Every finding on record at Embassy of Lebanon

Based on observation, staff interview and policy review, the facility failed to ensure that residents had the appropriate signage, Personal Protective Equipment (PPE), and orders for being in Enhanced Barrier Precautions (EBP). This affected two Residents (#28 and #40) of three residents sampled for enhanced barrier precautions. The facility census was 55. Findings include: 1) Review of the medical record revealed Resident #40 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), cerebral infarction, neuromuscular dysfunction of bladder, unspecified dementia, and seizures. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE], revealed Resident #40 was cognitively intact and was dependent on staff for Activities of daily living (ADL) including transfers. Observation on 05/21/26 at 10:00 A.M., revealed Resident #40 had a foley indwelling catheter with a dignity bag hanging on the side of his bed. There was no signage at the resident's room indicating the resident was ordered to be in EBP. Additionally, there was not a cart containing PPE outside of the room. During an interview on 05/21/26 at 12:05 P.M., the Director of Nursing (DON) confirmed that Resident #40 was ordered to be in EBP. The DON stated signage for EBP should be posted outside of a resident's room. The DON verified there was no signage posted or a PPE cart outside of Resident #40's room . 2) Review of the medical record revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses for Resident #28 include respiratory failure, hemiplegia, diabetes, and COPD. Review of the MDS comprehensive assessment dated [DATE], revealed Resident #28 had intact cognition and required maximum assistance with activities of daily living skills. Observation of Resident #28 on 05/21/26 at 9:35 A.M., revealed the resident had a Foley indwelling catheter in place. There was no signage near the entrance to the resident's room indicating he was in EPB and there was no PPE cart at the entrance. During an interview on 05/21/26 at 12:08 P.M., The DON verified Resident #28 had a foley catheter which required EBP isolation precautions. The DON verified there should have been EBP signage on Resident #28's door, PPE available outside the door and a disposal container for the PPE.Review of the policy titled Enhanced Barrier Precaution and dated 07/13/22 revealed an order for EBP would be obtained for residents with indwelling medical devices including urinary catheters. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions required PPE, and the high-contact resident care activities that require the use of gown and gloves. Gowns and gloves should be made available immediately outside of the resident's room.

Based on review of staffing schedules. staff and resident interviews and policy review, the facility failed to ensure a registered nurse (RN) was present in the facility for eight consecutive hours a day as required. This had the potential to affect all 59 residents residing in the facility. The facility census was 59. Findings include: Review of the staffing schedules dated 04/01/26 to 04/07/26 revealed a RN/Director of Nursing (DON) present in the facility for eight hours daily Monday through Friday. Review of the facility employment punches dated 04/06/26 revealed the facility did not have a registered nurse working at the facility. Additionally, the employment time punches revealed three Licensed Practical Nurses (LPN) each working 12 hours shifts remained in the facility to care for the residents. Interview on 04/08/26 at 12:41 P.M. with Resident #12 stated the DON had to go with him for the surgical appointment that was on Monday at an outpatient surgical center. Resident #12 stated there was a mix up with the times and the respiratory therapist could not go with him. Resident #12 reported the same thing happened for the appointment on 04/02/26. Interview on 04/08/26 at 2:40 P.M. with Transportation Coordinator (TC) #19 stated the DON left the facility with Resident #12 for his outpatient surgery in bordering city about 40 minutes from the facility at 10:00 A.M. TC #19 stated they had to be there a few hours before the procedure and the hospital staff required someone to be with the resident during the procedure. TC #19 stated the administration called the surgical center and verified that a respiratory therapist did not need to stay and the DON returned to the facility. TC #19 stated she was only in the facility for about 20 minutes and had to return to the surgical center to pick up Resident #19. TC #19 stated another staff member had to go to the surgical center as she had already left for the day. Interview on 04/08/26 at 4:56 P.M. with the DON verified that she accompanied Resident #12 to the surgical center on 04/02/26 and 04/06/26. DON verified the staffing tool reflected the incorrect hours for her on 04/06/26. DON verified she was not in the facility continuously for eight hours as required and did not have a registered nurse in the facility on 04/06/26. Interview on 04/13/26 at 9:13 A.M. with Administrator verified that DON went with Resident #12 to the appointment on 04/06/26 and was not in the facility for the required 8 hours. Interview on 04/13/26 at 2:12 P.M. with Regional RN #127 verified the employment punches on 04/06/26 did not have the required eight RN hours for facility coverage. Review of the facility policy titled Sufficient Staffing dated 01/2026 stated a registered nurse will serve as the Director of Nursing and will provide administrative oversight of nursing services consistent with regulatory requirements. This deficiency represents non-compliance investigated under Complaint Number 2794837.

Based on record review, review of facility self-reported incidents (SRI's), staff interviews and policy review, the facility failed to timely report an allegation of verbal abuse to the survey agency as required. This affected one (#53) of three residents reviewed for abuse. The facility census was 59. Findings include: Medical record review for Resident #53 revealed an admission on [DATE] with diagnoses including but not limited to chronic obstructive pulmonary disease, intermittent explosive disorder, psychosis not due to substance or physiological condition, dementia with behavioral disturbances and anxiety. Review of the annual Minimum Data Set (MDS) assessment for Resident #53 dated 03/27/26 revealed a severely impaired cognition. Resident #53 was not coded with any behaviors during the assessment period. Resident #53 was dependent for all activities of daily living. Resident #53 was coded as receiving the following medication drug classifications during the look back period: antianxiety, antidepressant, diuretic, opioid, hypoglycemic, anticonvulsant. Resident #53 was coded as receiving hospice services. Review of the plan of care for Resident #53 revealed resident had cognitive loss related to dementia as evidenced by memory problems, impaired decision making and altered mental status dated 05/19/2017. Interventions include daily interaction with family members, monitor Resident #53's responses to assess understanding and repeat as indicated, honor resident choices whenever possible and attempt to assess her preferences by monitoring response to care. Review of the progress note dated 03/25/26 at 5:38 P.M. for Resident #53 revealed resident experiencing increased anxiety. Nurse Practitioner increased Ativan to one milligram (mg) three times a day from 0.5 mg. Hospice sending nurse for additional evaluation. Review of the progress noted dated 03/26/26 to 04/18/26 was silent for any documentation related to behaviors. Review of the facility SRI's revealed there were no SRI's involving the incident for Resident #53. Interview on 04/09/26 at 4:33 A.M. with Licensed Practical Nurse (LPN) #35 stated the facility has several residents that have requested that Certified Nursing Assistant (CNA) #31 not provide care for them. CNA #31 has been reported to management for being verbally abusive to other staff members and was suspended during the investigation. LPN #35 stated the facility took staff witness statements at that time frame, but CNA #31 was able to return to work and then bragged about having a paid vacation. LPN #35 stated CNA #31 has refused to assist other staff members when asked. LPN #35 stated he/she was aware of CNA #31 being reported for bullying behaviors towards employees but does not have any information of a specific incident involving residents. LPN #35 confirmed multiple current residents have requested CNA #31 not be assigned to their care. LPN #35 denied knowledge of a formal list of residents that have requested facility to provide alternate staff when CNA #31 is assigned to the unit they reside on. Interview on 04/09/26 at 5:18 A.M. with CNA #33 stated he/she had knowledge of CNA #31 being escorted out of the facility in February for allegations of unacceptable behavior towards other staff members. CNA #33 reported that residents were questioned at that time and several residents reported the CNA as being loud and confrontational at times. Interview on 04/09/26 at 5:50 A.M. with CNA #32 stated she was in the room assisting CNA #31 with care for Resident #53 when she witnessed the staff member raise her voice and start clapping her hands in front of the residents' face while providing care. CNA #32 reported the incident to the Director of Nursing (DON) via text and stated she was never contacted for additional information. CNA #32 reported the incident in her opinion was verbal abuse. Review on 04/13/26 of a facility file revealed a witness statement dated 04/01/26 and handwritten by certified nurse assistant (CNA) #31. The document stated CNA #31 and CNA #32 revealed CNA had gotten Resident #53 up in her chair and the resident was screaming uncontrollably. CNA #31 documented that she gently clapped her hands together and stated the resident name and that she needed her to calm down. CNA #31 stated she was not aggressive but trying to get her attention. CNA #31 documented that when she clapped her hands and called the residents' name she calmed down. CNA #31 statement stated Resident #53 started screaming again because of the shower. Continued review of the documents revealed one other statement from Licensed Practical Nurse (LPN) #38 stating she did not witness CNA #31 being aggressive to Resident #53. The file also contained a document with current employee's names and phone numbers revealing that a test message titled Abuse and Neglect was sent on 04/01/26 at 7:53 A.M. The file did not include any other documentation, investigation, witness statements or body assessments related to the incident. Interview on 04/13/26 at 10:43 A.M. with DON stated she spoke with the staff member reporting the incident on the morning of 04/02/26 and requested that she write a witness statement. DON verified that she never received the information and concluded the incident was not abuse due to the knowledge of the residents' history of behaviors and staff statements that were provided. Interview on 04/13/26 at 1:31 P.M. with Administrator stated the facility did not initiate a SRI regarding the identified incident and should have. Review of the facility policy titled Abuse, Neglect and Exploitation, undated revealed reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies with specified time frames. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review, review of facility self-reported incidents (SRI), staff interviews and facility policy, the facility failed to have documented evidence that an allegation of abuse was thoroughly investigated for Resident #53. This affected one (#53) of three residents reviewed for abuse. The facility census was 59. Findings include: Medical record review for Resident #53 revealed an admission on [DATE] with diagnoses including but not limited to chronic obstructive pulmonary disease, intermittent explosive disorder, psychosis not due to substance or physiological condition, dementia with behavioral disturbances and anxiety. Review of the annual Minimum Data Set (MDS) assessment for Resident #53 dated 03/27/26 revealed a severely impaired cognition. Resident #53 was not coded with any behaviors during the assessment period. Resident #53 was dependent for all activities of daily living. Resident #53 was coded as receiving the following medication drug classifications during the look back period: antianxiety, antidepressant, diuretic, opioid, hypoglycemic, anticonvulsant. Resident #53 was coded as receiving hospice services. Review of the plan of care for Resident #53 revealed resident had cognitive loss related to dementia as evidenced by memory problems, impaired decision making and altered mental status dated 05/19/2017. Interventions include daily interaction with family members, monitor Resident #53's responses to assess understanding and repeat as indicated, honor resident choices whenever possible and attempt to assess her preferences by monitoring response to care. Interview on 04/09/26 at 5:50 A.M. with Certified Nursing Assistant (CNA) #32 stated she was in the room assisting CNA #31 with care for Resident #53 when she witnessed the staff member raise her voice and start clapping her hands in front of the residents' face while providing care. CNA #32 reported the incident to the Director of Nursing (DON) via text and stated she was never contacted for additional information. CNA #32 reported the incident in her opinion was verbal abuse. Review on 04/13/26 of a facility file revealed a witness statement dated 04/01/26 and handwritten by certified nurse assistant (CNA) #31. The document stated CNA #31 and CNA #32 revealed CNA had gotten Resident #53 up in her chair and the resident was screaming uncontrollably. CNA #31 documented that she gently clapped her hands together and stated the resident name and that she needed her to calm down. CNA #31 stated she was not aggressive but trying to get her attention. CNA #31 documented that when she clapped her hands and called the residents' name she calmed down. CNA #31 statement stated Resident #53 started screaming again because of the shower. Continued review of the documents revealed one other statement from Licensed Practical Nurse (LPN) #38 stating she did not witness CNA #31 being aggressive to Resident #53. The file also contained a document with current employee's names and phone numbers revealing that a test message titled Abuse and Neglect was sent on 04/01/26 at 7:53 A.M. The file did not include any other documentation, investigation, witness statements or body assessments or resident interviews were included in the investigation file Interview with the Administrator on 04/13/26 at 1:31 P.M. verified the above findings and confirming that a SRI and thorough investigation should have been completed and was not. Review of the facility policy titled Abuse, Neglect and Exploitation, undated revealed an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation occurs. Additionally, states identifying and interviewing all involved persons including the alleged victim, alleged perpetrator and witnesses. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review, observations, staff and resident interviews and policy review, the facility failed to ensure two (#22 and #21) dependent residents were assisted in a timely manner for meal assistance. Additionally, the facility failed to provide care and services for one (#46) dependent resident with facial hair. This affected three (#22, #21 and #46) out of three residents reviewed for activities of daily living. The facility census was 59. Findings include: 1. Medical record review for Resident #21 revealed an admission on [DATE] with diagnoses including but not limited to chronic respiratory failure, displaced fracture of third cervical vertebra, and quadriplegia. Review of the admission Minimum Data Set (MDS) assessment for Resident #21 dated 02/27/26 revealed an impaired cognition with a brief interview for mental status (BIMS) score of twelve. Resident #21 eating was coded as not applicable. Resident required total staff dependence for toileting, bed mobility and transfers. Resident #21 was coded as receiving nutrition via a feeding tube. Review of the plan of care for Resident #21 required assistance for activities of daily living (ADL) due to quadriplegia. Interventions included resident is totally dependent and does not participate in any aspect of care (eating, toileting, bed mobility bathing and mobility). Review of the active physician orders for Resident #21 revealed an order dated 03/18/26 for regular diet, pureed texture, and thin consistency. Observation on 04/08/25 at 5:25 P.M. of meal tray being delivered to residents' rooms. Observation on 04/08/26 at 6:08 P.M. of Resident #21 laying in bed with eyes closed. Observation of the meal tray sitting on the bedside table covered and in front of the resident. No staff are present in room assisting with meal. 2. Medical record review for Resident #22 revealed an admission on [DATE] with diagnoses including but not limited to amyotrophic lateral sclerosis (ALS). Review of the MDS assessment for Resident #22 dated 03/20/26 revealed an intact cognition with a brief interview for mental status (BIMS) score of eleven. Review of the comprehensive plan of care for Resident #22 revealed resident is at high risk for aspiration ad complications due to dysphagia related to respirator dependence. Interventions include diet as ordered, feed in upright position and maintain for one hour due to aspiration risk. Review of the active physician orders for Resident #22 revealed an order for regular diet, regular texture and regular fluids. Observation on 04/08/25 at 5:25 P.M. of meal tray being delivered to residents' rooms. Observation on 04/08/26 at 6:10 P.M. of Resident #22 sitting in his bed in his room. No staff are present in room assisting with meal. Observation of meal tray sitting on the table in the residents' room with cover on it and untouched. Interview on 04/08/26 at 6:05 P.M. with Resident #22 stated the staff have not been in to feed him yet and he is unable to feed himself. Resident #22 states he did not see the staff deliver the evening meal to the room as he has limited vision in his right eye. The meal tray was sitting to the right of the resident on a small table against the wall. Interview on 04/08/26 at 6:10 P.M. with Regional Director of Operations (RDO) verified the trays in Resident #21 and #22's room without staff assisting residents with meal consumption. RDO verified staff should not have left the tray in the room to deliver other trays. RDO stated it is the expectation of staff to assist residents with meals on delivery. Review of facility policy titled Nutrition Services dated 03/2017 stated the facility will provide meals for each resident with preferences accommodated, timely meal service and assistance with eating as needed. 3. Medical record review for Resident #46 revealed an admission on [DATE] with diagnoses to include but not limited to chronic obstructive pulmonary disease, moderate persistent asthma and schizoaffective disorder bipolar type. Review of the quarterly MDS dated [DATE] for Resident #46 revealed an impaired cognition with a BIMS score of eight. Resident #46 was note coded with any behaviors or rejection of care. Resident #46 required staff assistance for eating (set up or clean up), moderate assistance with bed mobility and transfers and dependent for toileting, personal hygiene and bathing. Review of the plan of care for Resident #46 revealed resident needs assistance with activities of daily living. Interventions include resident is totally dependent and does not participate in and aspect of the task, requires the assistance of two staff members for showering and bathing. Review of the facility shower schedule for Resident #46 revealed resident was scheduled for showers on Wednesday and Saturday on the evening shift. Review of the facility electronic health record for certified nursing assistant documentation revealed Resident #46 did not receive a shower on 04/04/26 as scheduled. Observation on 04/07/26 at 4:10 P.M. of Resident #46 talking on the phone with a family member. Resident #46 had long white facial hair on chin, jaw line and upper lip. Review of the shower sheets for Resident #46 dated 03/13/25, 03/15/26, 03/23/26 and 03/25/26 were silent for any documentation that Resident #46 was shaved during her shower. The facility was unable to provide shower sheets for shower completed on 04/01/26 or 04/04/26. Review of the electronic health record for Resident #46 bathing task documentation dated 04/04/26 indicated bathing showering task as not applicable. Interview on 04/08/26 at 4:25 P.M. with RDO verified Resident #46 had long hair on chin, jawline and upper lip. RDO stated he would have staff assist the resident with shaving. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on record review, staff interview, and policy review, the facility failed to ensure medications were administered to the correct resident resulting in significant mediation errors. This affected one (#60) of three residents reviewed for medication administration. The facility census was 59. Findings include: Medical record review for Resident #60 revealed an admission on [DATE] with diagnoses including but not limited to end stage renal disease, hemorrhage due to vascular prosthetic devices and implants, hypertension and hypothyroidism. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] for Resident #60 was not completed and in progress. Review of the plan of care for Resident #60 dated 04/04/26 revealed resident was prescribed antibiotic therapy related to pneumonia for seven days. Interventions included administer medication as ordered, observing adverse reactions related to antibiotics, and report pertinent laboratory results to physician. Review of the physicians orders for Resident #60 revealed orders for aspirin enteric coated 81 milligrams (mg) on tablet at bedtime dated 03/28/26, calcium carbonate vitamin D 600mg-10mg one tablet at bedtime dated 03/28/26, cefuroxime axetil 250 mg one tablet by mouth for seven days dated 03/28/26, dialysis on Monday, Wednesday and Friday, ferrous sulfate oral tablet 325 mg one tablet daily dated 03/28/26, latanoprost ophthalmic emulsion 0.0005 % one drop in both eyes at bedtime dated 03/28/26, levothyroxine sodium oral tablet 75 micrograms (mcg) on tablet daily dated 03/28/26, omega- three oral capsule 500 mg one capsule by mouth daily dated 03/28/26, Prevastatin sodium oral tablet 20 mg one table by mouth dated 03/28/26, prilosec over the counter tablet delayed release 20 mg one tablet daily dated 03/28/26, theragram M oral tablet give one tablet daily at bedtime dated 03/28/26, torsemide oral tablet 20 mg one tablet by mouth every Tuesday, Thursday, Saturday and Sunday dated 03/28/26, Vitamin b 12 oral tablet give one tablet by mouth daily dated 03/28/26, hydralazine oral tablet 25 mg one tablet by mouth three times a day dated 02/28/26, Review of the progress note for Resident #60 dated 04/03/28 at 8:30 P.M. revealed family member was notified of medication errors and new orders to obtain vital signs every four hours were given. Review of the progress notes for Resident #60 dated 04/03/26 at 10:28 P.M. revealed nurse administered another resident's (#5) medication to this resident. Vital signs taken were blood pressure 101.56, pulse 67, respirations 18 and temperature 98.0 Fahrenheit (F). On call Nurse Practitioner (NP) notified and instructed to start neuro checks every hour and vital signs every four hours. Intervention implemented 15-minute checks. Review of the e-interact change in condition evaluation dated 04/03/26 at 10:29 P.M. revealed abnormal vital signs and resident is tired, weak confused or drowsy. Vital signs were documented as blood pressure 71/44, pulse 60 and regular, respirations 10 and temperature was 98.8 F and oxygen saturation rate was 90 percent on room air. Resident #60 has a medication allergy to metformin. Resident #60 code states was do not resistate comfort care arrest. Resident #60 was experiencing a mental status change to include increased confusion with an abrupt onset. Resident #60 neurological assessment relevant to the change in condition has been reported and includes aletered level of consciousness, and abnormal speech. Family was notified along with the provider with orders to sent to the emergency room for evaluation and monitoring. Review of the hospital progress note dated 04/07/26 for Resident #60 revealed resident was admitted to hospital on [DATE] altered mental status. Diagnoses documented revealed acute hypoxic and hypercapnic respiratory failure requiring mechanical ventilation and extubated on 04/05/26. Resident #60 was diagnosed with septic shock secondary to pneumonia. Review of the facility investigation documents dated 04/04/25 revealed Resident #60 was hospitalized from [DATE] to 03/27/26 for sepsis secondary to pneumonia and hypothermia prior to admission. The medication error occurred at approximately 7:45 P.M. on 04/03/26 when Resident #60 received aspirin 81 mg one tablet, Entresto 24-26mg one tablet, Lasix 20 mg one tablet, Lexapro 20 mg one tablet, metformin 1000mg one tablet, metoprolol tartrate 12.5 mg one tablet, quetiapine fumarate 200 mg one tablet, Rexulti 2 mg one tablet, Seroquel 200 mg one tablet and Xanax 0.25 mg one tablet. Interview on 04/8/26 at 10:30 A.M. with Licensed Practical Nurse (LPN) #21 verified the medication error occurred involving Resident #60. LPN #21 stated the two residents involved had the same last name and resided on the same unit with rooms beside each other. LPN #21 stated she was interrupted during her medication pass by the potentially dangerous behaviors of another resident. LPN #21 stated she failed to follow the five rights of medication administration. LPN #21 stated once she realized the error she immediately notified on call nurse practitioner (NP) and began monitoring the resident vital signs as ordered. LPN #21 stated she obtained the vital signs and noted a change in mental status and low blood pressure, notified the NP again with new orders to transfer the resident to the hospital. LPN #21 verified the family was notified of the incident. Interview on 04/08/26 at 1:10 P.M. with NP #125 stated Resident #60 was being treated for sepsis prior to admission. NP #125 stated the resident was returned to the hospital on [DATE] due to a dislodged dialysis port and the antibiotic was initiated for pneumonia at that time. NP #125 stated Resident #60 was admitted and treated with mechanical ventilation for treatment of septic shock on 04/03/26. NP #125 stated it was her opinion that the hospitalization was due to the continued respiratory decline and not solely on the medication error that occurred. Review of the facility policy titled Adverse Consequences and Medication Errors dated 04/2014 stated a medication error is defined as the preparation of administration of drugs or biological which is not in accordance with the physicians' orders or accepted professional standards. In the event of a significant medication related error immediate action is taken as necessary to protect the residents' safety and welfare. Significant is defined as resulting in cognitive deterioration or impairment. This deficiency represents non-compliance investigated under Complaint Number 2975141.

Based on record review, observations, staff interviews and policy review, the facility failed to ensure prescribed medications were not left in residents room unsecured and unsupervised. This affected three (#29, #10 and #45) out of three residents reviewed for medication storage. The facility census was 59. Findings include: 1. Medical record review for Resident #45 revealed an admission on [DATE] with diagnoses including but not limited to cerebrovascular disease, hemiplegia affecting the right side, contractures of muscles multiple sites. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #45 dated 01/09/26 revealed an impaired cognition with a brief interview for mental status (BIMS) score of twelve. Resident #45 required set up assistance from staff for eating, dependent on staff for toileting, and moderate assistance for transfers and bed mobility. Resident #45 was incontinent of bladder and bowel. Resident #45 was coded as having applications of ointments and medication to areas other than feet during the assessment period. Review of the plan of care for Resident #45 dated 06/18/21and revised on 04/25/22 revealed resident had potential for alteration in skin integrity and requires protective/preventative skin care maintenance related to diabetes mellitus, decreased mobility, right sided hemiplegia, and chronic skin condition. Interventions include application of house barrier, weekly skin assessments and pressure relieving devices. Review of the active physicians' order for Resident #45 revealed an order for Diclofenac Sodium external gel 1 % apply to right shoulder 4 grams topically two times a day for pain dated 08/09/25. Observation on 04/08/26 at 10:05 A.M. of Resident #45's room revealed two tubes of diclofenac sodium gel in room unsecured and unsupervised. Additionally, one bottle of dyna-hex 4 antiseptic solution was located in Resident #45's room. Both items were labeled if ingested contract poison control Interview on 04/08/26 at 10:05 A.M. with Director of Nursing (DON) verified the tubes of diclofenac sodium gel and dyna-hex should not have been left in the residents room unsupervised and unsecured. DON verified items should be stored and locked in treatment cart. 2. Medical record review for Resident #10 revealed and admission on [DATE] with diagnoses including but not limited to acute chronic respiratory failure with hypoxia, non-traumatic subarachnoid hemorrhage, and hypothyroidism. Review of the quarterly MDS assessment for Resident #10 dated 03/27/26 revealed an impaired cognition with a BIMS score of eleven. Resident #10 required set up assistance from staff for eating, and was dependent on staff for toileting, transfers and bed mobility. Resident #10 was incontinent of bowel and was coded as having an indwelling urinary catheter. Resident #10 was coded as having applications of ointments and medication to areas other than feet during the assessment period. Review of the plan of care for Resident #10 revealed resident had potential for alteration in skin integrity and requires protective/preventative skin care maintenance related to decreased mobility, foley catheter, gastrostomy tube. Interventions included application of house barrier, weekly skin assessments and pressure relieving devices. Review of the physicians' orders for Resident #10 were silent for any topical medications. Observation on 04/09/26 at 3:15 P.M. of Resident #10 room revealed a bottle of prescription nystatin powder 100,000 units/gram sitting on the residents' dresser unsecured and unsupervised. Additionally, the pharmacy label adhered to the bottle stated for external use only keep out of eyes, inside of mouth or nose and to contact poison control if ingested. Interview on 04/09/26 at 3:20 P.M. with DON verified the Nystatin powder should not have been left in Resident #10's room and should be stored in the treatment cart. 3. Medical record review for Resident #29 revealed an admission on [DATE] with diagnoses including but not limited to neurocognitive disorder with Lewy bodies, dementia with psychotic disturbances, delusions, and Parkinson's disease. Review of the quarterly MDS assessment dated [DATE] for Resident #29 revealed impaired cognitive status with a BIMS score of twelve. Resident #29 requires set up assistance for eating, bed mobility and transfers. Resident #29 required moderate assistance for toileting. Review of the plan of care for Resident #29 revealed resident has neuromuscular impairment related to Parkinson's disease. Interventions include medications as ordered and caution resident to potential for increase unsteadiness and requested assistance as needed. Review of the active physician orders for Resident #29 revealed an order dated Inbrija (Parkinson treatment) inhalation capsule 42 milligrams (mg) inhale 2 puffs every 12 hours as needed for tremors sated 05/28/25. Observation on 04/07/26 at 1:20 P.M. of Resident #29 revealed the inhalation device for Inbrija inhaler in residents' room on her dresser unsecured and unsupervised. Interview on 04/07/26 at 1:20 P.M. with LPN #22 verified the inhaler for Resident #29 should not have been left in the room as she does not have an order for bedside self-administration. Review of the facility policy titled Storage of Medication dated 04/2007 stated the facility shall store all drugs and biological in a safe, secure and orderly manner. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on review of facility water management plan documents, staff interview, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to develop a comprehensive water management plan. This had the potential to affect all 59 residents residing in the facility. The facility census was 59. Findings include:Review of the facility undated water management plan (WMP) revealed a list of the WMP team members, description of the building water systems, diagrams showing water flow and areas where Legionella growth could grow and spread, control measures and monitoring, ways to intervene when control limits are not met, and a process for validation. The facility's control measures and monitoring included storing water at 140 degrees (Fahrenheit) delivering at 120 degrees (Fahrenheit), running water in empty rooms daily and weekly as needed, running water in all rooms monthly, and draining water heaters periodically to remove scale and sediment build up. The plan did not specify the specific areas or sources the water temperatures would be obtained from. Under the section for ways to intervene when control limits were not met the facility identified they would contact the water supplier to report any water issues, adjust temperatures to be within the correct range, and contact an outside contractor if unable to maintain water, pH (potential of Hydrogen) or chlorine. Under the facility validation process to make sure the program was running as designed, there were no specific measurements or processes identified, only to follow control measures to ensure they were effective and keep record of all findings and testing done in the facility.Review of the CDC website at https://www.cdc.gov/control-legionella/php/toolkit/control-toolkit.html revealed a document titled, Toolkit for Controlling Legionella in Common Sources of Exposure (Legionella Control Toolkit), version 1.3 and dated 02/17/26, revealed WMPs are a multiple step process to reduce Legionella growth and spread: including establishing a team, describing building water systems, identifying areas or devices where Legionella might grow or spread to people, determining control measures, monitoring control measures, establishing remediation activities and interventions when control measures are not met, ensuring the program is running as designed and is effective, and documenting all program activities. Further review of the document under the Operation, Maintenance, and Control Limits section, revealed no single measure can ensure Legionella control. A comprehensive WNP allows water system operators to layer a series of complementary control measures to create environmental conditions that prevent bacterial intrusion, growth, and transmission. The WMP should be developed or refined with guidelines in mind including monitoring temperatures, disinfectant residuals, and pH frequently based on performance of WMP or Legionella performance indicators for control. Ensure a disinfectant residual is detectable throughout the potable water system. Do not presume supplemental disinfection systems will control Legionella without adequate WMP. Interview on 02/10/26 at 3:39 P.M. with the Administrator verified she was unable to locate the WMP chlorine logs.Interview on 02/11/26 at 11:43 A.M. with the Administrator stated the facility would obtain a baseline of chlorine for the whole facility, and if there were any adverse findings, would follow the WMP. The Administrator verified there were not any logs of chlorine testing. Interview on 02/12/26 at 3:31 P.M., the Administrator verified the facility WMP was not a comprehensive plan that included the key elements according to the CDC guidelines. This deficiency represents non-compliance investigated under Complaint Number 2739025.

Based on observations, staff interview and record review the facility failed to store food in a manner to prevent spoilage. This had the potential to affect all residents as the facility identified all 58 residents received from the kitchen. The facility census was 58.Findings include: Observation of the kitchen on 09/15/25 at 8:58 A.M. with Dietary Manager (DM) #366, revealed the dry storage area had 12 individual servings of apple crisp on a tray and labeled with a date of 09/12/25. Interview with DM #366 at the same time who stated they were made for lunch on 09/12/25. There were 26 individual servings of dry cereal on shelf ready to use and not labeled with a date. The walk in freezer revealed six milkshakes on a shelf uncovered and unlabeled. DM #366 stated they were from night shift staff and should have been thrown out. Observation of the kitchen on 09/16/25 at 8:08 A.M. with DM #366, revealed the 26 individual servings of dry cereal remained on the shelf. DM #366 verified the cereal remained on the shelf and disposed of all of them during observation. DM #366 stated there was no policy that indicated how the facility was to store dry goods.Review of the policy named, food storage and expired food policy dated 02/22/25, revealed if a food item that is shelf stable is removed from the original packaging or box from shipment, the item must have a date marked that it was received. Use the standard storage guidelines established by the United State Department of Agriculture (USDA) for determining the length of time that the shelf stable item can be maintained in dry storage.

Based on observations, staff interviews and record review, the facility failed to ensure residents were provided with a dignified dining experience. This affected one (#17) of the six residents reviewed for dignity. Facility census was 58.Findings include: Review of the medical record revealed resident #17 was admitted to the facility on [DATE]. Diagnoses included paranoid schizoaffective disorder, bipolar type, anxiety disorder, unspecified dementia, Alzheimer ' s disease with early onset, malingerer, and rhabdomyolysis. Review of the Resident #17's most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Review of the care plan dated 08/19/25, revealed Resident #17 would maintain involvement in cognitive stimulation, social activities as desired and the resident would maintain current level of functioning. The Care Plan did not have any information related to Resident #17 being served food on paper products using plastic utensils. Review of a physician order dated 09/02/25 for Resident #17, revealed the resident was ordered to receive a regular diet, minced and moist texture, and regular consistency. Further review of the physician orders revealed no documented evidence Resident #17 was ordered to receive food on paper products using plastic utensils. Observation of the kitchen on 09/16/25 at 12:00 P.M. with Dietary Manager (DM) #366, revealed one set of plastic utensils wrapped in a napkin sitting alongside six sets of regular silverware. Interview at the same time with DM #366 who stated Resident #17 was to receive all plastic and paper products during dining for his safety. DM #366 stated Resident #17 had paranoid schizophrenia and he had an episode at another facility, so they were doing this as a precautionary measure. DM #366 stated this practice of serving food on plastic ware and plastic utensils was started when the resident was admitted . DM #366 stated the direction came to her from a dietary slip but could not state who gave it to her and did not have a current dietary slip. DM #366 stated Resident #17 asked why he had paper products when no one else was using disposable paper products. DM #366 stated Resident #17 eats in the dining area with the other residents. Observation of Resident #17 on 09/16/25 at 12:21 P.M., revealed the resident was in the dining area with six other residents eating. Resident #17 was using plastic utensils and paper products, and all other residents were eating on regular plates and using regular silverware.Interview with Resident #17 on 09/16/25 at 12:39 P.M. who stated he had an incident at another facility in March 2025, and he believed that was why he was being served with all paper products. He added that using paper and plastic products bothered him, and he had asked for staff to let him get regular dining plates and utensils since his admission. Interview with the Director Social Services (DSS) #700 on 09/16/25 at 12:42 P.M. and MDS Coordinator #371, revealed Resident #17 was not care planned to use paper products and plastic utensils. Both denied any knowledge of the resident actively using paper products and plastic utensil for dining or why he was using them. Interview with the Administrator and Director of Nursing (DON) on 09/16/25 at 12:58 P.M. who stated they did not know why the Resident #17 was being served food on throw away dining items. The Administrator was unaware when and how this practice was started. The DON stated she was not aware Resident #17 had requested regular eating utensils. Interview with Registered Dietician (RD) #621 on 09/16/25 at 1:16 P.M. who stated she only visited the facility one day a week and was not aware Resident #17 was dining with disposable items for dining.Review of the policy titled, resident rights dated 06/01/24, revealed the right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person centered plan of care. The resident has a right to be treated with respect and dignity.

Based on record review, resident interview, staff interview, and policy review, the facility failed to ensure residents received routine audiology services. This affected one (#06) of the three residents sampled for ancillary services. The facility census was 58. Findings include: Review of the medical record revealed Resident #06 was admitted to the facility on [DATE]. Diagnoses included unspecified Chronic Obstructive Pulmonary Disease (COPD), schizoaffective disorder bipolar type, major depressive disorder, post-traumatic stress disorder, type II diabetes, and generalized anxiety disorder. Review of the care plan dated 11/02/23, revealed Resident #06 was at risk for visual decline related to diabetes. Interventions included arranging eye appointments and notifying the provider of any complaints of decreased vision. Review of the 360-Care Audiology assessment dated [DATE], revealed Resident #06 received a hearing exam which indicated moderate sensorineural hearing loss in both ears. Resident #06 was not interested in any amplification devices at the time. During an interview on 09/17/25 at 12:15 P.M. Social Worker (SW) #700 verified Resident #06's last audiology exam was 02/20/2024. SW #700 stated Audiology services were offered in the building in April and July 2025 and Resident #06 was not assessed during either visit. Review of policy titled Ancillary Services dated 01/01/2025 revealed the facility assisted residents in obtaining routine and emergency ancillary services.

Based on review of the medical record, resident interviews, staff interviews, observations, and policy review, the facility failed to complete thorough fall investigations and implement appropriate interventions for falls. This affected one (#06) of the two residents sampled for falls. The facility census was 58.Findings include: Review of the medical record revealed Resident #06 was admitted to the facility on [DATE]. Diagnoses included unspecified Chronic Obstructive Pulmonary Disease (COPD), schizoaffective disorder bipolar type, major depressive disorder, post-traumatic stress disorder, type II diabetes, and generalized anxiety disorder. Review of the active care plan dated 07/19/22, revealed Resident #06 was at risk for falls and had a known behavior of placing herself on the floor. Interventions included anti-rollbacks to wheelchair, encouraging the resident to ask for assistance, offering the resident to lay down after lunch, placing a Dycem under cushion in wheelchair, offering toileting assistance every two hours, placing reminder signs to wear shoes when out of bed, and placing a fall mat to the left side of bed. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #06 had moderately impaired cognition, had verbal behaviors, did not wander, and did not reject care. Review of the incident report / investigation on 09/17/25 at 1:40 P.M. with Director of Nursing (DON), revealed on 08/23/25 at 3:40 A.M., Resident #06 was found seated on the floor on her fall mat and the resident stated she fell out of bed. There were numerous sections of the report that were not completed including Resident #06's metal status, predisposing environmental factors, and predisposing situation factors.Review of the incident report /investigation on 09/17/25 at 1:45 P.M. with the DON, revealed on 08/30/25 at 2:40 P.M., Resident #06 called the staff to her room, and the resident was lying on her stomach on the fall mat next to her bed and the resident stated she slid out of bed. There were numerous sections of the report that were not completed including Resident #06's metal status, predisposing environmental factors, and predisposing situation factors.Interview with the DON on 09/17/25 at 1:50 P.M., verified the incident reports/investigations for Resident #06s falls on 08/23/25 and 08/30/25 were not filled out completely and sections were left blank. The DON stated her expectations were that each section of the report would be filled out to specify if factors were or were not applicable to the cause of the fall. Review of policy titled Fall Prevention and Management Policy dated 01/08/2025 revealed all falls were reviewed and investigated to identify potential contributing factors and environmental concerns and prevent further falls.

Based on record review, resident interview, staff interviews, and policy review, the facility failed to provide follow-up care for dental services. This affected one (#06) of the two residents sampled for dental services. The facility census was 58. Findings include: Review of the medical record revealed Resident #06 was admitted to the facility on [DATE]. Diagnoses included unspecified Chronic Obstructive Pulmonary Disease (COPD), schizoaffective disorder bipolar type, major depressive disorder, post-traumatic stress disorder, type II diabetes, and generalized anxiety disorder. Review of the active plan of care for Resident #06 dated 11/02/23, revealed the resident was at risk for dental or chewing problems related to no natural teeth. Interventions included arranging for periodic dental consultations, assisting with oral hygiene, and using 360-Care dental services. Review of a 360-Care Summary Report dated 11/25/24, revealed Resident #06 was diagnosed with potential need to consult an oral Maxillofacial surgeon to determine if treatment could be completed in facility or if the resident needed to be referred out to a surgeon. Resident #06 potentially needed to be seen for alveoplasty (a surgical procedure that reshapes the alveolar ridge- the bone that supports the teeth) and recontouring of the jawbone to prepare for dental prosthetics. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #06 had moderately impaired cognition, had verbal behaviors, did not wander, and did not reject care. During an interview on 09/16/25 at 8:22 A.M., Resident #06 stated she needed to see a dentist and could not remember the last time she saw one at the facility. During an interview on 09/17/25 at 12:17 P.M., Director Social Services (DSS) #700 verified they had no record of any follow up for Resident #06's dental appointment 11/25/24. Review of policy titled Ancillary Services dated 01/01/2025 revealed the facility assisted residents to obtain routine dental services.

Based on record review, observation, staff interview, and facility policy review, the facility failed to ensure the medication error rate did not exceed five percent (%). Two medication errors occurred within 25 opportunities for an error rate of eight percent. This affected one (Resident #32) of two residents observed during medication administration. The facility census was 55.Findings included:Record review for Resident #32 revealed an admission date of 08/23/23. Diagnoses included kidney disease, metabolic encephalopathy, and seizures. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had mild cognitive impairment. Review of the active physician orders for Resident #32 for 07/01/25 revealed the orders included Aspirin 81 milligrams (mg) chewable one tablet every day for deep vein thrombosis (DVT) prevention and Mucinex (Guaifenesin) 12-hour 600 mg extended release twice a day four pneumonia. Observation on 07/07/25 at 9:40 A.M. revealed Licensed Practical Nurse (LPN) #255 administering medications to Resident #32. LPN #255 prepared Resident #32's medication which included: Aspirin 81 mg enteric coated one tablet and Guaifenesin 400 mg extended release one tablet. At 10:00 A.M., LPN #256 crushed the medications including Aspirin and Guaifenesin. Interview on 07/07/25 at 11:30 A.M. with LPN #256 verified she did crush Resident #32's Aspirin 81 mg enteric coated one tablet and verified Resident #32 was to receive Aspirin 81 mg chewable. LPN #256 also verified she crushed Resident #32's Guaifenesin 400 mg extended release one tablet and verified there was no physician order to crush Resident #32's medication. Interview on 07/07/25 at 3:01 P.M. with the Director of Nursing (DON) verified Resident #32 had no physician order to crush the medications. Review of the facility policy titled Medication Administration dated 08/22/22 revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Do note crush medications that are slow release and enteric coated. Review of the facility document titled Med Pass dated 2002 revealed medications not to be crushed included Guaifenesin extended release and Aspirin Enteric Coated. This deficiency represents non-compliance investigated under Complaint Number OH00167226 (1365859).

Based on medical record review, staff interview, and resident interview, the facility failed to ensure residents were free of significant medication errors. This affected one (Resident #27) of three residents reviewed for medication administration. The census was 58 residents. Findings included: Review of the medical record for Resident #27 revealed an admitted [DATE] with diagnoses including coronary artery disease, heart failure, hypertension, and diabetes. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #27 dated 10/16/24 revealed the resident was cognitively intact and was independent with activities of daily living (ADLs.) Review of a progress note dated 12/24/24 revealed no evidence the resident went on a LOA for the night. Review of the physician's orders for Resident #27 revealed the resident should receive the following medications on 12/25/24 between 6:00 A.M. and 10:00 A.M.: Norvasc 2.5 milligram (mg), Plavix 75 mg, Pepcid 20 mg, fenofibrate 48 mg, Jardiance 10 mg, Kapspargo 100 mg, magnesium oxide 400 mg, pantoprazole 40 mg, Gabapentin 800 mg, potassium 40 milliequivalents (MeQ) two tablets, Mirapex 0.125 mg, Senna 8.6 mg two tablets, Torsemide 100 mg , Effexor 37.5 mg, Vitamin B-12 500 micrograms (mcg.) Interview on 01/16/25 at 10:52 A.M with Resident #27 confirmed he left the faciity on a leave of absence (LOA) on 12/24/24 after Licensed Practical Nurse (LPN) #164 administered his morning medications. Resident #27 confirmed LPN #164 gave him his medications for the evening of 12/24/24 but she did not give the resident his morning medications for 12/25/24. Resident #27 confirmed when he woke up on 12/25/24 he discovered he did not have his medications for the morning. Resident #27 called the facility, and the staff told him the morning medications were still in the cart. Resident #27 confirmed he had vomiting and diarrhea on the morning of 12/25/24 and he didn't know if the symptoms were related to him not receiving his morning medications. Interview on 01/16/25 at 11:26 A.M. with LPN #159 confirmed she got a phone call from Resident #27 on the morning of 12/25/24 and the resident said LPN #164 had not given him morning medications for 12/25/24. LPN #159 confirmed when she looked in the medication cart, the resident's morning medications for 12/25/24 were still in the medication cart and had not been sent with the resident. This deficiency represents noncompliance investigated under Complaint Number OH00160745.

Based on medical record review, observations, interviews and policy reviews the facility failed to ensure urinary catheter care was provided in a dignified manner. This affected one (#19) out of three residents reviewed for resident rights. The facility census was 63. Findings include Review of medical record for Resident #19 revealed an admitted [DATE]. Diagnoses included neuromuscular dysfunction of bladder, inflammatory disorder of male genital organ, cystitis without hematuria, tracheostomy, and obstructive and reflux uropathy. Review of Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #19 revealed an resident was cognitively intact. Resident #19 was substantial maximal assistance for toileting, and bathing. Resident #19 was coded with placement if an indwelling urinary catheter. Review of plan of care dated 09/19/24 revealed that Resident #19 was at risk for potential for complications related to the use of suprapubic catheter related to neurogenic bladder. Interventions included change Foley collection bag per facility policy and as needed, encourage adequate fluid intake daily, notify the physician of abnormal lab values, obtain vital signs if resident becomes symptomatic, position catheter bad, and tubing below the level of the bladder to ensure no tubing, make sure tubing was not under resident legs, and provide Foley catheter care per facility policy and as needed. Review of the physician orders for Resident #19 revealed an order dated 12/11/23 catheter care every day shift and night shift. Observation on 11/18/24 at 2:20 P.M. with Certified Nursing Assistant (CNA) #20 revealed staff knocked on the door of Resident #19, donned personal protective equipment and advised Resident #19 that she would be providing catheter care. CNA #20 donned gloves and gown, entered residents room, gathered equipment, laid paper towel on the floor and set the urinal on the paper towel under the urinary drainage bag. CNA #20 removed the blanket and sheet exposing the superpublic cath. CNA #20 explained what she was going to be doing and then stabilizing the tubing using soap and water the CNA cleaned the tubing to the drainage bag. CNA #20 using an alcohol pad cleaned the tubing on the drainage bag and emptying the urine into the urinal without touching the sides of the urinal. Once completed the tubing was again wiped with alcohol and inserted into the storage tube on the drainage bag. CNA #20 then measured the urine and disposed the urine in the commode. Interview on 11/18/24 at 2:27 P.M. with CNA #20 verified she did not pull the curtain and did not shut the door to the room, potentially exposing Resident #19 to staff, residents or visitors passing in the hallway. Interview on 11/19/24 at 3:30 P.M. with Director of Nursing (DON) verified the curtain should have been pulled or the door should have been closed to provide resident with privacy. Review of the facility policy titled Quality of Life- Dignity dated 08/2019 stated under number 10, staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment and procedures. This deficiency represents non-compliance investigated under Complaint Number OH00159216.

Based on medical record review and staff interviews, the facility failed to ensure urinary catheter care was completed and documented as ordered. This affected one (#64) of three residents reviewed for catheter care. The facility census was 63. Findings include: Medical record review for Resident #64 revealed an admission on 05/20/24 and a discharge on 08/10/24 with diagnoses including but not limited to infection and inflammatory reaction due to other urinary catheter, neuromuscular dysfunction of the bladder, quadriplegia and history of sepsis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #64 revealed an intact cognition. Resident #64 was coded with delusions. Resident #64 was dependent on staff for eating, bed mobility, transfers and toileting. Resident #64 was assessed as having a urinary suprapubic catheter and a colostomy. Review of the plan of care for Resident #64 dated 05/21/24 revealed a potential for complications related to use of suprapubic catheter due to neurogenic bladder. Interventions included assist with suprapubic catheter care as needed, educate resident to report signs and symptoms of infections, and monitor for signs and symptoms of urinary tract infections. Review of the physicians orders for Resident #64 revealed an order dated 05/31/24 for suprapubic catheter care every shift. Review of the Treatment Administration Record (TAR) for June 2024 for Resident #64 revealed no documentation of completed or refused catheter care on 06/06/24, 06/10/24, 06/11/24, 06/12/24, 06/18/24, 06/19/24, 06/20/24, 06/21/24, 06/22/24, 06/23/24, 06/27/24 on day shift. Review of the TAR for July 2024 for Resident #64 revealed no documentation of completed of refused catheter care on 07/03/24, 07/05/24, 07/06/24, 07/07/24, 07/20/24, 07/21/24 on day shift. Interview on 11/25/24 at 3:10 P.M. with Director of Nursing (DON) verified the documentation for catheter care was not initialed as completed or refused and it should have been for Resident #64. This deficiency represents non-compliance investigated under Complaint Number OH00159216.

Based on medical record review, observation, staff interview and policy review, the facility failed to follow the physician orders for medication administration. This affected two (#30 and #64) of four residents reviewed for medication administration. The facility census was 63. Findings include: 1. Medical record review for Resident #30 revealed an admission on 07/03/24 with diagnoses of insomnia. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #30 revealed a moderately impaired cognition. Resident #30 requires staff assistance for the completion of activities of daily living. Review of the physicians orders for Resident #30 revealed an order dated 10/04/24 and a for melatonin oral tablets 3 milligrams with directions for administration to give 3 mg by mouth at bedtime for insomnia and an order dated 07/03/24 for melatonin oral tablets 3 mg with directions to administer 3 tablets by mouth at bedtime for insomnia. Review of the medication administration record (MAR) for the month of October 2024 for Resident #30 revealed resident was administered melatonin 3 mg tablets one tablet at bedtime and melatonin 3 mg tablets give three tablets at bedtime. Interview on 11/19/24 at 2:30 P.M. with the Director of Nursing (DON) verified the MAR for the month of October 2024 revealed Resident #30 received melatonin in error and should not have had two orders for the same medication. 2. Medical record review for Resident #64 revealed an admission on 05/20/24 with diagnoses that include quadriplegia, hypotension, and chronic pain. Review of the Admission MDS dated [DATE] for Resident #64 revealed an intact cognition. Resident #64 was dependent on staff for activities of daily living. Review of the active physician orders for Resident #64 for the month of May 2024 revealed an order dated 05/24/24 for midodrine oral tablet 10 milligrams (mg), give 10 mg by mouth every hour hours, hold if blood systolic blood pressure (SBP) is over 110. Review of the medication administration record for Resident #64 for the month of May 2024 revealed medication was administered eight times (05/24/24 at midnight, on 05/27/24 at midnight, on 05/28/24 at 4:00 P.M., on 05/29/24 at midnight, on 05/29/24 at 4:00 P.M., on 05/31/24 at midnight, at 8:00 A.M. and at 4:00 P.M.) when documented blood pressure was not obtained/documented or elevated over 110 SBP. Review of the active physician orders for Resident #64 for the month of June 2024 revealed an order dated 05/24/24 and discontinued on 06/14/24 for midodrine oral tablet 10 milligrams (mg), give 10 mg by mouth every eight hours, hold if blood SBP is over 110. Further review revealed a time of medication administration change dated 06/14/24. Review of the medication administration record for Resident #64 for the month of June 2024 revealed medication was administered seventeen times (06/01/24 at 4:00 P.M., 06/02/24 at 4:00 P.M., 06/06/24 at 8:00 A.M., 06/06/24 at 8:00 P.M., 06/08/24 at midnight, 06/09/24 at midnight, 06/10/24 at 4:00 P.M., 06/11/24 at 8:00 A.M., 06/11/24 at 4:00 P.M., 06/14/24 at midnight, 06/14/24 at 4:00 P.M., 06/15/25 at hour of sleep (hs), 06/15/24 at 2:00 P.M., 06/17/24 at 8:00 A.M., 06/19/24 at hs, 06/26/24 at hs and 06/28/24 at hs) when documented blood pressure was not obtained/documented or elevated over 110 SBP. Review of the active physician orders for Resident #64 for the month of July 2024 revealed medication was administered eight times ( 07/03/24 at 2:00 P.M., 07/04/24 at HS, 07/18/24 at HS, 07/19/24 at 2:00 P.M. 07/20/24 at 2:00 P.M., 07/21/24 at HS, 07/23/23 at 2:00 P.M. and 07/30/24 at HS) Review of the active physician orders for Resident #64 for the month of August 2024 revealed an order dated 06/14/24 for midodrine oral tablet 10 milligrams (mg), give 10 mg by mouth upon rising, 2:00 P.M. to 5:00 P.M. and at HS hold if blood SBP is over 110. Review of the MAR for Resident #64 for the month of August 2024 revealed medication was administered five times (08/01/24 at HS, on 08/03/24 at HS, on 08/04/24 at HS, 08/05/24 at HS and 08/10/24 at 8:00 A.M. Interview on 11/21/24 at 4:10 P.M. with the DON verified medication was not administered as ordered when SBP were elevated over 110 or the blood pressure was not obtained prior to administration. Review of the facility's policy titled Medication Administration dated November 2017 revealed it is the policy of this facility to administer medication as ordered in accordance with manufacturer recommendations. This deficiency represents non-compliance investigated under Complaint Number OH00159216.

Based on medical record review, observation, staff interview, review of medication manufacturer instructions, and review of facility policy, the facility failed to ensure a staff member primed (performed a safety test) when using an insulin pen-injector, resulting in a significant medication error. This affected one (#2) of five residents observed for medication administration. The facility census was 63. Findings include: Review of Resident #02's medical record revealed an admitted [DATE]. Diagnoses included type one diabetes mellitus. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #02 was cognitively intact and received insulin injections. Review of the physician orders for Resident #02 revealed orders dated 11/07/24 for Lantus SoloStar Subcutaneous Solution Pen-injector 100 units per milliliter (long-acting insulin) inject 45 units subcutaneously when rising for diabetes mellitus and Humalog kwik pen Subcutaneous Solution pen injector 100 unit/ml inject per sliding scale of 150-201 give three units, 201-250 give six units, 251-300 give nine units, 301-350 give 12 units and 351-400 give 15 units before meals and if blood sugar is over 400 call physician. Observation on 11/20/24 at 8:00 A.M. revealed Licensure Practical Nurse (LPN) #95 removed Resident #02's Lantus SoloStar Subcutaneous Solution Pen-injector and the Humalog Kwik Pen Subcutaneous Solution Pen injector from the medication cart and applied a new needle to both pens. LPN #95 then entered Resident #02's room. LPN #95 dialed 45 units on the Lantus SoloStar Subcutaneous Solution Pen-injector and dialed up 12 units of Humalog kwik pen subcutaneous solution per physicians order for blood sugars of 323. LPN #95 did not prime the Lantus SoloStar Subcutaneous Solution Pen-injector needle or the Humalog kwik pen subcutaneous solution pen injector before dialing the dose. LPN #95 then administered the insulin into Resident #34's right abdomen. During an interview on 11/20/24 at 8:20 A.M., LPN #95 confirmed she did not prime Resident #02's Lantus SoloStar Subcutaneous Solution Pen-injector needle or the Humalog Kwik Pen Subcutaneous solution pen injector before administering the ordered dose. Review of the manufacturer instructions for the Lantus SoloStar Subcutaneous Solution Pen-injector and the Humalog Kwik Pen Subcutaneous Solution Pen-injector revealed after attaching a needle to the pen, a safety test must be performed. A safety test was completed by: Dial a test dose of two units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test two more times. If there is still no insulin coming out, use a new needle and do the safety test again. Always perform the safety test before each injection. Never use the pen if no insulin comes out after using a second needle. Review of the facility's policy titled Medication Administration dated November 2017 revealed it is the policy of this facility to administer medication as ordered in accordance with manufacturer recommendations. This deficiency represents non-compliance investigated under Complaint Number OH00159216.

Based on medical record, staff interviews and policy review, the facility failed to ensure staff accurately documented dietary intake of meals. This affected one (#64) of three residents reviewed for staff assistance with dietary intake. The facility census is 63. Findings include: Medical record review for Resident #64 revealed an admission on 05/20/24 and a discharge on 08/10/24 with diagnoses including but not limited to quadriplegia and history of sepsis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #64 revealed an intact cognition. Resident #64 was coded with delusions. Resident #64 was dependent on staff for eating, bed mobility, transfers and toileting. Review of the plan of care for Resident #64 is at risk for self care deficit related to diagnoses sepsis, paraplegia due to post motor vehicle accident and chronic pain. Resident is alert and oriented times three, communicates needs effectively, and requires total assistance with activities of daily living. Review of the physicians orders for Resident #64 revealed a diet order for a regular, regular texture, thin liquid diet. Review of the medical nutrition and hydration assessment dated [DATE] for Resident #64 revealed admission weight of 127.9 pounds with an ideal body weight of 115 pounds, Resident #64 was a dependent diner with intakes of meals between fifty and seventy five percent. Registered dietician note revealed resident denies any chewing or swallowing problems on current diet with recommendations of fortified foods. Discharge weight on 08/10/24 revealed a weight of 116.2 pounds. Review of the facility staff schedule dated 06/28/24 revealed there was a staff member assigned to Resident #64 to assist with meal consumption. Review of the facility state tested nursing assistant (STNA) documentation for Resident #64 dated 06/15/24 to 06/28/24 revealed no documentation/percentages consumed for twenty one different meals. Further review of the document revealed no dietary intakes were recorded for 06/15/24, 06/16/24, 06/19/24, and partial documentation on 06/17/24 (no noon or evening meal), 06/18/24 (no evening meal), 06/20/24 (no evening meal), 06/21/24 (no evening meal), 06/23/24 (no noon or evening meal), 06/24/24 (no evening meal), 06/25/24 (no evening meal), 06/27/24 (no noon or evening meal and 06/28/24 (no evening meal). Interview on 11/20/24 with Registered Dietician (RD) #167 stated no concerns with weight loss during stay. RD #167 stated Resident #64 did not report to her any lack of staff support for meals or times when she did not receive a meal tray. RD #167 stated weight stabilized after admission and reflected loss of additional fluids received at the hospital. RD #167 verified the lack of documentation in the medical record for percentage of meals consumed and reports she completes her own assessment with interviews of residents. Interview on 11/25/24 at 3:25 P.M. with Director of Nursing (DON) verified the meal intake documentation was not complete as it should have contain percentages consumed for all meals and didn't. Review of the facility policy titled Activities of Daily Living (ADL's) Supporting, dated 03/2018 revealed the facility failed to implement the policy as written. The policy states appropriate care and services will be provided for residents who are unable to care out ADL's independently in accordance with the plan of care including dining (meals and snacks). This deficiency represents non-compliance investigated under Complaint Number OH00159216.

Based on medical record review, review of the incident investigation and witness statements, observations, staff and physician interview, review of the Emergency Medical Services (EMS) report and hospital records, and policy review, the facility failed to ensure the residents were free from burns sustained from the water in the shower room at the facility and failed to timely conduct a root-cause analysis of the resident's burns. This resulted in Immediate Jeopardy and serious life-threatening harm and/or injuries when Resident #17 sustained severe burns on the left leg from her inner thigh to the foot and to her right inner thigh from a shower in the [NAME] shower room on 07/21/23. Subsequently, Resident #17 required hospitalization due to the severe burns and developed Methicillin-resistant Staphylococcus aureus (MRSA) in the wounds. Additionally, the facility did not identify the root-cause analysis of Resident #17's burns until 08/10/23. This affected one (#17) of three residents reviewed for accident hazards and placed an additional 25 (#02, #08, #10, #11, #13, #14 #15, #19, #20, #22, #25, #27, #28, #31, #35, #38, #39, #42, #43, #45, #46, #47, #50, #51, and #52) residents at risk for potential serious harm and/or injuries as the [NAME] shower room remained in use for the residents to receive showers from 07/21/23 until 08/10/23 at which time the water supply was turned off to the [NAME] Shower room and it was closed to resident use. The facility census was 54. On 08/14/23 at 10:47 A.M., the Administrator, Director of Nursing (DON), Regional Director of Operations #200, and Regional Director of Clinical Services (RDCS) #190 were notified Immediate Jeopardy began on 07/21/23 when Resident #17 sustained severe burns to her left leg from her inner thigh to the foot and to her right inner thigh during her shower. The DON, Wound Nurse #87, and Licensed Practical Nurse (LPN) #08 felt Resident #17 sustained burns during her shower on 07/21/23. However, RDCS #190 felt the wounds were Moisture Associated Skin Damage (MASD) and had the facility classify the wounds as MASD. A treatment of Silvadene (a topical antibiotic used in partial thickness and full thickness burns to prevent infection) was implemented on 07/21/23. On 07/23/23, Resident #17 was started on an oral antibiotic due to the wounds on Resident #17's bilateral legs. On 07/30/23, Agency LPN #50 observed the wounds for the first time and immediately called emergency services due to the severe burns on Resident #17's bilateral legs. During the hospital stay, Resident #17 had severe non-healing wounds noted to the left leg from inner thigh to foot, black eschar, and an open blister at the bottom of her foot and intact blisters behind the knee. The right inner thigh had eschar present. The hospital noted the wounds were burns versus pressure related and surgical debridement was required. Resident #17 was treated with intravenous (IV) antibiotics for MRSA in the wounds. On 08/10/23, RDCS #190 stated Resident #17's wounds were MASD, that turned into cellulitis, then had MRSA in the wounds. RDCS #190 stated Physician #203 only wrote down burns in his history and physical on 08/06/23 because the hospital called them burns. On 08/14/23, Physician #203 stated he was not aware Resident #17 had burns to her bilateral lower legs until the hospital notified him and the physician stated Resident #17 clearly had burns sustained from the shower room on 07/21/23. From 07/21/23 to 08/10/23, the [NAME] shower room remained in use for the residents to receive showers in. The Immediate Jeopardy was removed on 08/15/23 when the facility implemented the following corrective actions: On 07/21/23, the facility implemented a Quality Assurance Performance Improvement (QAPI) plan, and it was continually updated and monitored on 07/24/23, 07/25/23, 07/31/23, 08/02/23, 08/07/23, 08/09/23, and 08/10/23. The QAPI plan included water temperatures obtained in the [NAME] shower room, an incident report along with staff statements obtained, the shower room chemicals and supplies were audited, and education on Activities of Daily Living (ADL) care to the licensed nurses was completed. On 08/05/23, the DON, Unit Manager #87, and Unit Manager #86 completed skin assessments on all 50 in-house residents and found no negative outcomes. On 08/05/23, Resident #17 returned to the facility with a physician order for Resident #17 to see an outside wound clinic for the burns on her bilateral legs. The initial appointment was scheduled for 08/11/23 but the wound clinic had to reschedule the initial appointment. On 08/06/23, Physician #203 assessed Resident #17's wounds as burns on the bilateral lower extremities. On 08/10/23, the Administrator, DON, Regional Director of Operations #200, and RDCS #190 completed a root cause analysis involving the incident where Resident #17 sustained burns in the shower on 07/21/23. The identified root cause was determined to be a faulty mixing valve which did not allow the shower to maintain proper water temperatures resulting in Resident #17 sustaining burns on her bilateral legs. The root cause analysis identified the following two issues: maintenance staff did not know how to identify water temperature issues and how to fix appropriately and the facility staff did not know how to properly notify maintenance staff on maintenance issues. On 08/10/23 at 10:22 A.M., Maintenance Supervisor #12 and Regional Maintenance Director #180 closed the [NAME] Shower room for no resident use and turned off the water supply to the [NAME] Shower room. On 08/10/23 at 5:00 P.M., Regional Maintenance Director #180 replaced the mixing valve to ensure proper temperatures are maintained for all residents. On 08/10/23, Maintenance Supervisor #12 and Regional Maintenance Director #180, audited all water temperatures throughout the building including the East and [NAME] shower rooms, all resident rooms, and common areas where water is accessible to the residents. There were no negative findings. By 08/14/23, the Administrator will educate all 87 staff on how to notify management staff on equipment issues and specifically how to address these in a timely manner to ensure the safety of the residents. On 08/14/23, the Administrator and DON implemented an Agency Binder for agency staff to utilize while working a shift at the facility. This binder includes education on how to report mechanical issues as well as other concerns and incidents to management staff in a timely manner. On 08/14/23, the Administrator educated Maintenance Director #12 on how to fix a mixing valve. On 08/14/23, the facility will conduct daily water temperature audits to ensure the water temperatures are accurate and within the appropriate guidelines. This will be completed by Maintenance Supervisor #12 and/or designee for two weeks and then three to five times per week for the next month with results being reported to the QAPI committee and interventions adjusted as indicated to maintain ongoing compliance. On 08/14/23 at 7:35 A.M., observation of the [NAME] shower room revealed the [NAME] shower room was open for residents to receive showers, and the shower control knob mixing valve for the cold and hot water were operating properly and hot and cold water was being released at the temperature as indicated on the shower control knob. On 08/14/23, staff interviews with LPN #04 and #87, State tested Nursing Assistants (STNA) #32, and #50, Housekeeper #69, and Receptionist #14 revealed they were educated on how to timely report equipment issues. On 08/15/23, the facility submitted a Self-Reported Incident (SRI) to the State Survey Agency. The SRI reported Resident #17 sustained an injury of unknown origin on 07/21/23. Although the Immediate Jeopardy was removed on 08/15/23, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #17's medical record revealed Resident #17 was admitted to the facility on [DATE]. Diagnoses included muscle weakness, repeated falls, dementia without behavioral disturbance, schizoaffective disorder, tremors, and history of encephalopathy. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of seven. Resident #17 required extensive one-person assistance with bed mobility, dressing, and personal hygiene and was dependent on one-person for showering/bathing. Resident #17 had no pressure ulcers or venous and arterial ulcers present. Review of the care plan revised 08/24/21 revealed Resident #17 required assistance with activities of daily living (ADL) related to immobility, generalized weakness, repeated falls, confusion and memory loss, tremors, history of encephalopathy, dementia, anxiety, and schizophrenia. Resident #17 was able to make needs known. ADLs may vary over the course of the day, usually received extensive assistance with ADLs. Interventions included to provide additional assistance as needed and document accordingly. Report any significant changes to the charge nurse and physician. Further review of the resident's care plan revealed Resident #17 had the potential for alteration in skin integrity and required protective/preventive skin care maintenance related to bladder incontinence, impaired mobility, impaired cognition, and unable to recognize risk. Interventions included to inspect the skin condition daily during personal care and report any impaired areas to the charge nurse. Resident #17 required extensive assistance with weight bearing for bathing. Provide additional assistance as needed and document accordingly. Review of the skin assessment dated [DATE] revealed Resident #17 had no skin impairments and the resident's skin was intact. Review of the facility incident report titled Skin Alteration, dated 07/21/23 at 4:47 P.M., revealed Resident #17 was observed with an area of moisture between thighs and calves during routine ADL care by an STNA. Nursing was then alerted. Resident #17 was unable to give a description of the incident. The predisposing physiological factors included immobility, incontinence, and fragile skin. The Interdisciplinary Team (IDT) review on 07/25/23 documented by the DON revealed Resident #17 was observed with skin impairment to bilateral inner legs and left foot. Resident #17 was followed by Wound Nurse Practitioner (WNP) #400 and a treatment was in place. The physician and family were notified. The Regional Nurse (RDCS #190) instructions/direction carried out at time of event. Review of STNA #402's witness statement dated 07/21/23 revealed STNA #402 gave a shower to Resident #17 on 07/21/23. The resident did not have any redness noted to her bilateral legs prior to the shower. While in the shower, STNA #402 adjusted the water temperature to the residents' request. Resident #17 did have a large bowel movement in the shower. STNA #402 stated she did clean the resident after the bowel movement with the pink house body wash. No redness was noted at that time to her bilateral legs. Resident #17 had an episode of unresponsiveness while in the shower. Resident #17 was not left unattended and STNA #402 went to the shower room door and shouted for LPN #08. After LPN #08 took the resident's vital signs and finished her evaluation, STNAs #402 and #52 took Resident #17 back to her room and transferred the resident to bed. After transferring the resident to bed, redness was noted to her bilateral thighs. The resident denied the redness was painful. The resident continued to have diarrhea throughout the shift. The resident had three more bowel movements during the shift. Review of STNA #52's witness statement dated 07/21/23 revealed she assisted STNA #402 to transfer Resident #17 to the shower chair and the resident was fine. The STNA revealed she went to the shower room to throw away trash and observed STNA #402 washing the resident's hair. The resident was okay. The STNA did not notice Resident #17's legs until Resident #17 was unresponsive and LPN #08 was in the shower room assessing Resident #17. Review of LPN #08's witness statement dated 07/21/23 at 2:30 P.M., revealed upon going into the shower room, she noticed Resident #17 was arousable to pain, blood pressure was 133/55 millimeters of mercury (mm/Hg), heart rate 80 beats per minute and unable to obtain an oxygen saturation, respirations were twelve breaths per minute, easy and unlabored. LPN #08 noted red marks on Resident #17's inner thighs. Resident #17 was covered up then taken back to her room and put in bed. Upon assessment, Resident #17's left leg from her thigh to her foot was red and the skin was peeling, and the right thigh was red. LPN #08 reported her assessment to the unit manager. Review of the skin assessment dated [DATE] at 4:47 P.M., after the resident received a shower, revealed Resident #17 had Moisture Associated Skin Damage (MASD) to her left thigh measuring 35 centimeters (cm) in length, 11 cm in width, and the depth could not be determined. The resident's left calf was assessed to have MASD that measured 20 cm in length, 14 cm in width and the depth could not be determined. The resident's left foot was assessed to have MASD and measured 15 cm in length, and 8.0 cm in width, the depth could not be determined. The resident's right thigh revealed the resident had MASD measuring 27 cm in length, 4.0 cm in width and the depth could not be determined. Review of the nursing progress note dated 07/21/23 at 4:55 P.M. revealed the wound nurse, LPN #87 documented Resident #17 was noted with an area of moisture between her thighs and calves during routine ADL care by an STNA. An STNA alerted nursing. The wound nurse assessed area and immediately initiated a treatment plan. All documentation completed. The responsible party, Resident #17's primary care physician, the DON, and WNP #400 were made aware. Review of WNP #400's progress note assessment, dated 07/25/23 at 8:30 A.M., revealed Resident #17 was seen for full thickness, non-pressure wounds to her bilateral legs with an onset date of 07/21/23. Wounds were currently being treated with Silvadene. Physician #203 started Resident #17 on a ten-day course of Vibramycin (oral antibiotic to treat and prevent infections). WNP #400's new orders on 07/25/23 were to clean the bilateral legs with facility wound cleanser. Apply silver wound gel (contains silver that inhibits the growth of microorganisms). Cover with oil emulsion dressing (non-adherent gauze mesh impregnated with white petrolatum that permits the flow of exudate without sticking to the wounds). Secure with ABD pad and kerlix. Change daily. Review of Resident #17's nursing progress notes revealed there was no documentation on 07/30/23 when the resident was sent to the hospital for evaluation. Review of the EMS report dated 07/30/23 at 5:23 P.M., revealed Resident #17 began to have pain in her legs about a week ago. The resident's family visited today (07/30/23) and urged the facility to have Resident #17 transported to the hospital for evaluation. The nurses stated they were told not to send Resident #17 out (to the hospital). The residents' son stated Resident #17 was not acting like her normal self and stated she was very sluggish and not talkative like she would be on a normal day. Facility staff stated they were breaking their procedures and called to have Resident #17 transported to the hospital. Resident #17 was complaining of pain in lower extremities. Resident #17 has what appeared to be burns running the medial side of her left leg from the thigh down to her left foot. Wounds on her ankle and foot were open and less healed than those proximal. Resident #17 had the beginnings of similar burn like wounds on the medial side of her right thigh trailing off to redness as they extended distal to the knee. Review of the hospital encounter report dated 07/30/23 revealed Resident #17 was diagnosed with burns to her left thigh, down her left leg from inner thigh to foot, black eschar, and an open blister at the bottom of her foot and intact blisters behind the knee. A burn on the right inner upper thigh eschar was present. Resident #17's wounds were debrided on 07/31/23. Resident #17 was diagnosed with MRSA on bilateral leg wounds and the left foot and ordered IV antibiotics consisting of Vancomycin 1,000 milligrams (mg/10 milliliters (ml) once daily in the evenings for ten days, and Cefepime two gram (gm)/100 ml to be administered every twelve hours for ten days. Resident #17 returned to the facility on [DATE] at 7:30 P.M. Review of the care plan revised on 08/01/23 revealed Resident #17 has an actual area of skin impairment related to open wounds to her bilateral legs and left foot. Interventions included to ask the resident about pain level prior to dressing change procedure, medicate if needed. Avoid tight clothing. Continue treatment as ordered by the physician or nurse practitioner (NP). Nursing to observe the wound dressing daily to ensure the dressing remains intact and there were no signs or symptoms of infection or increased drainage. Review of Resident #17's re-admission assessment to the facility dated 08/05/23 revealed the residents' wound measurements to the right thigh were 16 cm in length, 5.0 cm in width, and depth could not be determined. The left thigh wound from her left thigh to the left foot measured 78 cm in length, 13 cm in width, and depth could not be determined. The resident was diagnosed with MRSA of bilateral leg wounds and left foot and returned to the facility with orders from the hospital to continue IV antibiotics consisting of Vancomycin 1,000 mg/10 ml once daily in the evenings for ten days, and Cefepime 2.0 gm/100 ml to be administered every twelve hours for ten days. Additional orders included for Resident #17 to follow up with Wound Clinic #750 on 08/11/23 and schedule an appointment with infectious disease physician as soon as possible. Review of Resident #17's History and Physical dated 08/06/23 completed by Physician #203 revealed Resident #17 was admitted to the nursing home from the hospital. Resident #17 required admission to the hospital for treatment of burns on both legs that also had a secondary infection. She underwent debridement of the abnormal tissue. She was evaluated by an infectious disease physician. She was placed on IV cefepime and vancomycin. She was sent to the facility with orders for a ten-day course of antibiotic therapy. She had a peripherally inserted central catheter (PICC) line placed. Resident #17 stated she was not experiencing discomfort to the wounds on her legs. On 08/09/23 at 10:30 A.M., during an interview with Wound LPN #87 revealed on 07/21/23 at approximately 2:00 P.M., she was alerted by LPN #08, Resident #17's assigned nurse, Resident #17 had redness to her lower legs after receiving a shower. The wound nurse stated she questioned STNA #402 who gave the resident a shower earlier and the STNA insisted it could not have been the shower because the water was not that hot. The wound nurse stated she texted pictures of the wounds to RDCS #190, WNP #400, and the DON. The DON was on vacation on 07/21/23. The wound nurse stated the wounds appeared to her as burns. The wound nurse stated RDCS #190 responded to her and stated the wounds appeared as MASD because Resident #17 had just got out of the shower and it looked like to her skin stuck together and ripped off related to the shape and there were no other burns on her body. RDCS #190 instructed to classify the wounds as MASD. The wound nurse stated the DON responded to her and stated the wounds appeared to be burns and WNP #400 responded with a question, Did the resident spill something hot on her? The wound nurse stated she responded to WNP #400 that RDCS #190 instructed to classify the wounds as MASD because there were no other burns on the resident's body. The wound nurse asked WNP #400 if it was OK to label the wounds as MASD. The wound nurse stated WNP #400 responded, I guess if we can't explain a burn. During the interview, LPN #87 became tearful and stated she had been the wound nurse at the facility for approximately three weeks and did not feel the wounds to Resident #17's legs were MASD. LPN #87 stated she was following the instructions from RDCS #190, because she was an RN and had more experience with wounds. On 08/09/23 at 12:25 P.M., during a telephone interview with WNP #400 stated she was informed by Wound LPN #87 of Resident #17's wounds to her bilateral legs on 07/21/23 and she did not assess the residents' wounds until 07/25/23, when she does her weekly wound rounds in the facility on Tuesdays of every week. WNP #400 stated she classified the wounds as full thickness non-pressure wounds that had 100% yellow slough (necrotic tissue). WNP #400 stated she was notified by Wound LPN #87 on 07/21/23 that RDCS #190 had classified the wounds as MASD, and the skin peeled off when Resident #17 crossed/uncrossed her legs. WNP #400 stated she has known of patients who experience spontaneous blisters from Bullous pemphigoid (a rare skin condition causing large fluid-filled blisters). On 08/09/23 at 2:15 P.M., during an interview with STNA #52 revealed she worked on 07/21/23 and was not Resident #17's assigned STNA. STNA #52 stated she assisted the resident's assigned STNA #402 to transfer Resident #17 from the bed to the shower chair after breakfast but was not certain of the time. STNA #52 stated she could see the residents' arms and legs during the transfer and Resident #17 had no redness or blisters to her arms or legs. STNA #52 stated she heard STNA #402 yell for the nurse (LPN #08) because Resident #17 had become unresponsive in the shower room. STNA #52 stated she saw LPN #08 go into the shower room and the nurse came out of the shower room and asked both STNAs #402 and #52 to take Resident #17 back to her room and put her in bed. STNA #52 stated a blanket was on the resident, which was always done when transporting a resident from the shower to prevent the resident from getting cold. STNA #52 stated when she assisted STNA #402 to transfer Resident #17 from the shower chair to her bed she noticed Resident #17 had very reddened areas to both her legs that were not there prior to the resident's shower. STNA #52 stated she asked STNA #402 what happened, and she stated she didn't know. On 08/10/23 at 8:29 A.M., during a telephone interview with STNA #402 revealed on 07/21/23, she was Resident #17's assigned STNA. STNA #402 stated after breakfast, she was not certain of the time, she gave the resident a shower. STNA #402 stated Resident #17 had no redness to her skin prior to her shower. STNA #402 stated Resident #17 became unresponsive during the shower, and she yelled for LPN #08 and the LPN came into the shower room to assess Resident #17. Resident #17 became responsive, and LPN #08 instructed her to take the resident back to her room and put her back to bed. STNA #402 stated she wrapped Resident #17 in a blanket and with the assistance of STNA #52, they took the resident back to her room. When Resident #17 was in her room, STNA #402 removed the blanket, she saw Resident #17 had very reddened areas to both her legs and the left foot and reported it to LPN #08. STNA #402 stated the water was not too hot during the shower and she does not know what could have caused the very reddened areas to Resident #17's legs and foot. On 08/10/23 at 9:03 A.M., during a telephone interview with LPN #08 revealed she was Resident #17's assigned nurse on 07/21/23. LPN #08 stated after breakfast not certain of the time, STNA #402 came to her informing her Resident #17 did not want to take her scheduled shower. LPN #08 stated she spoke with Resident #17 and told her she would feel better after a shower and the resident agreed. LPN #08 stated she observed both STNAs #52 and #402 transport the resident to the shower. LPN #08 stated she saw STNAs #52 and #402 standing in the hallway outside the [NAME] shower room door, which was approximately 15 feet from the nurse's station, discussing a comb and could not hear all the conversation. LPN #08 stated STNA #402 went back into the shower room and a few minutes later yelled out the shower room door that Resident #17 was not responding. LPN #08 stated she immediately assessed Resident #17 and did the sternal rub (a technique to test an unconscious person's responsiveness). LPN #08 stated Resident #17 became responsive, and her vital signs were within normal limits. LPN #08 stated she did notice some redness to the residents' legs, but nothing alarming, and instructed STNA #52 and STNA #402 to take Resident #17 back to her room and put her back into bed. LPN #08 stated after the resident was returned to bed and after lunch approximately 1:30 P.M., she assessed the resident again and found the resident's left leg and foot and right thigh were red and had what appeared to be blisters. LPN #08 immediately reported her findings to Wound LPN #87. LPN #08 stated she checked the [NAME] shower that day (07/21/23) and noted the shower control knob was backwards and in order to turn the shower off, the knob had to be positioned in the hot position to the left instead of to the right which was the cold position and also the off control. LPN #08 stated she immediately reported her findings to Maintenance Supervisor #12 verbally but did not complete a written notification. LPN #08 stated she was aware the residents' wounds were classified as MASD and in her experience she has never known MASD with a specific pattern on the legs and not include other areas such as the buttocks or perineal area. On 08/10/23 at 8:10 A.M., during an observation/interview with Maintenance Supervisor #12 confirmed the shower control in the west shower room was not functioning properly. Maintenance Supervisor #12 denied being aware of this prior to 08/10/23 and revealed he was just finding this out during the interview and observation at 8:10 A.M. Maintenance Supervisor #12 revealed if the shower control knob was functioning properly to receive hot water, the knob must be positioned to the left and to receive cold water and to turn the shower off the knob should be positioned to the right. During the observation with Maintenance Supervisor #12, he confirmed to turn off the water, the shower control knob had to be positioned to the far left in the hot position and when the shower control knob was positioned in the cold/off position cold water was received and the shower could not be turned off. Maintenance Supervisor #12 stated no one had reported shower control in the [NAME] shower was not functioning properly and he was not aware any resident sustained burns from the shower. Maintenance Supervisor #12 contacted the Regional Maintenance Director #180. On 08/10/23 at 10:22 A.M., during an observation/interview with Regional Maintenance Director #180 confirmed the [NAME] shower control knob was not functioning properly and to turn the water off, the shower control must be positioned in the opposite position to the left labeled hot and should be positioned to the right in the cold/off position. Regional Maintenance Director #180 revealed the shower control knob mixing valve for the cold and hot water was stripped and he would repair/replace the shower control mixing valve as soon as possible. Regional Maintenance Director #180 placed an out of order sign on the [NAME] shower room and turned the water to the shower room off. On 08/10/23 at 2:26 P.M., during an interview with RDCS #190 stated Resident #17's wounds were a result of MASD that developed into cellulitis and MRSA. RDCS #190 stated the reason Resident #17's Physician #203 classified the residents' wounds as burns was because of the information in the hospital report dated 07/30/23 and the EMS classified the wounds as burns because it was reported to them by LPN #50 prior to the resident being transported to the hospital on 07/30/23. On 08/14/23 at 8:50 A.M., during an interview with the DON revealed she was on vacation on 07/21/23 and she received a text message with pictures of Resident #17's wounds to her bilateral lower legs, and they were discovered when the resident was put back to bed after receiving a shower. The DON stated she notified the Administrator and RDCS #190 to get staff statements, have Maintenance Supervisor #12 check the water temperatures in the facility and notify Physician #203 and the resident's family. The DON instructed Wound LPN #87 to take corrective actions as this could be an Immediate Jeopardy as Resident #17 sustained severe burns from the shower. The DON stated the corrective actions were not implemented on 07/21/23 because RDCS #190 said Resident #17's wounds were MASD, not burns. The DON stated she did not see the residents' wounds until she returned from vacation on 07/25/23 and there were no blisters, and the wounds had yellow slough on the base. The DON stated she has never seen MASD turn into blisters and the skin peel away especially in the pattern and location where the residents' wounds were. The DON stated Wound LPN #87 classified the wounds as MASD as RDCS #190 directed her to. The DON stated the family came in the facility to visit the resident on Sunday 07/30/23 and saw the wounds and wanted the resident sent to the hospital. The DON stated on 08/10/23 before 5:00 P.M., the Regional Maintenance Director #190 went to the local hardware store and purchased the mixing valve shower cartridge and repaired the shower on the west hall, the shower was functioning properly, and the water temperatures were calibrated at 110 degrees Fahrenheit (F). Maintenance Supervisor #12 was monitoring the water temperatures daily. On 08/14/23 at 8:55 A.M., during a telephone interview with Physician #203 stated he was not aware Resident #17 had burns to her bilateral lower legs until the hospital notified him. Physician #203 stated Resident #17 clearly had burns sustained from the shower room on 07/21/23 due to the pattern and location of the burns. Physician #203 stated you can't get MASD on the top of your foot during a shower. An attempt to interview LPN #50 during the investigation was unsuccessful. Review of the facility policy titled Abuse, Neglect and Exploitation, revised 10/01/22, revealed the policy of this facility is to provide protections for health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Definitions: Serious Bodily Injury means an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization , or physical rehabilitation; or an injury resulting from criminal sexual abuse. This deficiency represents non-compliance investigated under Complaint Number OH00145032.

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, resident interview, and review of the facility ' s smoking policy, the facility failed to ensure Resident #34 did not smoke while wearing oxygen. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or injuries when agency State tested Nursing Assistant (STNA) #10 took Resident #34 outside for a smoke break and lit the resident ' s cigarette while Resident #34 was wearing oxygen per nasal cannula. The oxygen ignited, resulting in [CONDITION(S)] to both nostrils and singed the nose hairs. This affected one (Resident #34) of four residents reviewed for smoking. The facility identified 16 residents (#01, #02, #05, #06, #09, #17, #19, #20, #22, #34, #39, #44, #45, #48, #52, and #156) who smoke and six residents (#05, #17, #19, #20, #34, and #45) who use oxygen and smoke. The facility census was 58. On 10/05/2022 at 11:51 A.M., the Administrator, Director of Nursing (DON), and Regional Clinical Director #125 were notified Immediate Jeopardy began on 09/04/22 at 9:30 A.M. when Resident #34, who utilized oxygen therapy via nasal cannula, was assisted by STNA #10 to smoke while wearing oxygen. STNA #10 took Resident #34 outside for a smoke break and lit the resident ' s cigarette resulting in the oxygen igniting. Consequently, the resident sustained [CONDITION(S)] to both nostrils and singed nose hairs. The Immediate Jeopardy was removed on 09/05/22 and the deficient practice was corrected on 10/02/22 when the facility implemented the following corrective actions: On 09/04/22 at 9:35 A.M., Licensed Practical Nurse (LPN) #23, LPN #38, and Respiratory Therapist (RT) #73 assessed Resident #34 and had no concerns. Resident #34 refused to go to the hospital for evaluation and treatment. Medical Director #150 was notified and instructed staff to continue monitoring and call if Resident #34 had a change of condition. On 09/04/22 at 9:45 A.M., the DON verified safety devices (smoking blanket and fire extinguisher) were present in the designated smoking area. On 09/04/22 at 11:30 A.M., RT Manager #20 assessed Resident #34. Vital signs were stable and there was no acute distress noted. The DON assessed Resident #34 and noted a blister to the resident s nose and cheek near the right nostril. On 09/04/22 at 1:19 P.M., the DON educated all staff regarding the smoking policy and oxygen use. The DON sent education via email to all staffing agencies the facility used, posted the smoking policy at each nurse ' s station, and placed the smoking policy in the agency staff orientation binder. On 09/04/22 at 1:30 P.M., the DON posted signs stating Absolutely no oxygen beyond this point on smoke doors and verified safety devices were present in the designated smoking area. On 09/04/22, audits of current resident smokers were completed to ensure care plans for smoking were in place and smokers who used oxygen had physician orders for oxygen to be removed prior to smoking. On 09/04/22 at 1:15 P.M., the DON conducted audits for supervised smoke breaks to include every scheduled smoke break through 09/06/2022, then random audits of supervised smoke breaks twice weekly for six weeks to ensure compliance with oxygen removal before smoking. Audits will be completed by the DON/designee. On 09/06/22, the Quality Assurance and Performance Improvement (QAPI) committee met to review all measures implemented to ensure ongoing compliance, and the QAPI committee will review audits to determine the need for continuation. Review of audits revealed the facility audited all supervised smoke breaks from 09/04/22 at 1:15 P.M. to 09/06/22 at 10:00 P.M. to ensure that all breaks were supervised by staff and oxygen was removed prior to smoking. Additional audits of random smoke breaks were conducted twice weekly starting on 09/07/22 with no concerns noted for smoking safety. Observation on 10/04/22 at 3:45 P.M. of the scheduled smoke break revealed staff were outside supervising the residents. Resident #34 was not present, and there were no oxygen tanks or unsafe smoking practices observed. During staff interviews conducted 10/03/22 from 12:03 P.M. to 12:05 P.M., STNA #24, STNA #32, and STNA #54 stated they had been educated on the smoking policy after the incident took place with Resident #34. Residents had to remove oxygen prior to smoking and there was no oxygen allowed in the designated smoking area. During an interview on 10/06/2022 at 2:05 P.M., STNA #15 stated she had read the smoking policy in the agency orientation binder and acknowledged she had understood the policy before beginning her assignment at the facility. Findings include: Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with [CONDITION(S)], [CONDITION(S)] ([CONDITION(S)]), unspecified [CONDITION(S)], unspecified anxiety disorder, and mild intellectual disabilities. Review of the care plan dated 08/04/22 identified Resident #34 had potential for safety hazard or injury related to smoking. Resident was able to smoke with supervision by staff or family. Interventions included resident must remove oxygen while smoking, smoking in designated areas only, notify management if resident was observed being unsafe during smoking, observe for burn holes, educate to smoking policy, smoking assessment completed on admission and quarterly, and direct supervision by family or staff when smoking. Review of the most recent Minimum Data Set (MDS) assessment, dated 08/11/22, revealed Resident #34 had moderately impaired cognition, had verbal and self-directed behaviors, did not wander, and rejected care one to three out of seven days per week. Resident #34 was a one-person assist, required limited assistance with personal hygiene, and required supervision with all remaining Activities of Daily Living (ADL). Resident #34 was a current tobacco user. Resident #34 had physician orders dated 08/13/22 for oxygen to be removed while smoking and an order dated 09/09/22 for oxygen via nasal cannula, titrate to maintain stats greater than 90 percent. Review of the smoking assessment completed on 09/04/22 revealed Resident #34 had cognitive loss which impaired his ability to smoke safely. Resident #34 smoked five to ten times daily, used oxygen, and was able to light his own cigarettes. Resident #34 was a supervised smoker and required continuous education to remove oxygen before smoking. Review of the nursing progress notes revealed on 09/04/22, Resident #34 was wearing oxygen while smoking which resulted in singed nose hairs and [CONDITION(S)] to tip of the nose and right cheek. Resident #34 refused to go to the hospital for evaluation and treatment. Resident #34 was assessed by respiratory therapy, nursing applied a hydrogel dressing, and the resident was educated about wearing oxygen while smoking. Resident #34 had no emergency contacts listed for notification. Review of a witness statement dated 09/04/22 indicated Agency STNA #10 stated she took Resident #34 outside for a smoke break and was outside for approximately 10 minutes when Resident #34 ' s Nose tube set flame. Resident #34 was immediately assessed by LPN's #23, #28 and RT #73. The resident kept stating he was okay. During an interview on 10/05/22 at 9:02 A.M. the DON stated the resident was outside with an agency aide. He was having increased behaviors. She took him out for an unscheduled smoke break, and she was so flustered she did not think about what she was doing. STNA #10 lit his cigarette, and he was wearing his oxygen. They were out there for about 10 minutes before the injury occurred. As soon as she saw the flames, she removed the oxygen, grabbed the cannula, threw it on the ground, and brought the resident in. RT #73 assessed the resident, and the doctor was called. The resident originally refused to go out, agreed on re-approach, and within minutes stated he felt fine and refused to go. The Medical Director (#150) was aware and said to monitor. Medical Director (#150) came in the next day and assessed the resident. Wound NP #140 followed the resident until the blisters healed. He was just taken off wound rounds last week. The DON further stated she came straight into the facility and educated all staff immediately, sent education to the agencies they used, placed signs on the doors to remove oxygen before residents went out, and put a copy of the smoking policy in the agency binder and at every nurse ' s station. The DON met one on one with STNA #10, assessed the designated smoking area to ensure it had a fire blanket and extinguisher and completed assessments of all smokers for orders to remove oxygen prior to smoking and ensured care plans were up to date. The DON completed audits of every smoke break for a few days and then two random smoke breaks per week. The QAPI committee met to review the incident and interventions placed to prevent further incidents and would continue to review audits monthly and as needed to ensure compliance. Review of policy titled Resident Smoking, no date, revealed safety measures for designated smoking included prohibition of oxygen use in the smoking area.

Based on medical record review, staff interview, review of facility policy, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to adequately assess and monitor Resident #35's skin, who was at risk for developing pressure ulcers. This resulted in actual harm when Resident #35 developed a pressure ulcer, which was first identified as a stage three (full thickness skin loss involving damage or death of subcutaneous tissue, which may extend down to, but not through, underlying fascia) pressure ulcer to the resident's coccyx (tailbone). This affected one of two facility-identified residents with pressure ulcers. The census was 61. Findings include: Review of the medical record for Resident #35 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively impaired and required extensive assistance with activities of daily living (ADLs). Further review of the MDS revealed the resident had an unstageable pressure ulcer and was at risk for the development of pressure ulcers. Review of the care plan updated 06/22/22 revealed Resident #35 was at risk for poor skin integrity related to advanced age, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a current pressure ulcer to the coccyx, which was unstageable and had slough in the wound bed. Interventions included the following: float heels in bed as tolerated, monitor, document and treat any skin injury, pressure reduction cushion to the wheelchair, pressure reduction mattress to the bed, weekly skin assessment, and notify the physician of any changes to the skin. Review of the weekly skin assessment dated [DATE] revealed Resident #35's skin was intact. Review of the weekly skin assessment dated [DATE] revealed Resident #35 had a stage three pressure area to her coccyx with a dry dressing in place. Further review of the medical record revealed no weekly skin assessments being completed between 03/28/22 and 04/11/22. Review of the wound assessment dated [DATE] revealed Resident #35 had a stage three pressure ulcer to her coccyx which measured 4.0 centimeters (cm) in length by 3.0 cm in width by 0.1 cm in depth with 75 percent (%) granulation tissue and 25% slough tissue and minimal serous drainage. Review of the April 2022 Treatment Administration Record (TAR) for Resident #35 revealed an order dated 04/12/22 to cleanse pressure ulcer to coccyx with normal saline (NS), pat dry, apply skin prep to peri wound, place collagen to fit open area, then cover with foam dressing every shift and as needed. Review of the most recent wound assessment dated [DATE] revealed Resident #35's wound had declined, measuring 7.5 cm in length by 11.0 cm in width with depth unable to be determined. (The resident had refused wound measurements in subsequent weeks). Review of the July 2022 TAR for Resident #35 revealed an order dated 06/14/22 to apply Dakin's solution (quarter strength) to wound bed and cover with dry dressing once daily and as needed. Interview on 07/08/22 at 12:58 P.M. Resident #35 verified she had the treatment done to the wound on her coccyx earlier in the day, so wound observation would not be possible. Resident #35 further confirmed the wound to her coccyx, which she had since April 2022, caused her intermittent moderate to severe pain. Interview on 07/08/22 at 5:10 P.M. with the Director of Nursing (DON) confirmed residents should have a skin assessment at least weekly per a licensed nurse. The DON verified Resident #35 did not have weekly skin assessments completed between 03/28/22 where her skin was assessed as intact and 04/11/22 where the resident was identified with a stage three pressure ulcer. Review of the facility policy titled, Pressure Ulcer Identification and Wound Management, dated 03/01/22 revealed facility staff would assess resident's skin weekly and would identify the presence of pressure ulcers. Review of the NPUAP guidelines dated 2014 pages 70-71 reviewed from www.npiap.com, revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, [CONDITION(S)], and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for [CONDITION(S)] (redness of the skin) was the first component of every skin inspection. Skin redness and tissue [CONDITION(S)] resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. This deficiency substantiates Complaint Number OH 620.

Based on record review, observation, and interview the facility failed to ensure a resident was accurately assessed and interventions were put into place to prevent fluid overload. The resulted in actual harm when Resident #12 became short of breath and requested to be sent out to the hospital where he required a procedure to remove 5.3 liters of fluid off of his abdomen. This affect one (Resident #12) of three residents reviewed for hospitalization . The faciltiy also failed to complete wound treatments as ordered. This affected one (Resident #13) of four residents reviewed for skin related conditions. The facility census was 64. Findings include: 1. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set (MDS) assessment, dated 08/03/19, identified Resident #12 as having intact cognition, requiring extensive assistance of two staff members for bed mobility and dressing, extensive assistance of one staff for personal hygiene and totally dependent upon two staff members for transfers and toileting. Review of the progress notes documented by Social Service Worker (SSW) #19, dated 07/25/19, stated Resident #12 returned from paracentesis today and and has a standing order to have paracentesis until 11/15/19. The documentation did not identify how often the paracentesis was to be completed. Review of SSW #19's notes dated 08/02/19 at 11:55 [NAME]M. revealed paracentesis was scheduled for Resident #12 every Thursday from 08/08/19 though 10/03/19. Per the scheduler at the hospital, the facility is to call at the end of (MONTH) for the rest of the appointments from 10/03/19 though 11/18/19. Resident is notified of these appointments. Review of the physician order [REDACTED]. There was no order as to when or how often the residents was scheduled to receive paracentesis. Review of the daily weights revealed no documentation as to what Resident #12 weighed on 10/03/19, 10/04/19, 10/05/19, 10/18/19, 10/20/19, or 10/27/19. Review of the nursing documentation, dated 10/05/19 at 1:30 P.M., revealed the resident was up in his electric wheelchair when he complained of increased shortness of breath. Resident #12 was assisted back into bed via mechanical lift. His blood pressure was 120/75, pulse 66, respirations 24, and oxygen saturation 87 to 91 percent on 2 liters of oxygen. The resident's spouse wanted the resident to go out to the hospital; 911 called; resident transported to the hospital. Review of the hospital documentation, dated 10/05/19, revealed Resident #12 was admitted on [DATE] due to anasarca (swelling) from [MEDICAL CONDITION] of the liver and [MEDICAL CONDITION]. On this date Resident #12 underwent paracentesis for the removal of 5.3 liters of fluid off of his abdomen. During interview on 10/28/19, Resident #12 revealed that he has [MEDICAL CONDITION] of the liver and fills up with fluid. Once he fills up with fluid it becomes hard for him to breathe. He had been going out to get paracentesis done each week. Then he thought they were changing it to every other week and then every third week but he was not sure. He was sure that on 10/05/19 he became very short of breath , it was awful, could not get his breath. His wife was there and told the nurses to send him out to the hospital now. He felt his appointments were messed up and he should have already been sent out for the paracentesis, then he would not have gotten into the crisis of not being able to breathe. During interview on 10/30/19 at 10:40 [NAME]M., the Director of Nursing (DON) confirmed that Resident #12 had not been weighted as ordered six times in the month of (MONTH) and that the weights were not done on the two days prior and the day of the emergency hospitalization for fluid overload. The DON also revealed on 09/19/19 Resident #12 came back from paracentesis and his wife told the DON they were now going to go to have the paracentesis procedure done every other week instead of every week, so she canceled his weekly transportation on that date. When the resident went out on 10/25/19 for the appointment with his liver specialist he did return with an order for [REDACTED]. When questioned the DON confirmed that the physician had not given any parameters to monitor for increased fluid, nor did any nurse call the physician to clarify the orders. The DON confirmed on 10/05/19 at 1:30 P.M., Resident #12 required emergency services due to an overload of fluid on his abdomen causing him severe shortness of breath. 2. Record review revealed Resident #15 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the Treatment Administration Record (TAR) dated (MONTH) 2019 revealed no documentation the treatment had been completed on 10/29/19 and 10/30/19 as ordered. Observation on 10/31/19 at 11:14 [NAME]M., of wound care with Registered Nurse (RN) #57 revealed the old dressing was removed and it was dated 10/28/19 with Licensed Practical Nurse (LPN) #25's initials on the dressings. here was no odor or necrotic tissue noted at this time. There was no other concern with the treatment completed. Interview on 10/31/19 at 11:45 [NAME]M., RN #57 verified the old dressings had a date of 10/28/19 and the initials of LPN #25 on them who had worked on Monday 10/28/19. This deficiency substantiates Complaint Number OH 812.

Based on record review, observation, staff interview, resident interview, staff training, and policy review the facility failed to ensure a resident properly transferred with a slide board and with the assistance of two staff. This resulted in actual harm for Resident #53 when she was transferred via slide board with only one staff member assisting; during the transfer, the resident felt her knee pop, the knee became swollen and she had a decline in transferring. This affected one (Resident #53) of 25 sampled residents. The facility census was 64. Findings include: Record review revealed Resident #53 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the plan of care, revised 09/27/19, revealed she had a activity of daily living self care deficit related to decreased mobility. The goal was to maintain current level of functioning in bed mobility, transfers and toilet use. Interventions included she may complete slide board transfers to and from bed with the assistance of two staff who must be trained by therapy prior to completion; otherwise remain a mechanical lift transfer. Review of the physician order [REDACTED]. Staff must be trained by therapy prior to completion; otherwise she was to remain transfer via a mechanical lift. Review of the Minimum Data Set (MDS) assessment, dated 10/03/19, revealed the resident had intact cognition. She required extensive assistance of two staff for bed mobility, transfer and surface to surface transfers. She used a wheelchair and had impairment on one side. Review of the occupational therapy (OT) notes dated from 10/15/19 through 10/18/19 revealed Resident #53 was able to complete bed and wheelchair transfers utilizing a slide board. A two person assist was recommended due to residents right lower leg having impaired range of motion. She was also able to use the transfer bar installed in her room, and completed a sit to stand to use the bedside commode with standing tolerance greater than two minutes. On 10/19/19, OT documented Resident #53 was scheduled for OT discharge, but an incident yesterday afternoon (10/18/19) with State tested Nursing Assistant (STNA) #27 resulted in pain to right knee. The resident had [MEDICAL CONDITION], warmth, and significant pain to the lateral right knee. Resident #53 stated during a slide board transfer, STNA #27 blocked her right lower leg so it could not move and then transferred the resident over to the bed, resulting in the knee popping. No mobility or range of motion completed, discussed transfers with two current STNA's and they reported she had been doing great with them and no concerns. Order submitted previously and remained active documented the resident was a two person assist for slide board transfers and that in order to complete they must have been trained prior, otherwise they were to use a mechanical lift to transfer the resident. Review of the nursing note dated 10/19/19 documented the resident complained of right knee pain and the area was swollen. Medical Doctor (MD) #60 was notified and a two view X-ray ordered. During interview on 10/26/19 at 1:36 P.M., Resident #53 stated she had increased pain from an incident that happened a couple of weeks ago and she now had to be transferred by the mechanical lift, and she pointed to the lift pad underneath her in the wheelchair. A physician order [REDACTED]. Interview on 10/30/19 at 1:21 P.M., Licensed Practical Nurse (LPN) #12 stated she was not here when the transfer occurred on Friday 10/18/19. She came in on 10/19/19 and she was given report by night shift LPN #13 who reported the resident had hurt her knee. LPN #12 stated she made notification to MD #60 who ordered an X-ray. She went to look at her knee and it was warm, swollen and she could not handle any pressure on the area. She had narcotic pain medication as needed and she gave her this for the pain. During observation and interview on 10/30/19 at 1:26 P.M., Resident #53 stated STNA #27 was trying to use the slide board and blocked her right foot from moving. It could not kick out so it twisted her leg when she turned her and put her in bed. She moved and her leg stayed still and she felt a pop. It hurt badly. She stated she had to use the mechanical lift until her knee feels better and she is able to step down on it. Her knee was observed and most of the swelling had gone down; this was confirmed by LPN #12 at the time of the observation . During interview on 10/31/19 at 7:42 [NAME]M., OT #66 stated she had been working with the resident to decrease the use of the mechanical lift and using a slide board, to increase her independence with transfers. She was doing well and ready for therapy discharge. She had trained all of the STNA's who had been working with the resident. She said STNA #27, who normally worked on the night shift, worked the day shift for a few hours on 10/18/19. She transferred the resident by herself using the slide board and she had not even been trained on the transfer technique for the resident. The order was clear in the electronic health record that specified if you had not been trained, use the mechanical lift for transfers. She came in Saturday morning 10/19/19 and was told by STNA #7 and #31 what had happened. She assessed the resident and recommended they leave her in bed. She said this was reported in morning meeting by the Therapy Director #67 and they were not aware of the situation. She then talked to LPN #12 about a possible magnetic resonance imaging (MRI) which would rule out and show if there was a tear in the cartilage or tendons due to the twisting motion and the foot being blocked in place as the resident described. The resident has had a decline in her transfer status and cannot bear weight on the right leg at this time. During interview on 10/31/19 at 8:17 [NAME]M., STNA #31 stated the resident was at the point where she could use the transfer pole placed in her room and help get herself up. She got hurt and it brought her all the way back down in her transfer progress. During interview on 10/31/19 at 8:51 [NAME]M., the Director of Nursing (DON) stated they were not made aware of any incident, they just found out about it the following Monday, 10/21/19, in morning meeting when they saw the X-ray report. She was aware STNA #27 had only used one person to transfer the resident, but did not report anything happening. She also said STNA #27 had not been trained on the slide board, only on using the bedside pole to assist with using the bedside commode. She also reported she had not educated STNA #27 for completing the transfer improperly or as ordered. During interview on 10/31/19 at 9:28 [NAME]M., MD #60 stated he reviewed the X-ray report and it was negative. If it was an injury of the cartilage it would have come from a cutting motion such as in sports; he related the joint swelling to possible arthritis. He was also unaware STNA #27 transferred the resident alone, using the slide board to put her to bed. He stated even if their was a cartilage injury he would treat her conservatively and her decline would be temporary. During interview on 10/31/19 at 12:10 P.M., STNA #27 stated Resident #53 was ready to lay down. She said she lifted the right armrest put the slide board under her right side and locked the wheelchair. The resident slid her from the chair into bed. She picked her legs up and swung them in the bed. She said she had not been trained on the slide board, she did not ask for help during the transfer and the resident only had her normal moaning and did not complain of pain. She also was not aware she required two people to transfer her on the slide board. Review of the staff training dated 09/14/19 documented caregiver training for how to complete slide board transfers two person assist with Resident #53. The following staff were trained: STNA #7, STNA#23, STNA #44, STNA #47 and STNA #68 on the transfer technique. STNA #27 was not on the list of staff that had been trained. Review of the policy titled Safe Lifting and Movement of Residents, revised (MONTH) (YEAR), revealed staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards), and mechanical lifting devices. In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriated techniques and devices to lift and move residents. Manual lifting of residents shall be eliminated when feasible. This deficiency substantiated allegations contained in Complaint Number OH 120.

Based on record review, observation, staff interview, consultant dietician interview, and policy review, the facility failed to assess and timely implement interventions to prevent significant weight loss. This resulted in actual harm to Resident #33, who had a significant weight loss and the facility failed to implement nutritional interventions to prevent further weight loss. This affected one (Resident #33) of five residents reviewed for nutrition. The facility census was 64. Findings include: 1. Record review revealed Resident #33 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On 03/04/19, the resident weighed 168 pounds. On 04/23/19, the physician ordered Ensure Plus at bedtime. Review of the nutritional note dated 09/02/19 revealed the resident had experienced a significant weight loss and due to his choice of gluten free and lactose intolerance was part of the problem. Review of the annual minimum data set (MDS) assessment dated [DATE] documented he had impaired cognition, required extensive assistance of two people for activity of daily living, was independent with eating and required set up assistance, and he had open [MEDICAL CONDITION]. On 09/05/19, the resident weighed 151 pounds, which was a 10.45 percent loss over a six month period. On 09/26/19, an additional supplement, Hi Cal supplement 2.0, 60 milliliters (ml) was ordered, 21 days after the significant weight loss was identified. Review of the Medication Administration Record [REDACTED]. Review of the nutritional risk assessment dated [DATE] documented Resident #33 had an eight percent weight loss over a two month period from 165.20 pounds to 154 pounds. The resident had a high calorie supplement and ensure plus ordered in September. Review of the plan of care with a target date of 12/17/19 documented he had a nutritional problem related to dementia, intellectual disability, difficulty chewing, gluten and lactose sensitivity. The goal was to maintain adequate nutritional status as evidenced by maintaining weight with no further significant loss from 151 pounds. Interventions included medications as ordered, allow adequate time for self-feeding, obtain weight per facility protocol, provide puree gluten free diet with no milk as ordered, and Registered Dietician (RD) to evaluate and make diet change recommendations as needed. During observation on 10/28/19 at 5:00 P.M., Resident #33 was sitting in his room alone, eating in his bed. He had food particles on his gown, and he was attempting to eat his meal. He had pureed food in a divided dish and when moving his hands to eat, food would fall from the spoon. During observation on 10/29/19 at 8:40 [NAME]M., Resident #33 had eaten all of his breakfast. There were food particles spilled on his bed and on his gown. During observation on 10/30/19 at 12:18 P.M., Resident #33 was sitting in his room alone, eating his lunch. He had pureed chicken dish and mixed vegetables. He was eating with a regular utensil and a divided plate. He had some spillage of food on his gown and bed. During interview on 10/30/19 at 3:51 P.M., outside Consultant RD #69 stated the regular RD was on vacation and he was filling in for her. He said her nutritional note about his choice of being gluten free was actually meaning it was hard to find food choices for his special diet. He reported his intakes were documented as good at 75 to 100 percent and he was getting supplements. He also said he was going to weigh him today. At 4:49 P.M., RD #69 stated the resident had a decline and weighed 148 pounds. He did not address the resident eating in his room alone and the use of verbal cueing or supervision while eating. Review of the policy titled Weight Management Guidelines, revised (MONTH) 2019, documented monthly weights should be obtained between the first and the fifth day of each month, monitoring was the final step of the process which the RD uses to determine if the resident has achieved, or is making progress toward, the planned goals. It was the dieticians responsibility to notify the physician and responsible party of weight change and plan of care.

Based on closed medical record review and staff interview, the facility failed ensure interventions were in place to prevent an avoidable fall. This affected one Resident (#9) of three reviewed for falls. This resulted in actual harm to Resident #9 who sustained a fall with fractures and was admitted to the hospital. The facility identified 62 residents at moderate or high risk for falls. The facility census was 73. Findings include: Closed medical record review for Resident #9 revealed the resident was admitted on [DATE] and had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] noted the resident was cognitively intact and required the extensive assistance of two persons for transfers, toileting and walking in room. The assessment noted the resident was unsteady, required staff assistance to stabilize for all transition and walking tasks. The assessment further noted Resident #9 had a fall within the month prior to admission to the facility and a fracture related to a fall within the six months prior to admission to the facility. Further medical record review noted an acute Interdisciplinary Plan of Care dated 12/20/16 which documented the resident's potential for falls was moderate due to history of falls and the resident required assistance with transfers. Interventions initiated were assessing fall potential on admission, quarterly and with changes in condition, monitoring for and intervening in risk factors for falls, providing verbal reminders to not transfer or ambulate without assistance and provided appropriate assistance, keeping call light in reach and orienting to facility and environment. Review of a progress note dated 12/30/16 at 5:02 A.M., Registered Nurse (RN) #33 documented Resident #9 attempted to self-transfer to the bedside commode twice. An alarm on the bed had notified staff the resident was up and staff had safely assisted the resident back into bed. RN #33 reeducated Resident #9 on the need to call for assistance and noted the resident implied understanding and demonstrated use of the call light. Further review revealed no notation indicating why or when the bed alarm was added for Resident #9. A review of the Skilled Charting note dated 12/30/16 at 5:05 P.M. revealed despite the documented attempts of self transfers, Resident #9 was still noted as making consistent, reasonable decisions and the bed alarm use was not noted. Review of a progress note dated 12/31/16 at 12:57 A.M., RN #36 documented Resident #9 was found in her room, on the floor, lying on her right side, with no shoes or socks on, and a liquid supplement was on the floor. Resident #9 and State tested Nurse Assistant (STNA) #92 reported Resident #9 attempted to self-transfer from the bedside commode back to bed and fell . Resident #9 reported pain in her right shoulder and hip pain with the right leg noted to be shorter than the left with a slight external rotation. Resident #9 was sent to a local emergency room for further evaluation. Education was given to the STNA involved to have non-slip socks on the resident while in bed and during transfers. It was also noted the resident was not to be left alone while on the bedside commode. Review of a progress note dated 12/31/16 at 4:23 A.M., RN #36 documented upon speaking with the local emergency room , Resident #9 sustained a fractured humorous and fractured inferior/superior rami. Review of the comprehensive plan of care revealed it was initiated on 12/31/16 (the date of the resident's injury and transfer from the facility). A review of the daily pocket care planner for State tested Nurse Assistant (STNA) use, noted the resident was to have non-skid socks and an alarm to the bed. The pocket care planner had no date for when these interventions were added. Review of the Interdisciplinary Team (ID) Post Fall Investigation/Summary completed on 01/03/17 documented Resident #9 was assisted to the bedside commode. When STNA #92 reentered the room, Resident #9 was observed on the floor. Contributing factors to the fall were noted as a history of falls, confusion, weakness and decreased safety awareness. Interventions to be implemented were to wear non-skid socks and not to be left alone on the bedside commode. Review of the Risk Management Note dated 01/03/17 noted a review found appropriate interventions implemented post fall for Resident #9 included addressing pain prior to transfers, non-skid socks to be worn and not to be left alone while on bedside commode. Review of facility documentation revealed an in-service was conducted with all nursing staff regarding ensuring residents were wearing non-skid footwear every time they were gotten up to prevent falls and possible injury. No other staff education was provided. An interview was conducted with the Director of Nursing (DON) on 01/26/17 at 11:53 A.M. The DON confirmed Resident #9 had fallen during an attempt to self-transfer from a bedside commode. The DON confirmed Resident #9 was not wearing non-skid socks or shoes during the transfer to the bedside commode and was left unmonitored on the bedside commode staff. The DON agreed it would not be appropriate to leave a resident alone on a bedside commode when the resident had been attempting to self-transfer from the bed within the previous twenty-four hours and had a bed alarm. The DON reported non-skid footwear during transfers was a standard intervention for all residents. During a subsequent interview with the DON on 01/26/17 at 1:10 P.M. the DON reported STNA #92 left Resident #9 alone on the bedside commode to find the nurse to request pain medication for the resident. Interviews were conducted with STNA #76 and #83 and LPN #46 on 01/26/17 between 3:30 PM and 3:45 PM. Each staff member reported it would never be appropriate to leave a resident alone on the toilet or bedside commode especially if the resident had recently attempted to self-transfer from the bed, was a fall risk, and/or who had a bed or chair alarm. This deficiency substantiates Complaint Number OH 992.