perform routine preventive maintenance to the facility oxygen concentrators and provided replacement of oxygen equipment to include oxygen tanks, regulators and other related equipment. Further interview noted the company performed a staff in-service at the facility with the scope of training dated 12/10/18 and 12/11/18 on Oxygen Handling with a listed curriculum to include the storage, transportation and use of portable oxygen cylinders. The training also included the proper removal and installation of portable oxygen regulators to cylinders. [NAME]R #134 could not verify if all staff had attended the training. [NAME]R #134 verified the oxygen cylinder was received by the fire department for a duration of three days for investigative purposes and was returned to the facility. After the regulator was returned from the fire department, the Oxygen Company obtained the oxygen cylinder and regulator for an internal investigation with no additional information provided on how long it could take for the results of the investigation. [NAME]R #134 stated the facility has purchased six to eight new oxygen regulators from the company. Interview with LPN #01 on 12/24/18 at 3:10 P.M. revealed LPN #01 received oxygen training when she was hired in (YEAR) but has not received any training since then. LPN #01 verified at 3:10 P.M. she did not attend the annual fire safety, evacuation training on 04/13/18 or 06/20/18 provided by the local fire department. LPN #01 stated she has participated in monthly fire drills and has been trained in fire safety, fire evacuation in accordance with the facility fire plan. Interview with LPN #02 on 12/24/18 at 3:10 P.M. revealed she did not attend the annual fire safety, evacuation training on 04/13/18 or 06/20/18 provided by the local fire department. LPN #02 stated she has participated in monthly fire drills and has been trained in fire safety, fire evacuation in accordance with the facility fire plan when hired in (YEAR). Interview with CRCA #03 on 12/24/18 at 3:10 P.M. revealed she did not attend the annual fire safety, evacuation training on 04/13/18 or 06/20/18 provided by the local fire department. Interviews on 12/24/18 between 3:11 P.M. and 3:30 P.M. with MRC #27, LPNs #27 and #129, and CRCA #96, verified the staff have been trained on fire evacuation procedures in accordance with the facility fire plan and that they have participated in fire drills at the facility. However, the staff verified they have not received oxygen handling, storage or safety training in the removal and installation of oxygen regulators since they were hired. In addition, all staff noted it was common practice for aides and or CRCAs to change oxygen cylinders prior to 12/09/18. During an interview conducted on 12/26/18 at 3:38 P.M., CSCS #102 stated staff were recently retrained on oxygen and regulators and CRCAs are no longer permitted to change regulators. CSCS #102 stated there was no training provided to staff concerning oxygen cylinder regulators prior to the incident on 12/09/18. Interview with Fire Fighter (FF) #138 on 12/27/18 at 12:43 P.M. revealed the fire department observations upon arrival to the facility included smoke to be noted in the room, with Resident #01 still in the room. FF #138 stated he was unsure who had removed the oxygen cylinder from the room or when it was removed. FF #138 stated at no time was the facility instructed by the fire department not to evacuate the resident. FF #138 stated the staff were very startled from the event. FF #138 stated when he interviewed the facility staff after the event, one staff member replied, we all ran out of the room because we thought the cylinder was going to blow up. FF #138 provided photos of the oxygen cylinder and regulator which included charring black marks at the top of the cylinder and regulator. Telephone interview on 12/28/18 at 10:29 A.M. with Hospice Nurse (HN) #137 revealed she arrived at the facility and was there to assess Resident #01 during the event on 12/09/18. HN #137 stated upon arriving to the facility, two family members, two nurses, and an aid were all in Resident #01's room providing care. During the event, someone brought an oxygen cylinder into the room and you could hear it leaking loudly. HN #137 stated she thought the regulator was not applied right because of the hissing. HN #137 stated she does not think the nurses heard the hissing until they turned off the suction machine. HN #137 stated the oxygen cylinder was on five liters while they were suctioning Resident #01 and then it just started sparking like a fourth of (MONTH) sparkler coming from the top of the cylinder, and then a lot of smoke. HN #137 stated there was only about two to three feet of room on the left of the bed, and about five or six feet on the right. Since the cylinder was on the right side and there was not enough room on the left side of the bed, they were unable to get the resident out of the room, so they all exited and left the resident in the room. HN #137 stated if Resident #01 was a more mobile resident, maybe there would have been a better outcome. HN #137 stated she does not remember if anyone turned off the oxygen cylinder or unhooked the oxygen mask from the resident or oxygen cylinder prior to exiting the room. HN #137 stated do you worry about one resident or twenty-five residents in this type is situation. HN #137 stated the fire department showed up while staff were shutting other resident's doors, and she removed herself to another hall until the all clear was sounded. Review of the facility's undated Emergency Operation plan titled Fire Emergency revealed the staff was to rescue anyone in immediate danger. Remove the resident(s) from the immediate area and close the door of the room or area where the fire is located. Evacuate residents from unsafe areas only. Move all residents inside a safe room with a smoke door and close windows. No residents should remain in hallways or open common areas that are not protected with smoke doors in close proximity. Do not evacuate residents unless they are in an unsafe area. Do not evacuate residents outside of the building unless told to do so by Incident Command. Review of the facility policy titled Guidelines for the Administration of Oxygen, dated 09/17/18, revealed a nursing assistant may place the nasal cannula around the resident's ears and in the nose but not adjust the setting on the concentrator or other administration device. The policy also indicated to check the mask, oxygen cylinder, humidifying jar, etc. to be sure they are in good working order and securely fastened but did not state specific staff that may perform this task. This deficiency substantiates Complaint Number OH 819

Based on medical record review, Nursing Home Fire Report review and staff interviews, the facility failed to maintain an accurate and complete medical records for a resident. This affected one (#01) of four medical records reviewed for accuracy. The facility census was 66. Findings include: Review of the closed medical record revealed Resident #01 was admitted to the facility 12/07/18, with [DIAGNOSES REDACTED]. Resident #01 was admitted to local Hospice services on 12/07/18, with [DIAGNOSES REDACTED]. Comprehensive review of the medical record revealed there was no documentation of an incident of fire and/or respiratory distress incident on 12/09/18. The resident passed away at the facility on 12/17/18 from terminal [MEDICAL CONDITION]. Review of the Nursing Home Fire Report reported on 12/10/18 at 4:03 P.M., revealed on 12/09/18 at 2:00 P.M., a staff member reported one oxygen cylinder was leaking, with the presence of sparks, inside a resident room. Furthermore, the report noted one staff member was injured and the resident was not evacuated from the room. The report indicated a manual pull station was used to activate the fire alarm system. Interview with Licensed Practical Nurse (LPN) #01 on 12/24/18 at 10:31 A.M., revealed she was providing resident care to Resident #01 on 12/09/18. LPN #01 stated while suctioning the resident, she checked his oxygen saturation and it was dropping, so she asked Certified Resident Care Associate (CRCA) #3 to obtain an oxygen cylinder from storage. After she completed suctioning Resident #01 she turned off the suction, and she could hear the oxygen cylinder had been turned on and was making a hissing sound. LPN #01 stated she went to turn the cylinder off to replace the regulator, and when she touched the cylinder she heard a pop and sparks were coming from it. LPN #01 stated she turned her back to the cylinder and it continued having sparks and smoke coming from it. LPN #01 stated she maintained her body between the oxygen cylinder and the resident. She stated she then instructed LPN #02 to pull the fire alarm and CRCA #03 to call 911. LPN #01 stated she did not feel she could get the resident out safely so everyone left the room and shut the door behind them, leaving the resident in the room with the flaming oxygen cylinder. The occupants of the room were evacuated. The occupants included: LPN #01, LPN #02, CRCA #03, Hospice Nurse (HN) #137, and two-family members, the resident was not evacuated. LPN #01 stated, we closed the door to the resident room and have no idea if he was still connected to the cylinder, but the cylinder was still on. LPN #01 stated there was smoke coming from the room, but there was no smoke in the hall. LPN #02 then began closing other resident rooms doors in the 300-hall smoke compartment. LPN #01 stated after a few minutes later, a female police officer from the police department arrived and removed the oxygen cylinder from Resident #01's room and moved the cylinder out the back door outside. LPN #01 remembers nursing staff, which responded to the fire alarm evacuated Resident #01 while the fire department was on scene but could not recall who evacuated the resident. Interview conducted on 12/27/18 at 4:51 P.M. Campus Support of Clinical Services (CSCS) #102 verified there was no documentation in Resident #01's record regarding the incident with fire, smoke, respiratory distress, and/or need for suctioning noted. CSCS #102 stated staff chart by exception and she would expect there to be some documentation in the chart regarding in incident. This deficiency is an incidental finding discovered during the investigation of Complaint Number OH 819.

Based on medical record review, observations and staff interviews, the facility failed to ensure bilateral palm and splints were in place at all times as indicated on the comprehensive person-centered care plan. This affected one resident (#41) of 16 reviewed for care plans. The facility census was 71. Findings include: Medical record review for Resident #41 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. The MDS also indicated Resident #41 required excessive assistance of two plus people for bed mobility. Review of the physician's orders [REDACTED]. There was also an order [REDACTED]. Review of Resident #41's plan of care initiated on 03/09/18 revealed the resident was to be wearing bilateral palm protectors, except for during ADLs of showers and skin assessments. An observation on 08/27/18 at 2:30 P.M., revealed Resident #41 was not wearing palm protectors or splints. Observations on 08/28/18 at 2:07 P.M., 3:35 P.M., and 5:23 P.M. revealed Resident #41 was not wearing palm protectors or splints. Observations on 08/29/18 at 8:55 A.M., 10:55 A.M., 1:19 P.M., 3:08 P.M., 3:26 P.M., and 4:10 P.M. revealed Resident #41 was not wearing palm protectors or splints. Interview on 08/29/18 at 1:19 P.M., with Certified Registered Care Assistant (CRCA) #104 revealed Resident #41 was not currently wearing palm protectors or splints, but that the resident was going to be put in the chair and splints would be applied. She further revealed that she was not sure what palm protectors were. Interview on 08/29/18 at 3:26 P.M., with Licensed Practical Nurse (LPN) #8 revealed Resident #41 was to be wearing palm protectors or splints and verified that he was not currently wearing either. After checking in his room, she stated the palm protectors were in the laundry to be washed. Interview on 08/29/18 at 4:55 P.M., with Director of Health Services (DHS) #108 confirmed the resident was not wearing palm protectors or splints, and stated that they are the same thing. She further revealed she will be clarifying the orders for palm protectors and splints with the physician or nurse practitioner. The DON brought in one palm protector and stated that the facility will be laundering this one now because it is soiled and a second pair will be ordered to ensure the resident always has a clean pair to wear.

Based on observation, record review, and staff interviews, the facility failed to ensure physician ordered fall precaution interventions were in place as ordered and care planned. This affected one (#29) of ten residents reviewed for accidents. The facility census was 71. Findings include: Review of Resident #29's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], indicated resident required extensive assist of one to two staff for activities of daily living and had severe cognitive deficits. Review of physician orders [REDACTED]. Review of a care plan dated 09/29/16, revealed a problem of at risk for falls with approaches of hipsters and mats to the sides of bed. Observation on 08/28/18 at 1:43 P.M., Resident #29 up in wheelchair in common area. Dressed in street clothes and gym shoes, there was no visible evidence of hipsters being on the resident. Resident #29 alert to name only. Dycem (anti-skid sheet) seen in wheelchair with pressure reduction cushion. Interview on 08/28/18 at 1:55 P.M. with Licensed Practical Nurse (LPN) #103 verified Resident #29 was not wearing hipsters stating staff was aware this morning of missing hipsters. Observation of Resident #29 on 08/29/18 at 7:56 A.M. up in wheelchair, dressed, interacting with staff. There was no visible evidence of the resident wearing hipsters. Interview with State tested Nurse Assistant (STNA) #12 on 08/29/18 9:44 A.M., verified Resident #29 was not wearing hipsters. Interview in 08/29/18 at 9:51 A.M. with LPN #10 verified Resident #29 was not wearing hipsters and then went to laundry and retrieved a pair for resident.

Based on record review and staff interview, the facility failed to ensure there was appropriate indication for use of an indwelling urinary catheter for a resident and maintain a foley catheter to prevent infection. This affected one (#36) of two residents reviewed for an indwelling urinary catheter. The facility identified six residents currently utilizing an indwelling urinary catheter in the facility. The facility census was 71. Findings include: Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #36's Significant Change in Status, Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had moderately impaired cognition. The resident was assessed as requiring extensive one-person assistance for toileting, the resident was involved in activity and staff provided weight-bearing support. The resident was assessed as having an indwelling catheter and was always continent of bowel. The resident did not have [MEDICAL CONDITION] bladder or [MEDICAL CONDITION] as a [DIAGNOSES REDACTED]. Further review of the MDS revealed in section H0200 question A- Has a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) been attempted on admission/reentry or since urinary incontinence was noted in the facility was coded no. Review of the medical record revealed hospital discharge instructions dated 05/21/18, with instructions to continue urinary catheter, [DIAGNOSES REDACTED]. Further review of the resident's medical record revealed [REDACTED].#501 documented: Patient recently hospitalized for [REDACTED]. Her hemoglobin was 8.2 upon readmission. She is also requesting to have her Foley (indwelling urinary catheter) discontinued. Per hospital records her Foley was placed due to [MEDICAL CONDITION]. NP #501 ordered remove Foley, replace if she does not void in eight hours. Review of nurse's notes date 05/30/18 at 2:18 P.M., Licensed Practical Nurse (LPN) #126 documented Catheter replaced no urine output this shift, with an 18 French (fr) Foley placed with 10 cubic centimeter (cc) balloon. Patient tolerated well, son updated on Foley being replaced and new orders. Further review of Resident #36's medical record revealed no additional attempts were made by the facility to remove the resident's indwelling urinary catheter. Observation and interview on 08/29/18 at 8:50 A.M., revealed Certified Resident Care Associate (CRCA) #100 assist Resident #36 to the bathroom. The observation revealed Resident #36 sitting in her wheel chair in the bathroom with the catheter tubing lying on the bathroom floor. CRCA #100 assisted the resident to transfer from the wheel chair to the toilet. Resident #36 was able to transfer to the toilet and required assist of CRCA #100 to stabilize during the transfer. During the observation CRCA #100 revealed Resident #36 can verbalize her need to toilet and will use her call light most of the time. CRCA #100 verified the catheter tubing was on the floor and stated the facility provides Velcro straps that attach to the resident's leg to hold the catheter tubing in place to prevent the tubing from touching the ground. CRCA #100 verified Resident #36 was not wearing the Velcro device. Interview on 08/29/18 at 9:10 A.M., with LPN #126 revealed she removed Resident #36's catheter on 05/30/18 as ordered by NP #501 and had to replace it eight hours later because the resident had no urine output. After reviewing Resident #36's medical notes, LPN #126 confirmed no other attempts were made to remove the resident's catheter during the past ninety days. Review of the facility's policy Guidelines for the use of Indwelling Catheter revised 11/09/17, revealed the purpose of urinary catheterization is to provide urinary drainage when medically necessary and to evaluate it continued use. A resident who enters the campus with an indwelling urinary catheter, or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that categorization is necessary. Services are provided to restore or improve normal bladder function to the extent possible, after the removal of the catheter: and a resident with or without a catheter, receives the appropriate care and services to prevent infection to the extent possible.

Based on record review, nurse practitioner and staff interview, the facility failed to ensure a resident was free from a significant medication error when receiving a blood thinning agent. This affected one (#29) of five residents reviewed for unnecessary medications. The facility census was 71. Findings include: Review of Resident #29's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated resident required extensive assist of one to two staff for activities of daily living and had severe cognitive deficits. Review of the monthly physician orders [REDACTED]. Review of Medication Administration Records (MAR) for (MONTH) (YEAR) revealed an elevated international normalized ratio (INR) of 5.5 on 08/20/18. Review of a nurse progress note dated 08/20/18 documented a new order to hold [MEDICATION NAME] and recheck on Thursday. Further review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of the Nurse Practitioner ordered dated 08/27/18 revealed an order to hold [MEDICATION NAME] and INR's to be checked daily, the [MEDICATION NAME] was to be resumed when INR below 2.9. Further review of the resident record revealed the resident did not demonstrate any medically related problems due to receiving the extra doses of [MEDICATION NAME]. Interview with Director of Nursing (DON) on 08/30/18 1:25 P.M., reported she believed the Nurse Practitioner was notified of the INR 5.5 and ordered [MEDICATION NAME] to be held only one day and retested on regular schedule Monday. The DON reported the [MEDICATION NAME] was continued at 4 mg daily and denied that a continuation of administration was contraindicated with a elevated result of 5.5. DON denies any facility policy for laboratory results or INR. Interview with Nurse Practitioner (NP) #500 on 08/30/18 at 1:43 P.M., who stated awareness of elevated INR for Resident #29 and denied giving orders to continue the [MEDICATION NAME]. NP #500 stated she wanted the [MEDICATION NAME] to be held and the INR to be rechecked before restarting the [MEDICATION NAME]. NP #500 stated if a INR was above 3.0 her orders would be hold to [MEDICATION NAME] and retest INR before restarting. Interview with DON on 08/30/18 at 2:00 P.M., stated she is the person who tracked all facility INR's and was unaware of the progress note dated 08/20/18 for Resident #29 to hold [MEDICATION NAME]. The DON reported the order was not put into the electronic health system correctly thus [MEDICATION NAME] was continued and the INR was not repeated as ordered by the NP.

Based on medical record review and staff interview, the facility failed to issue written notice for transfer to the hospital to the resident representative. This affected one (#47) of one resident reviewed for hospitalization s. The facility census was 71. Findings include: Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Review of the medical record for Resident #47 revealed the resident was transferred to the hospital on [DATE], 07/24/18, and 08/01/18. Further review of the medical record revealed Resident #36 returned to the facility on [DATE], 07/27/18, and 08/03/18. Review of the medical record revealed the record contained no documented evidence of the resident representative being notified in writing of the transfer/discharge on 06/24/18, 07/24/18 or 08/01/18. Interview with the Director of Health Services (DHS) #108 on 08/30/18 at 07:55 A.M., verified the nurses and/or social services document on completion and distribution of the written notification for transfer/discharge to the resident's representative in the progress notes. DHS #108 further verified there was no documentation of the transfer/discharge for the hospitalization s on 06/24/18, 07/24/18, or 08/01/18 in the resident's record.

Based on medical record review, staff interview and policy review, the facility failed to issue written notice of the bed hold policy to a resident/resident's representative. This affected one (#47) of one resident reviewed for hospitalization s. The total facility census was 71. Findings include: Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 07/19/18, revealed the resident had a Brief Interview Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Review of the medical record for Resident #47 revealed the resident was transferred to the hospital on [DATE]. Further review of the medical record revealed Resident #36 returned to the facility on [DATE]. Nursing progress note dated 08/01/18 revealed no evidence of the resident or resident representative being notified of the bed hold policy or bed hold days. Interview with the Director of Health Services (DHS) #108 on 08/30/18 at 07:55 A.M., verified the nurses and social services document on completion and distribution of the bed hold policy to the resident and resident representative in the progress notes, and further verified there was no documentation of the bed hold policy being given in the progress note from 08/01/18. Review of the facility policy titled, Bed Hold Policy with a review date of 05/23/18, revealed in cases of emergency transfers, the notice of bed-hold policy should be provided to the resident or resident's representative within 24 hours of the transfer, and may be sent with other papers to the hospital.

Based on closed medical record review, interviews with staff and the pharmacy the facility failed to ensure a resident received pain medication in a timely manner. This affected one Resident (#121) of 16 residents interviewed for control of pain. This resulted in actual harm to Resident #121 who complained of unbearable pain and waited for five hours for pain medications. The facility identified 49 residents on a pain management program. The census was 73. Findings include: Former Resident #121 was admitted on [DATE] with [DIAGNOSES REDACTED]. Former Resident #121 was assessed to be at risk for pain due to recent amputation. Review of the pain care plan revealed goals were to have pain relief within 30 -40 minutes of intervention, to have a tolerable pain level in which resident could cope and interventions included monitor resident for nonverbal signs and symptoms of pain, provide nonpharmacological interventions for pain and to administer pain medication as needed. Review of the physician order [REDACTED].#121 was ordered to receive [MEDICATION NAME] 10 milligrams (mg) every twelve hours by mouth for pain. On 02/04/16 the physician ordered an additional 15 mg of [MEDICATION NAME] to be given every four hours as needed for pain. This additional order was to only be used for the next three days for breakthrough pain. Review of the nursing documentation for 02/12/16 at 12:30 A.M., confirmed Former Resident #121,was complaining of pain in his left lower extremity at the surgical site of his amputation. The nurse confirmed there was no current order for breakthrough pain. The physician on call was called and a message was left at 12:30 A.M. At 2:00 A.M., the nurse made a second attempt to reach the on call physician. Another message was left on his voicemail. The nursing documentation stated will continue to reach the on call physician. At 3:00 A.M., a third attempt was made to reach the on call physician. Former Resident #121 had not rested because of the pain. Resident stated pain was unbearable and the resident was visibly upset and in discomfort. The nurse documented the resident was assured that all efforts were being made to address his complaint of pain. A fourth attempt to reach the physician was made at 4:00 A.M. Unable to leave a message due to the mailbox was now full. At 5:30 A.M., the on call physician called the facility and gave a order for additional pain medication, five hours after Former Resident #121, first complained of pain. On 04/05/16 at 4:30 P.M., an interview was conducted with the Director of Nursing (DON)as well as a review of the facilities policy for physician notification was conducted. The DON confirmed Former Resident #121 should not have had to endure the pain for five hours due to the on call physician not returning the call. The nurse should have followed the facilities policy which indicates if the physician does not respond to notification after three phone calls the Medical Director and the Director of Health Services (DON) should be notified for further instructions. On 04/07/16 at 1:05 P.M., a telephone interview was conducted with the Medical Practice Manager. The Medical Practice Manager confirmed their practice would expect the facility that was unable to reach the on call physician to send the resident out to the emergency room for pain management. This deficiency is an example of continued non-compliance from a complaint survey completed on 03/08/16. This deficiency substantiates Complaint Number OH 195