Every finding on record at Emerald Pointe Health and Rehab CTR

Based on record review, interview and facility policy review, the facility failed to ensure Resident #62 received all medication doses a physician ordered intravenous (IV) antibiotic. This affected one (Resident #62) of three residents reviewed for medication administration. The facility census was 61. Findings include:Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including acute pyelonephritis, sepsis, bacteremia, urinary tract infection (UTI), acute kidney injury (AKI), anemia, polyneuropathy, hyperlipidemia, obstructive sleep apnea (OSA), obstructive and reflux uropathy, and calculus of kidney with calculus of ureter. Resident #62 was discharged on 11/22/25.Review of facility November 2025 infection control log revealed Resident #62 was receiving IV antibiotics beginning 11/11/25 and ending on 11/22/25.Review of Resident #62 history and physical completed by Medical Director #600 on 11/12/25 revealed Resident #62 was admitted to the facility to continue antibiotics and physical therapy. Resident #62 was admitted to the facility for IV antibiotics following a hospital admission due to urosepsis, AKI with acute pyelonephritis, found with pseudomonas UTI and bacteremia.Review of Resident #62 Minimum Data Set (MDS) assessment completed on 11/18/25 revealed the resident was on an antibiotic, IV medications, and had central IV access.Review of Resident #62 physician's orders revealed an order placed my Medical Director #600 on 11/11/2025 for Cefepime-Dextrose IV Solution Reconstituted 2-5 gram (GM)-%50 milliliter (ML). Use one dose IV every 12 hours for pyelonephritis for 10 days. With the order discontinued on 11/22/25.Review of Resident #62 orders revealed an order placed on 11/11/25 for a Peripherally Inserted Central Catheter (PICC) line to be maintained with a transparent dressing and a dressing change every six days.Review of Resident #62 Medication Administration Record (MAR) for November 2025 revealed on 11/18/25 at 6:00 P.M. the ordered IV antibiotic [Cefepime-Dextrose IV Solution Reconstituted 2-5 GM-%50 ML every 12 hours had no documented evidence of administration or refusal.Interview on 12/09/25 at 2:15 P.M. with Licensed Practical Nurse (LPN) #47 revealed if there is a medication not signed off on the MAR you would check to see if the medication was still present in its storage area, you would then determine if the medication had been given or not. After you administer a medication to a resident, you mark it off as administered on the MAR. If a resident refuses medication, you are to document that and notify the physician. Interview on 12/09/25 at 3:00 P.M. with LPN #95 revealed you check the resident's MAR to ensure a medication was given, and any medication you give, you mark it off on the MAR.Review of Resident #62's progress notes revealed no documentation of a rationale for IV antibiotics not being administered on 11/19/25 at 6:00 P.M., no documentation of a physician notification, and no documentation of attempts to contact the pharmacy regarding missing IV medication or missing IV medication dose, and/or no documentation of resident refusal of the medication. Interview on 12/09/25 at 12:45 P.M. with the Director of Nursing (DON) on confirmed on 11/19/25, Resident #62's MAR revealed no documented evidence the IV antibiotic was administered.Review of facility policy titled Medication Administration, effective 06/21/2017, revealed medications will be administered in accordance to applicable state, local, and federal laws consistent with accepted standards of practice. The resident has the right to refuse medication. It is, however, the nurses responsibility to review with the resident the consequences of their refusal and document it accordingly. If a medication is unavailable, contact the pharmacy and document it accordingly. After medication administration document medication administration with initials on the MAR immediately after administering medication to each resident. This deficiency represents noncompliance investigated under Complaint Number 2677502.

Based on medical record review, policy review and interview, the facility failed to ensure accurate and thorough medical records were maintained. This affected three residents (#13, #18, and #34) of 19 residents sampled. The census was 63. Findings include: 1. Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including heart failure, anemia, coronary artery disease, atrial fibrillation, cellulitis, hypertension, diabetes mellitus, hyperlipidemia, arthritis. Record review of the minimum data set 3.0 (MDS) assessment completed on 01/20/25 revealed a brief interview for mental status score (BIMS) of 14, which indicated Resident #34 was cognitively intact. Record review of the MDS section N for medications completed on 01/30/25 revealed Resident #34 was on antibiotics. Record review revealed an order placed on 01/29/25 by the Medical Director for antibiotic oral capsule 500 milligram (mg) (Cephalexin) to be given 1 capsule by mouth two times a day for right hand cellulitis for eight days starting 01/29/25 with a stop date of 02/05/25. Record review of the medication administration record (MAR) revealed no documentation of Keflex 500 mg being administered on 02/04/25 for the evening dose. Interview on 02/25/25 at 10:23 A.M. with assistant director of nursing (ADON) verified Keflex was not documented as given on Tuesday 02/04/25 P.M. for dinner dose and progress note from 02/04/25 at 10:44 P.M. stated Resident #34 remained on antibiotic therapy with no adverse effects. No notes of the dose being missed/refused, no one notified of missing dose. No documentation of why the dose was not documented or a physician being notified of a missing dose. Review of medication administration policy 5.3 (effective 06/21/2017) the resident had the right to refuse medication. It is, however, the nurses responsibility to review with the resident the consequences of their refusal and document accordingly. If a medication is unavailable, contact the pharmacy and document accordingly. If a resident refuses medication, document on the medication administration record (MAR). Note refusal or ingestion of less than 100% of dose on the MAR in the designated area. 2. Medical record review revealed Resident #13 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disorder (COPD), asthma, cognitive communication deficit, muscle weakness, acute kidney failure, chronic kidney disease stage four, pleural effusion, atrial fibrillation, generalized anxiety disorder. Medical record review of Resident #13's minimum data set (MDS) completed 1/24/25 revealed a brief interview for mental status (BIMS) score of 15. Medical record review revealed an immunization consent form dated 01/07/25 Resident #13 consented to the Prevnar 20 Pneumococcal vaccine (PCV20). Medical record review revealed, an order placed on 01/14/25 by the Medical Director that ordered Prevnar 20 Suspension Prefilled Syringe 0.5 milliliter (ML) (Pneumococcal 20-[NAME] Conj Vacc) Inject 0.5 ml intramuscularly one time only for vaccine for 1 Day. Record review of Resident #13's medication administration record (MAR) for January of 2025 revealed no documentation the PCV20 vaccination had been administered to Resident #13. Interview on 02/27/25 at 1:23 P.M. with the ADON confirmed in point click care documentation is not on the MAR for the PCV20 immunization being administered. She stated she was not sure if something was wrong with their point click care but she was going to put in a work order. 28704 3. Medical record review revealed Resident #18 was admitted on [DATE] with diagnoses including atrial fibrillation, history of venous thrombosis/ embolism, end stage renal disease and dependence on renal dialysis. a. Review of the care plan: At Risk for Bleeding, Bruising, Abnormal Labs related to use of anticoagulant/thrombolytic medications initiated 06/01/23 revealed the resident was receiving coumadin (anticoagulant). Review of the electronic Physician Orders dated February 2025 revealed Resident #18 received apixaban (Eliquis) 5 milligrams twice a day. There was no evidence Resident #18 was receiving coumadin. b. Review of Resident #18's Kardex revealed the resident went to dialysis three times a week on Tuesday, Thursday and Saturday. On 02/26/25 at 12:48 P.M., interview with the Director of Nursing (DON) stated the resident dialysis days changed a long time ago due to transportation concerns and resident convenience. The DON verified the information in the Kardex was not accurate for dialysis scheduled days.

Based on medical record review and interview, the facility failed to develop comprehensive and individualized care plans. This affected one resident (#3) of two residents reviewed for Communication-Sensory concerns. The facility census was 63. Findings include: Medical record review revealed Resident #3 was admitted on [DATE] with diagnoses including end-stage macular degeneration and cerebral infarction. Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact for daily decision-making, had highly impaired vision (object identification in question but eyes appear to follow objects) with corrective lenses and had obvious, likely cavities or broken natural teeth. Review of the Eye Care Chart Note dated 12/04/24 revealed the resident complained of right eye poor vision for many years and glasses help the left eye a little. The resident's visual acuity of the right eye was 20/80 and his visual acuity of the left eye was 20/30. On 02/24/25 between 3:15 P.M. and 3:33 P.M., interview with Resident #3 revealed he cannot see out of one eye and has had the same glasses for a long time. Resident #3 stated the dietary/menu card print was too small to read and he could not see/read the card to choose what he would like to eat for the upcoming meals. Resident #3 stated it was frustrating and just picks without knowing what he was choosing. During the interview, Resident #3 was observed wearing glasses, his upper teeth and a lower tooth appeared decayed and in poor condition. Resident #3 stated his teeth bother him and he had seen a dentist before Christmas but they never did anything about his teeth and was told his teeth condition was too bad to get an implant. On 02/25/25 at 3:15 P.M., Resident #3 was observed wearing glasses while working on a puzzle. On 02/26/25 at 7:20 A.M., Resident #3 was observed sitting at a table in the main dining room wearing glasses. At 7:25 A.M., certified nurse aide (CNA) #242 was observed giving a meal card to Resident #3 for him to choose his meal options for lunch and dinner. Resident #3 was looking at the menu card without choosing any meal options. The surveyor asked Resident #3 what he was going to have for lunch and he stated he was unable to read the menu card as the print was too small and could not see what the menu options were. CNA #237 was observed walking past the resident's table and stopped to see if the resident was done filling out the menu card when Resident #3 stated he could not see the menu. CNA #237 stated she was unaware Resident #3 could not see the printed words on the menu card. On 02/27/25 at 12:59 P.M., interview with Social Services #216 verified Resident #3 did not have a individualized care plan for vision or dental. On 02/27/25 at 3:40 P.M., interview with Regional Director of Clinical Services #276 verified Resident #3 did not have a comprehensive vision or dental care plan.

Based on medical record review and interview, the facility failed to ensure a resident did not receive unnecessary medication when a resident was administered antibiotics not at the ordered dose. This affected one resident (#27) of five residents reviewed for unnecessary medications. The census was 63. Findings include: Medical record review revealed Resident #27 was admitted on [DATE] with diagnoses including breast cancer, chronic kidney disease, cardiac murmur, atrial septal defect, hypertension, diabetes mellitus, renal insufficiency and urinary tract infection. Review of the Progress Note dated 02/06/25 revealed facility had received a call from Resident #27's urology office stating the urinalysis done at their office showed the resident had an UTI. The physician office sent in an order for Bactrim DS (antibiotic) twice a day to be administered for 10 days. A Physician order was written and the antibiotic was started on 02/07/25 and administered through 02/17/25. Review of the electronic Medication Administration Record dated February 2025 revealed Resident #27 received 21 doses of Bactrim DS instead of the ordered 20 doses. On 02/27/25 at: 10:45 A.M., interview with Director of Nursing verified the resident was only ordered to receive two doses a day for 10 days.

Based on medical record review and interview, the facility failed to ensure physician notification of a resident's blood pressure when outside of listed blood pressure parameters. This affected one resident (#27) of five residents reviewed for unnecessary medications. The census was 63. Findings include: Medical record review revealed Resident #27 was admitted on [DATE] with diagnoses including breast cancer, chronic kidney disease, cardiac murmur, atrial septal defect, hypertension, diabetes mellitus, renal insufficiency and urinary tract infection. Review of the nurse practitioner Nurse's Note dated 06/08/23 revealed to discontinue amlodipine 5 milligrams (mg) due to edema. Continue atenolol 50 (mg) and lisinopril 10 (mg) daily. Monitor blood pressure (BP) and consider increasing lisinopril if greater than (>) 130/80 mmHg with close monitoring of BMP. Continue atorvastatin 20 (mg) and will obtain echocardiogram due to murmur. Review of the cardiology advanced practice professional Progress Note dated 08/21/24 revealed Resident #27 was seen for routine follow-up evaluation for diagnoses including a murmur and essential hypertension. Orders included no discontinued medications and plan was to continue atenolol 50 (mg) and lisinopril 40 (mg) daily with a target blood pressure less than 130/80 mmHg. Review of the electronic Medication Administration Record (MAR) dated December 2024, January 2025 and February 2025 revealed a physician order to monitor BP/pulse every shift and as needed. The physician was to be notified if the resident's BP was greater than 130/80 mmHg with close monitoring of BMP. Review of the medical record revealed no evidence the physician was notified of the following BP readings greater than 130/80 as per order: On 12/02/24, night BP 146/82 with pulse of 62. On 12/13/24, day BP 134/86 with pulse 86. On 12/13/24, night BP 148/86 with pulse 62. On 12/14/24 , day BP 146/81 with pulse 73. On 12/14/24, night BP 132/84 with pulse 76. On 12/17/24 night BP 146/84 with pulse 60. On 12/21/24, night BP 136/84 with pulse 62. On 12/22/24,day BP 138/82 with pulse 82. On 12/22/24, night BP 140/84 with pulse 60. On 12/26/24, night BP 152/82 with pulse 66. On 01/13/25, night BP 140/84 with pulse 60. On 01/14/25, night BP 134/86 with pulse 62. On 01/16/25, day BP 158/92 with pulse 58. On 01/16/25, night BP 132/82 with pulse 62. On 01/26/25, day BP 138/88 with pulse 67. On 02/01/25, day BP 132/82 with pulse 54. On 02/05/25, day BP 140/86 with pulse 59. On 02/05/25, night BP 146/88 with pulse 63. On 02/14/25, night BP 173/82 with pulse 64. On 02/24/25, day BP 132/86 with pulse 65. On 02/26/25 at 5:27 P.M., interview with the Director of Nursing verified there was no evidence Resident #27's physician was notified of the above BP's exceeding the ordered parameters.

2. Medical record review revealed Resident #27 was admitted on [DATE] with diagnoses including renal insufficiency, non-Alzheimer dementia and urinary tract infection (UTI). Review of the annual Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #27 was cognitively intact for daily decision-making and had no UTI's in the last 30 days. Review of the Progress Note dated 02/06/25 revealed facility had received a call from Resident #27's urology office stating the urinalysis done at their office showed the resident had an UTI. The physician office sent in an order for Bactrim DS (antibiotic) twice a day to be administered for 10 days. Copies of laboratory results and progress note was requested. A Physician order was written and the antibiotic was started on 02/07/25 and administered through 02/17/25. Review of the electronic Medication Administration Record dated February 2025 revealed Resident #27 received 21 doses of Bactrim DS instead of the ordered 20 doses. Review of the medical record revealed no evidence the results of the urinalysis obtained on 02/04/25 or results of the urine culture was received between 02/06/25 and 02/17/25. On 02/27/25 at 8:09 A.M. Resident #27's Molecular Pathology Report (dated 02/05/25) was faxed to the facility revealing Streptococcus Agalactiae (Group B Strep) and Staphylococcus aureus (MRSA) had been detected and the microbial load was less than 100,000 CFU/mL with a potential resistance to Methicillin, carbapenems, cephalosporins, penicillins and beta-lactamase inhibitors was detected. Review of the record revealed the facility did not have the resident on any type of contact isolation precautions between 02/06/25 and 02/17/25. Review of the Minimum Criteria for Initiating Antibiotic Therapy form dated 02/07/25 revealed Resident #27 complained of urgency and frequency. No other symptoms were documented. Date of infection was 02/06/25 when order received for antibiotic. There was no documentation of the organism or determination if an infection criteria was met. On 02/27/25 at 9:52 A.M., interview with Assistant Director of Nursing (ADON) #200 verified the facility had not received the urinalysis/pathogens detected report from the urologist until today and verified contact isolation should have been initiated for MRSA/Group B Strep urine results. On 02/27/25 at: 10:45 A.M., interview with Director of Nursing verified facility requested the urine culture but had not received result until after requested by the surveyor and the resident was only ordered to receive two doses a day for 10 days. 35765 Based on observations, review of the medical record and interview with staff the facility failed to appropriately monitor a resident experiencing signs and symptoms of a contagious respiratory illness and failed to implement contact isolation precautions for a resident with an infectious microorganism in the urine. This affected one resident (#21) of two residents reviewed for respiratory care and one resident (#27) of three residents reviewed for antibiotic usage. Findings included: 1. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE]. Diagnoses chronic obstructive pulmonary disease, diabetes, asthma, acute respiratory failure, schizophrenia, psychosis, hypertension, fibromyalgia, sleep apnea, migraine, generalized anxiety disorder, peripheral vascular disease, and insomnia. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #21 had intact cognition and refused the influenza vaccine. Review of the February Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation Resident #21's temperature was monitored from 02/20/25 to 02/25/25. Review of the vital signs, including temperature, documented in Point Click Care revealed the last documented temperature for Resident #21 was on 02/19/25 at 98 degrees Fahrenheit. Review of the February 2025 physician's orders revealed Resident #21 had an order for Allegra 180 milligrams at bedtime for cold symptoms and nasal congestion dated 02/20/25 Review of the health status note dated 02/20/25 at 6:43 P.M. revealed Resident #21 complained of sinus congestion and cold symptoms. The Physician was updated and a new order was received for Allegra once a day for seven days. The resident was afebrile, lungs were clear, skin was warm, dry and flesh tone. There was no documentation regarding the resident's respiratory status (lung sounds, cold symptoms), including temperature, on 02/21/25. Review of the health status note dated 02/22/25 at 6:23 A.M. revealed Resident #21 complained of continued sinus congestion, dizziness, cough. Her vital signs were temperature 98.0 degrees Fahrenheit, oxygen saturation was 96 percent on room air, lungs were clear, respiration were 18 and her blood pressure was 122/70. She continues on Allegra at bedtime for sinus congestion. There was no documentation regarding the resident's respiratory status (lung sounds, cold symptoms), including temperature, on 02/23/25. There was no evidence Resident #21 was tested for COVID or influenza even though she exhibited signs and symptoms of a respiratory illness that could be contagious to others. On 02/24/25 at 8:55 A.M. an interview with Resident #21 revealed she felt like she was getting the flu. She stated she was coughing, had nasal congestion, was having some nausea but no vomiting or diarrhea. Observation on 02/24/25 at 11:15 A.M. revealed Resident #21 was out in the dining room sitting. The resident was not wearing a mask. Observation on 02/25/25 at 10:20 A.M. revealed Resident #21 was out in the dining room for an activity. The resident was not wearing a mask. On 02/26/25 at 1:15 P.M. an interview with Director of Nursing (DON) indicated she would expect the staff to monitor and take the temperature routinely for a resident experiencing respiratory signs and symptoms to make sure they were not getting worse. On 02/27/25 at 2:21 P.M. an interview with Regional Director of Clinical Services #27 indicated they should assess the resident, monitor, and if symptoms continue they would test for COVID. She stated they were doing a respiratory assessment however there was a glitch and the temperature section was never added so they were never done. On 02/27/25 at 2:31 P.M. an interview with the DON confirmed there was no monitoring from the first signs of flu like symptoms 02/20/25 to 02/22/25 then from 02/22/25 to 02/26/25. Review of the Centers for Disease Control website, Testing and Management Considerations for Nursing Home Resident with Acute Respiratory Illness Symptoms when SARS_CoV-2 and influence Viruses are Co-circulating (dated 11/14/23) revealed you could not tell the difference between flu and COVID-19 by symptoms alone because many signs and symptoms are the same. Testing was needed to confirm a diagnoses. Signs and Symptoms of both COVID-19 and flu included fever but not everyone with the flu would have a fever, cough, shortness of breath, fatigue, sore throat, runny or stuffy nose, muscle pains, headache, vomiting , diarrhea and change in or loss of taste and smell. Review of the facility policy titled, Infection Control-Infection Surveillance, (dated 11/28/17) revealed the system of surveillance was utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. Nurses participate in surveillance thorough assessment of resident and reporting changes in condition to the resident's physicians and management staff.

Based on record review and interview the facility failed to ensure antibiotics were not ordered without meeting the required criteria for Resident #32. This affected one resident (#32) of three residents reviewed for antibiotic use. Facility census was 63. Findings include: Review of the medical record revealed Resident #32 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included chronic kidney disease, hydronephrosis, neuromuscular dysfunction of bladder, type 2 DM, urinary tract infection, acute kidney failure with tubular necrosis, and paraplegia. A care plan dated 08/09/24 revealed Resident #32 was at risk for infection related to suprapubic catheter, type 2 diabetes, and urinary retention. Interventions included to administer antibiotics as ordered and monitor of signs and symptoms of a urinary tract infection. A health status note dated 12/23/24 at 3:22 A.M. revealed Resident #32 reported testicle pain. Resident #32 reported he usually had a urinary tract infection when he felt testicle pain. Resident #32 requested his urine to be checked. A urine test strip, used as a basic diagnostic tool to determine pathological changes, was positive. An order was received for urinalysis. Urine results faxed to the facility on [DATE] revealed Resident #32's urine was abnormal with moderate leukocytes and blood, and was positive for nitrites. A health status note dated 12/23/24 at 4:20 P.M. revealed the facility physician was notified of urinalysis results. The facility physician instructed the nurse to contact Resident #32's urologist. The infection control log revealed Resident #32 had onset of symptoms of testicle pain on 12/23/24 and chronic urinary tract infections. The urine results identified mixed flora. Cipro (antibiotic) 250 milligram (mg) was ordered twice a day for seven days by the urologist. The Loeb's minimum criteria (a set of clinical guidelines used to determine the need for antibiotic therapy in long-term care residents) form for initiating antibiotic therapy revealed no minimum criteria marked. A handwritten note on the form revealed Resident #32 had a history of chronic infections and complaints of testicular pain which was a usual sign of infection. A culture and sensitivity was done. The urologist was notified and ordered an antibiotic for Resident #32. A health status note date 12/24/24 at 12:10 P.M. revealed the urologist ordered Cipro for Resident #32. Review of the medication administration record (MAR) revealed Resident #32 was administered the first dose of Cipro the evening of 12/24/24. Urine culture results faxed to the facility on [DATE] revealed Resident #32's urine culture had mixed commensal flora. Mixed commensal flora in a urine sample is a mix of different bacteria that usually reside in the urinary tract without causing infection. This does not necessarily indicate a problem, and could be a sign of contamination during the sample collection. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #32 was cognitive intact. Interview on 02/26/25 at 10:12 A.M. Director of Nursing (DON) verified a culture and sensitivity was not completed due to urine results had mixed flora. The DON verified the use of Cipro did not meet the criteria and had been ordered by urologist.

Based on observation, review of the medical record, and interview with staff revealed the facility failed to ensure safe storage of medications. This affected one resident (#7) of five residents reviewed for accidents. Finding included: Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included fracture of the T5 and T6 vertebra, fracture of one rib, ankylosing spondylitis of the thoracic, acute respiratory failure, muscle weakness, dysphagia, pneumonia, hemothorax, atrial fibrillation, congestive heart failure, generalized anxiety disorder, peripheral vascular, hyperglycemia, gout, vertigo, osteoarthritis, chronic pain syndrome, chronic rhinitis, major depressive disorder, hypertension, hypothyroidism, insomnia and a pacemaker. Review of the Quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #7 had intact cognition. Review of the February 2025 physician's order revealed Resident #7 had an order for Fluticasone Propionate Nasal Suspension 50 micrograms, one spray in both nostrils once daily. Resident #7 did not have an order to self administration or have nasal spray at bedside. Observation on 02/24/25 at 4:35 P.M. revealed she had a bottle of Fluticasone propionate nasal spray on top of her refrigerator in her room Observation on 02/25/25 at 9:50 A.M. revealed she had a bottle of Fluticasone propionate nasal spray on top of her refrigerator in her room. On 02/25/25 at 9:50 A.M. an interview with Licensed Practical Nurse #224 confirmed Resident #7 had a bottle to Fluticasone propionate nasal in her room. She verified Resident #7 did not have an order to self administer or to have her Fluticasone propionate nasal spray at bedside.

Based on medical record review and interviews the facility failed to ensure identification, assessment, and appropriate interventions were put in place to achieve [NAME] bowel function for Resident #13, Resident #46, and Resident #51. This affected three residents (#13, #46, and #51) out of four residents reviewed for bowel and bladder. Facility census was 63. Findings include: 1. Review of the medical record revealed Resident #13 was admitted on [DATE] with diagnoses of metabolic encephalopathy, asthma, cognitive communication, acute kidney failure, chronic kidney disease stage 4, and urinary retention. A care plan dated 11/07/24 revealed Resident #13 was at risk for constipation. Interventions included to administer medication as ordered and monitor for constipation and causes. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #13 was cognitively intact, occasionally incontinent of urine and always continent of bowel. Resident #13 required substantial/maximal assistance for toilet hygiene and partial/moderate assistance for toilet transfer. Review of the bowel elimination documentation revealed Resident #13 had a bowel movement on 02/14/25. The bowel elimination documentation from 02/15/25 to 02/25/25 revealed Resident #13 did not have a bowel movement. The next bowel elimination documentation was on 02/26/25. Review of the medication administration record (MAR) revealed on 02/16/25 Resident #13 was administered Bisacodyl enteric-coated delayed release (laxative) five milligrams. The Bisacodyl was effective. Further review of the MAR revealed no other medication being administered to help facilitate a bowel movement. Interview on 02/26/25 at 12:42 P.M. the Director of Nursing (DON) verified the facility did not have a bowel protocol in place and did not use standing orders for medications to help facilitate a bowel movement. The DON verified if a resident did not have a bowel movement for three days, the physician should be notified and orders obtained as needed. An additional interview on 02/26/25 at 2:17 P.M. the DON verified there was no documentation of Resident #13 having a bowel movement from 02/17/25 through 02/25/25. 2. Review of the medical record revealed Resident #46 was admitted on [DATE] with diagnoses that included normal pressure hydrocephalus, dysphagia, Alzheimer's disease, chronic kidney disease, anxiety, and acute kidney failure. A care plan dated 08/14/24 revealed Resident #46 was at risk for constipation. Interventions included to administer medications as ordered and to monitor for constipation and causes. The 5-day MDS dated [DATE] revealed Resident #46 had cognitive impairment and was always incontinent of bowel and bladder. Review of the bowel elimination documentation from 02/15/25 to 02/18/25 revealed Resident #46 did not have a bowel movement. Resident #46 had a bowel movement on 02/19/25 and 02/22/25. The bowel elimination documentation from 02/23/25 to 02/27/25 revealed Resident #46 did not have a bowel movement. Review of the MAR for February 2025 revealed no evidence of Resident #46 being administered medication to help facilitate a bowel movement. Interview on 02/26/25 at 12:42 P.M. the Director of Nursing (DON) verified the facility did not have a bowel protocol in place and did not use standing orders for medications to help facilitate a bowel movement. The DON verified if a resident did not have a bowel movement for three days, the physician should be notified and orders obtained as needed. An additional interview on 02/27/25 at 1:42 P.M. the DON verified there was no documentation of Resident #46 having a bowel movement from 02/15/25 through 02/18/25 and 02/23/25 through 02/27/25. 51519 3. Record review revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's, muscle weakness, thyrotoxicosis, osteoporosis, glaucoma, constipation, anxiety, vitamin D deficiency, and major depressive disorder. Review of the Minimum data set (MDS) completed on 01/29/25 revealed Resident #51 had a brief interview for mental status (BIMS) score 00, which indicated cognitive impairment. The MDS also revealed Resident #51 had bowel continence, required substantial/maximal assistance for toileting, and had a history of constipation. Record review of Resident #51 task for bowel assessment revealed no documentation of a bowel movement (BM) on 02/13/25, 02/14/25, 02/15/25, or 02/16/25. Record review of Resident #51 task for bowel assessment revealed no documentation of a bowel movement on 02/23/25, 02/24/25, 02/25/25, 02/26/25. Record review of Resident #51 medication administration record (MAR) and treatment administration record (TAR) for February 2025 revealed no documentation Resident #51 had received interventions to assist in a bowel movement. Record Review of Resident #51's care plan dated 02/11/25 revealed Resident #51 was at risk for constipation related to decreased mobility, medication use, malnutrition, and a history of constipation. Interventions included monitoring for constipation. Interview on 02/24/25 11:20 A.M. resident representative for Resident #51 stated that Resident #51 did have issues with constipation. Family representative stated she will ask staff if Resident #51 has had a bowel movement but she was not sure how honest staff are being. Resident #51's representative was not sure if Resident #51 had been getting any laxatives' or stool softeners to assist in relieving bowels. Interview on 02/26/25 at 12:43 P.M. with the Director of Nursing (DON) revealed implementation of interventions to promote bowel movements would depend on the residents but the expectation is around day two to three (with no bowel movement) they would begin to investigate the issue. She stated the nurses on the floor monitor frequency of bowel movements on their shift. A nurse or certified nursing assistant (CNA) should document if the resident has had a bowel movement and communicate information in report. It should flag on the dashboard of the electronic medical record (EMR) if someone has not had a bowel movement in a certain number of days. It should be communicated in report from shift to shift if the resident has had a BM or not; there is no record or protocol it is just the expectation. The DON stated the nurse would need to call the doctor for a stool softener or laxative because there was no standing orders. The DON confirmed Resident #51 had gone four days with no bowel movement, no identification of no bowel movement by staff, and no interventions implemented.

Based on medical record review and interview, the facility failed to ensure a resident's nephrologist was notified of abnormal laboratory results. This affected one resident (#27) of five residents reviewed for unnecessary medications. The census was 63. Findings include: Medical record review revealed Resident #27 was admitted on [DATE] with diagnoses including breast cancer, chronic kidney disease, cardiac murmur, atrial septal defect, hypertension, diabetes mellitus, renal insufficiency and urinary tract infection. Review of the Comprehensive Metabolic Panel dated 07/26/24 revealed BUN (blood urea nitrogen) was 28 (normal 7-17 mg/dL), creatinine 1.40 (normal 0.5-1.0 mg/dL), BUN/Crea ratio was 20 (normal was 6-20) and estimated GFR was 41 (normal >60 mL/min/L). Physician #279 ordered to follow-up with Resident #27's renal physician (nephrologist) regarding the above lab results. Review of the Comprehensive Metabolic Panel dated 01/02/25 revealed abnormal laboratory findings including: BUN was 37 (normal 7-17 mg/dL), creatinine was 1.44 (normal 0.5-1.0 mg/dL), BUN/Crea ratio was 26 (normal was 6-20), estimated GFR was 40 (normal >60 mL/min/L), hemoglobin was 11.0 (normal 11.5-16.0 g/dL) and hematocrit was 34.3 (normal 34.8-46.0%). Physician #279 ordered to follow-up with Resident #27's renal physician regarding the above lab results. Review of the medical record revealed no evidence Resident #27's renal physician/nephrologist was notified of the above lab results on 07/26/24 or 01/02/25. Review of the annual Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #27 was cognitively intact for daily decision-making, had no UTI in the last 30 days and was receiving a diuretic, On 02/27/25 at 10:17 A.M., interview with the Director of Nursing verified there was no evidence Resident #27's abnormal labs were reported to the nephrologist.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, review of camera footage, employee statement review and policy review, the facility failed to provide care and services, including appropriate supervision levels, to prevent resident neglect. This affected one resident (Resident #10) of three residents reviewed for neglect. The facility census was 58. Findings included: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, muscle weakness, osteoporosis, vertigo, anxiety, and restlessness and agitation. Review of Resident #10's care plan, dated 05/23/23, revealed the resident was at risk for alteration in comfort with interventions including to reposition the resident for comfort. Further review revealed the resident was at risk for falls related to weakness, poor safety awareness, osteoporosis, glaucoma, vertigo, and anxiety with interventions including to encourage and remind the resident to ask for assistance and to monitor/anticipate/intervene for causative factors. Review of the care plan, dated 09/23/24, revealed the resident had an alteration in skin integrity as evidenced by moisture-associated skin damage (MASD) of the right buttock with interventions including to provide skin care as needed. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/09/24, revealed Resident #10 was severely cognitively impaired and required moderate/substantial staff assistance with toileting and showers/baths. The assessment indicated the resident was occasionally incontinent of urine and was at risk for developing pressure ulcers. Review of the facility's Fall Investigation, dated 10/28/24, revealed on 10/28/24 at 7:45 A.M., Resident #10 was observed in her room, on her bottom with her feet in front of her. She was incontinent of urine, fully dressed, and wearing anti-skid socks. The resident was wincing in pain, but unable to tell where the pain was located. Range of Motion (ROM) was within normal limits and vital signs were stable. The resident was assisted up with the assistance of three staff. The physician and the family were notified. Review of nursing progress note, dated 10/28/24 at 10:15 A.M. (noted as a late entry), revealed Resident #10's daughter contacted the nurse regarding her mother's fall. Resident #10 was reassessed for injury by performing a head to toe assessment. Vitals signs were at baseline and the resident showed no visible signs of injury. Soreness was apparent with range of motion (ROM). The resident was assisted to bed and no pain medication was required. The resident was resting comfortably with call light in place. Review of nursing progress noted, dated 10/30/24 at 1:14 P.M., revealed the physician reviewed the x-ray of the left wrist and stated there is no suspicion of a fracture per his assessment. Review of the camera footage provided by Resident #10's Family Member #20 dated/timestamped 10/27/24 at 10:57 P.M. through 10/28/24 at 4:42 A.M., revealed Resident #10 was located on the floor in front of her recliner, in either a sitting, reclining, or lying position. Review of CNA #60's Witness Statement, dated 10/28/24 at 4:00 P.M., revealed Resident #10 was in her recliner and had no issues or complaints. CNA #60 stated she did not check on the resident for the rest of the night shift because the resident is usually independent and will come into the hall if she needs anything. CNA #60 stated she was aware of the two hour check and change standard, however, she thought Resident #10 would come out into the hall to get her if she needed anything. Interview on 11/12/24 at 1:29 P.M. with Resident #10 revealed she could not recall the incident on 10/27/24. Interview on 11/12/24 at 2:00 P.M. with Human Resources Director #50 revealed Certified Nursing Assistant (CNA) #60 was terminated following the incident of lack of care for Resident #10 on 10/27/24. Interview on 11/12/24 at 2:51 P.M. with Registered Nurse (RN) #64 revealed she worked on 10/27/24 until 11:00 P.M. RN #64 stated she last observed Resident #10 sitting in her recliner, and she appeared to be happy and in no distress, with ice water on her bedside table and her call light within reach. RN #64 stated that she administered Resident #10's medications and left the room. Interview on 11/12/24 at 3:15 P.M. with Director of Nursing (DON) revealed it was her expectation that the staff should do rounds every two hours. The DON stated Resident #10 did prefer to have her door closed and would sometimes get upset if she was awakened, however, staff should still observe the resident. The DON confirmed CNA #60 was terminated due to the incident on 10/27/24 involving Resident #10. Interview on 11/12/24 at 3:32 P.M. with Administrator revealed he was notified in the morning of 10/28/24 by RN #67 that Resident #10 was found on the floor when her breakfast tray was delivered, and the Resident's daughter was on the phone and upset. The Administrator stated he spoke with Resident #10's daughter on the phone and assured her that a full investigation would be initiated. It was determined through interviews that CNA #60 did not check on the resident after 10:30 P.M. and the resident did not receive proper care. The Administrator stated that he did not believe there was malice or willful neglect on the part of CNA #60; however, the Administrator stated CNA #60 was terminated because this is not something we are comfortable with and not our standard of care. Interview on 11/12/24 at 3:38 P.M., Corporate RN #240 confirmed Resident #10 was a fall risk and on a toileting program and should have been checked on multiple times throughout the night. Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 11/21/2016, revealed it is the facility's policy to investigate all alleged violation involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property. Additionally, the facility should immediately report all such allegations to the Administrator and to the state agency. The definition of neglect is the failure of the facility, its employees, or facility service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility policy titled, Resident Supervision, dated 06/11/24, revealed it is the policy of this facility to ensure residents receive adequate supervision and assistance, while making every attempt to balance safety needs, resident rights, and quality of life issues that will positively impact each resident's individual situation. As a result of the incident, the facility took the following actions to correct the deficient practice by 10/30/24: Immediately following notification of the incident on 10/28/24, Resident #10 was assessed for injury by Licensed Practical Nurse (LPN) #67. The Unit Nurse immediately notified the physician and family. X-rays were ordered on 10/28/24 by physician at the family's request. The x-rays resulted negative. Interviews were conducted by the Administrator and Human Resources Director on 10/28/24 with staff who were working on 10/27/24 night shift into the morning on 10/28/24. Initial audit completed on 10/28/24 by the Minimum Data Set (MDS) nurse and Assistant Director of Nursing (ADON) of like residents who keep their door shut when in room, independent for most activities of daily living (ADLs), residents who keep to themselves and don't like disruption, resistant to care. Care plans were reviewed for those identified. Staffing numbers were reviewed by the Administrator on 10/28/24 to ensure proper staffing numbers for the acuity of the facility. Staffing was found to be appropriate for care needs. Fall during the last 90 days were reviewed by the Regional Clinician on 10/29/24 and completed on 10/30/24 with fall interventions noted to be appropriate. Direct care staff and licensed staff were reeducated by the Administrator, ADON, and HR Director on 10/28/24 the fall management policy, falls best practice and ensuring supervision and care rounds of residents throughout the shift. Education was completed via conference call with 100% participation. Ongoing audits were initiated on 10/28/24 by the Administrator/and or designee weekly for four weeks or as directed by the Quality Assurance (QA) committee, observational rounds to ensure safety checks/routine rounds are being conducted by the direct care staff. Negative findings will be corrected by reeducation of staff and performing a round ensuring the safety/wellbeing of current residents. Ongoing audits were initiated on 10/28/24 by the Administrator/and or designee weekly for four weeks or as directed by the Quality Assurance (QA) committee, the Administrator or designee will interview five random residents to ensure their needs are met timely and that the residents are being checked on consistently by staff. Negative findings will be corrected by reeducating staff. QA committee meeting will be conducted weekly for four weeks to review audit results. This deficiency represents non-compliance investigated under Complaint Number OH00159347.

Based on record review, interview, review of camera footage, employee statement review, self-reported incident review, and policy review, the facility failed to report an allegation of resident neglect to the state survey agency This affected one (Resident #10) of three residents reviewed for neglect. The facility census was 58 Findings include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, muscle weakness, osteoporosis, vertigo, anxiety, and restlessness and agitation. Review of Resident #10's care plan, dated 05/23/23, revealed the resident was at risk for alteration in comfort with interventions including to reposition the resident for comfort. Further review revealed the resident was at risk for falls related to weakness, poor safety awareness, osteoporosis, glaucoma, vertigo, and anxiety with interventions including to encourage and remind the resident to ask for assistance and to monitor/anticipate/intervene for causative factors. Review of the care plan, dated 09/23/24, revealed the resident had an alteration in skin integrity as evidenced by moisture-associated skin damage (MASD) of the right buttock with interventions including to provide skin care as needed. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/09/24, revealed Resident #10 was severely cognitively impaired and required moderate/substantial staff assistance with toileting and showers/baths. The assessment indicated the resident was occasionally incontinent of urine and was at risk for developing pressure ulcers. Review of the facility's Fall Investigation, dated 10/28/24, revealed on 10/28/24 at 7:45 A.M., Resident #10 was observed in her room, on her bottom with her feet in front of her. She was incontinent of urine, fully dressed, and wearing anti-skid socks. The resident was wincing in pain, but unable to tell where the pain was located. Range of Motion (ROM) was within normal limits and vital signs were stable. The resident was assisted up with the assistance of three staff. The physician and the family were notified. Review of nursing progress note, dated 10/28/24 at 10:15 A.M. (noted as a late entry), revealed Resident #10's daughter contacted the nurse regarding her mother's fall. Resident #10 was reassessed for injury by performing a head to toe assessment. Vitals signs were at baseline and the resident showed no visible signs of injury. Soreness was apparent with range of motion (ROM). The resident was assisted to bed and no pain medication was required. The resident was resting comfortably with call light in place. Review of the camera footage provided by Resident #10's Family Member #20 dated/timestamped 10/27/24 at 10:57 P.M. through 10/28/24 at 4:42 A.M., revealed Resident #10 was located on the floor in front of her recliner, in either a sitting, reclining, or lying position. Review of CNA #60's Witness Statement, dated 10/28/24 at 4:00 P.M., revealed Resident #10 was in her recliner and had no issues or complaints. CNA #60 stated she did not check on the resident for the rest of the night shift because the resident is usually independent and will come into the hall if she needs anything. CNA #60 stated she was aware of the two hour check and change standard, however, she thought Resident #10 would come out into the hall to get her if she needed anything. Review of the Self-Reported Incidents submitted to the state survey agency (from this provider) between 10/28/24 and 11/14/24 did not include any SRI reports that pertained to Resident #10 and an allegation of neglect. Interview on 11/12/24 at 2:00 P.M. with Human Resources Director #50 revealed Certified Nursing Assistant (CNA) #60 was terminated following the incident of lack of care for Resident #10 on 10/27/24. Interview on 11/12/24 at 3:15 P.M. with Director of Nursing (DON) revealed it was her expectation that the staff should do rounds every two hours. The DON stated Resident #10 did prefer to have her door closed and would sometimes get upset if she was awakened, however, staff should still observe the resident. The DON confirmed CNA #60 was terminated due to the incident on 10/27/24 involving Resident #10. Interview on 11/12/24 at 3:32 P.M. with Administrator revealed he was notified in the morning of 10/28/24 by RN #67 that Resident #10 was found on the floor when her breakfast tray was delivered, and the Resident's daughter was on the phone and upset. The Administrator stated he spoke with Resident #10's daughter on the phone and assured her that a full investigation would be initiated. It was determined through interviews that CNA #60 did not check on the resident after 10:30 P.M. and the resident did not receive proper care. The Administrator stated that he did not believe there was malice or willful neglect on the part of CNA #60; however, the Administrator stated CNA #60 was terminated because this is not something we are comfortable with and not our standard of care. The Administrator confirmed he did not report the incident to the state survey agency because he did not believe it was neglect. Interview on 11/12/24 at 3:38 P.M., Corporate RN #240 confirmed Resident #10 was a fall risk and on a toileting program and should have been checked on multiple times throughout the night. Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 11/21/2016, revealed it is the facility's policy to investigate all alleged violation involving abuse, neglect, exploitation, mistreatment of a resident, or misappropriation of resident property. Additionally, the facility should immediately report all such allegations to the Administrator and to the state agency. The definition of neglect is the failure of the facility, its employees, or facility service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. This deficiency is an incidental finding discovered during the complaint investigation.

Based on record review, review of a medication error report and the facility's related investigation, resident interview, staff interview, review of employee personnel files, and policy review, the facility failed to have competent nurse staffing to ensure medications were administered to residents to meet professional standards of nursing. This affected two residents (#41 and #44) of four residents reviewed. Findings include: 1 a.) Review of Resident #44's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included congestive heart failure (CHF), chronic ischemic heart disease, hypertension (HTN), and atrial fibrillation. Review of Resident #44's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not known to have displayed any behaviors or reject care during the seven days of the assessment period. Review of Resident #44's physician's orders revealed she received the following cardiac related medications: Digoxin 250 micrograms (mcg) by mouth (po) every day; Diltiazem HCL 60 milligrams (mg) po three times a day for HTN; Isosorbide Mononitrate 60 mg po once daily for angina; Metoprolol Tartrate 25 mg po twice a day for HTN. Review of Resident #44's medication administration record (MAR's) for February 2024 revealed she received the following medication the morning of 02/07/24: Eliquis 5 mg po, Aspirin (ASA) 81 mg po, B-12 1,000 mcg po, Digoxin 250 mcg po, Diltiazem HCL 60 mg po, Isosorbide Mononitrate 60 mg po, Jardiance 10 mg po, Levothyroxine Sodium 88 mcg po, Loratadine 10 mg po, Metformin 1000 mg po, Metoprolol Tartrate 25 mg po, Miralax 17 Grams po, Protonix 40 mg po, and UTI Stat 30 ml po. All medications were signed off as having been given by Registered Nurse (RN) #100. Review of Resident #44's progress notes revealed a nurse's note dated 02/07/24 at 11:37 A.M. that revealed the resident was awake and alert. She denied any problems or discomforts at that time. She was seated in her chair at the bedside. She stated her blood pressure was being monitored by the nurse. She was aware of receiving medications that morning. Her physician was updated regarding medication clarification and medications taken that morning and her vital signs. No new orders were given at that time. They planned to continue to monitor the resident. Further review of Resident #44's progress notes revealed a nurse's note dated 02/07/24 at 6:50 P.M. that indicated the nurse updated the physician that the resident's blood pressure just reached 100/51 mm/hg. The nurse continued to monitor the resident all day and she had been asymptomatic with her blood pressure slowly rising. The physician gave a verbal order to send the resident to the emergency room , if her BP went below 100 systolic or she became symptomatic. Review of Resident #44's blood pressures recorded under the vital sign tab of the electronic medical record (EMR) revealed the following blood pressure readings: 02/07/24 at 10:31 A.M.- 98/53; 02/07/24 at 11:12 A.M.- 98/51; 02/07/24 at 12:28 P.M.- 87/55; 02/07/24 at 2:42 P.M.- 81/43; 02/07/24 at 6:46 P.M.- 100/51. 1 b.) Review of Resident #41's EMR revealed she was admitted to the facility on [DATE]. Her diagnoses included atrial fibrillation, CHF, HTN, chronic ischemic heart disease, atherosclerotic heart disease, and schizo-affective disorder. Review of Resident #41's quarterly MDS assessment dated [DATE] revealed she had no communication issues and was cognitively intact. She was not known to have displayed any behaviors or reject care during the seven day assessment period. Review of Resident #41's MAR's for February 2024 revealed the resident was due to receive the following po medications the morning of 02/07/24: Apixaban 5 mg po, Carafate 1 Gm po, Lasix 80 mg po, Januvia 100 mg po, Jardiance 25 mg po, Lactulose 15 ml po, Linzess 145 mcg po, Lisinopril 20 mg po, Loratadine 10 mg po, Metformin 1000 mg po, Metoprolol Succinate ER 50 mg po, Nexium 40 mg po, Senna Plus 8.6 mg-50 mg po, and Synthroid 137 mcg po. The medication administration times when those medications were given were for 6:00 A.M. or rising. All of the above medications were signed off as having been given by RN #100. Review of the facility's medication error report from 01/01/24 through 05/21/24 revealed they only had one medication error incident that allegedly occurred during that time period. Resident #44 was identified as being the resident involved. Review of the incident report for the alleged medication error for Resident #44 revealed it was dated for 02/07/24 at 6:00 A.M. The facility's Director of Nursing (DON) was the one who completed the medication error report. Information provided on the medication error report indicated the resident with the same last name with rooms across from each other. They were sisters who requested to be across the hall from one another. Notes included as part of the medication error report indicated the DON was informed of a possible medication error by the day shift nurse. They monitored the resident's blood pressure and pulse frequently. The resident had no complaints, concerns, or discomforts. Her daily routine by the resident was indicated to be as per her usual. Her appetite had been good and she was taking fluids well. The physician was notified of the possible medication error. Nurses were interviewed and voiced no medications were administered wrongly. The intervention added was all residents with the same last name were identified with alerts added to medication carts to identify such. Review of the facility's related investigation into the alleged medication error involving Resident #44 revealed statements were obtained from RN #100 and RN #225. RN #100's statement dated 02/07/24 indicated, while passing morning medications on the 300 hall, she took Resident #41's medications to her. Resident #41 only wanted her Carafate and Synthroid at that time. Another nurse assisting her with the medication pass administered Resident #44's medications. RN #100 indicated she returned Resident #41's medicine cup in Resident #44's slot in the medication administration cart in error. RN #225's written statement indicated during the 4:00 A.M. medication pass, he had pulled Resident #44's medications out from the medication administration cart and administered medication to the resident on 02/07/24. Further review of the facility's investigation into the alleged medication error revealed it included interview notes from the DON with conversations she had with RN #100, RN #225, and RN #300. The interview notes with RN #300 revealed the nurse was concerned Resident #41's morning medications were in a cup in Resident #44's slot in the medication administration cart. She reported her concerns to Human Resources, who in turn, notified the DON. The DON interviewed RN #100 and was told she gave Resident #41's Carafate and Synthroid. The rest had been placed back into the drawer of the medication cart. The DON's interview with RN #225 indicated he gave all of Resident #41's medications to her. The DON's interview with Resident #41 indicated she got her thyroid medication and her stomach medication. The DON's interview with Resident #41 indicated she got all of her medications. A second page of interview notes with RN #100 revealed the medications placed in Resident #44's slot in the medication cart by the night shift nurse were the ones the day shift nurse saw in the wrong slot and was unsure about the medications. The DON indicated in her notes that she had verbally educated both night shift nurses on the need to destroy opened/ not taken medications as opposed to returning them to the medication administration cart and only to sign off medications that they have administered. On 05/21/24 at 12:25 P.M., an interview with Resident #44 (while she was visiting with Resident #41) revealed she suspected she was given the wrong medication, which was intended for her sister, the morning of 02/07/24. The medication she thought she had received in error included blood pressure medication. She claimed she did not take any blood pressure medications herself, despite her having HTN and medications ordered to treat HTN. She claimed she was informed she received her sister's blood pressure medication, but was not sure what other medications she may have been given along with it. Resident #41 added that she took Metoprolol for her blood pressure. Resident #44 indicated it was a new male nurse that gave it to her. She was not sure of his name, but when the male nurse's name was mentioned she stated yes that was it. Resident #44 also stated the male nurse did not sign off on her being given her medications and another nurse signed it off instead. She reported as a result of getting that medication, her blood pressure was low. She was not sure how low it got, but they were worried about it. She claimed she felt lightheaded, dizzy, and weak after she was given that medication (not supported by the nurses' progress notes). She reported the facility was very secretive about the whole situation. On 05/21/24 at 1:48 P.M., an interview with RN #100 revealed she was the nurse that worked on 02/07/24, when the alleged medication error occurred. She stated she was the night shift nurse that night and it was at the end of the shift. She was helping with the end of the medication pass on the 300 hall. She was not familiar with the residents over there, as she was normally in the office. She pulled the medications for Resident #41 and went to give them to her. Resident #41 only wanted to take a couple of them at that time. She did not want all of her medications at once and only took her Synthroid and the Carafate. The remaining medications were in a plastic medicine cup and taken back to cart. She had a nurse with her helping pass the medications (RN #225). He was working nights with her and she instructed him to go ahead and give Resident #41's medications to her. She stated she handed him the medications to give to Resident #41, after she had pulled them from the medication cart. She admitted she had placed Resident #41's medications back into the medication cart under Resident #44's slot. She denied that Resident #44 was given the wrong medication. She gave report to the day shift nurse and informed her that Resident #41 only took a couple of her morning medications. The day shift nurse assumed Resident #44 received Resident #41's medications due to Resident #41's medications erroneously being put in Resident #44's slot in the top drawer of the medication cart. They monitored Resident #44 following that as a precaution. She reported they were not supposed to sign off on a resident's medications if they were not the one who gave them. She confirmed she had done that that night as it was a crazy night and they were behind in their medication pass. She signed off Resident #44's medications the morning of 02/07/24, despite RN #225 being the one who gave them. She also signed off all of Resident #41's day shift medications, even though she only gave the Carafate and Synthroid and her other morning medications were given by the day shift nurse. She could not recall if she signed the medications off ahead of time or not. She denied they had been given by the day shift nurse at the time she signed the eMAR to reflect they had been given. On 05/21/24 at 2:26 P.M., an interview with the DON/ Administrator revealed they were not able to determine Resident #44 received the wrong medications that was ordered for Resident #41. Resident #41's medications were allegedly returned to the medication cart, when she did not take them all. The DON denied that she checked the medications that had been returned to the medication cart to see what they were or which resident they belonged to. She did not try to determine if they were Resident #41's to rule out Resident #44 being given them by mistake. She just disposed of them as they should not have been returned to the medication cart, after they had been opened. She took the nurses word for it that Resident #44 was not given the wrong medications. She acknowledged Resident #44 had a drop in her blood pressure that was not her normal readings on 02/07/24, when the alleged error occurred. She stated Resident #44 had a lot of cardiac problems going on and she could not say for sure that her drop in blood pressure wasn't related to that. She also stated they were not regularly obtaining Resident #44's blood pressure to see if it had been running low prior to them checking it on 02/07/24. She reported both residents were on similar medications and both received similar medications for HTN. She was not concerned with the male nurse giving medications to a resident that he did not pull from the medication cart himself. She stated he was in the general area and likely observed what was going on. She acknowledged nurses were taught in nursing school to never administer medications to a resident that they did not prepare themselves. They were required to review the orders and verify the labels on medications when pulling them out of the medication cart to verify the five rights of drug administration were followed. Attempted to interview RN #225 regarding the alleged medication error without success. Calls were placed on 05/21/24 at 4:36 P.M. and again on 05/22/24 at 10:06 A.M. with messages left on voicemail. A call back number was provided with each message, but no return call was received. The facility's DON reported he no longer worked at the facility and had taken a job elsewhere. On 05/22/24 at 10:10 A.M., a follow up interview with the facility's DON revealed, although she could not confirm whether a medication error occurred, she was able to identify concerns with RN #100 returning opened medications back to the medication administration cart when refused by a resident. She stated the nurse should have just went away and discarded the medications as they could not have an unlabeled medicine cup in the top of the medication cart where the medications could not be identified as to what they were or who they belonged to. She also identified concerns with a nurse signing off the MAR's to show medications had been administered, when she was not the nurse that gave them. She confirmed she provided education to the nurses about both those areas. Out of an abundance of caution, she also implemented an alert system in the medication cart when residents had the same last names. She did not want a similar situation to occur in the future, even though they could not prove either resident was given the wrong medications. On 05/22/24 at 10:48 A.M., a phone interview with RN #300 revealed she was the day shift nurse that worked on 02/07/24 and found Resident #41's medications in the wrong slot of the medication cart. She did not use them to give to the resident the morning of 02/07/24. She pulled the morning medications for the following day to be given to Resident #41 as hers that were left in the medicine cup in the top of the medication cart had been disposed of. She did not look at them closely enough to see for certain they were Resident #41's medications. She reported they were similar, but she could not say for certain that they were or weren't Resident #41's. She confirmed she monitored Resident #44's blood pressure throughout the day and it was low for the resident. She denied the resident reported any problems when she asked her if she was lightheaded, dizzy, or was having any chest pain. She denied she would ever administer medications to a resident that she did not pull out of the medication cart herself. Review of the employee personnel files for RN #100 and RN #225 revealed both nurses had active licenses. Both employees received education on medication pass procedures and five rights of drug administration as part of their orientation process. Their orientation checklist indicated the employee and their preceptor signed off to reflect both were reviewed upon hire. It did not include a competency check-off for medication administration, but the orientation checklist included a column to mark if additional training was being requested. The facility's DON confirmed new nurses were observed to administer medications as part of their orientation process and the employee and preceptor signed off when that had been completed. Review of the facility's Medication Administration policy (effective 06/21/17) revealed medications would be administered by legally-authorized and trained persons in accordance to applicable State, Local, and Federal laws consistent with accepted standards of practice. The procedure included the need for the nurse administering the medication to read the label comparing it to the MAR before preparing the medication. After the medication was given, the nurse was to return to the medication cart and document medication administration with initials on the MAR immediately after administering medication to each resident. Once removed from the package or container, unused doses should be destroyed following facility policy. This deficiency represents non-compliance investigated under Complaint Number OH00152938.

Based on observation, record review, and interview, the facility failed to ensure pressure reduction measures were in place as ordered. This affected two residents (#4, #15) of three residents reviewed for skin impairment. Findings include: 1. Record review of Resident #4 revealed a 01/24/24 admission with diagnoses including hemiplegia,hemiparesis following cerebral infarct affecting left non dominate side, protein calorie malnutrition, muscle weakness, dysphasia, muscle wasting and atrophy, proximal atrial fibrillation, tremor, hypercalcemia, gastrointestinal hemorrhage, pulmonary hypertension, major depressive disorder, hypertension, iron deficiency, anemia, hyperlipidemia, heart failure, pain, nausea and vomiting, urine retention, and benign prosthetic hyperplasia. Review of a 01/31/24 admission Minimum Data Set Assessment (MDS) revealed the resident was independent for daily decision making, had upper extremity impairment on one side, and required maximum assist for turning and rolling in bed. Review of a 02/15/24 Pressure Skin Grid revealed a right heel unstageable (full thickness tissue loss where the depth of the wound or bed sore is completely obscured by eschar in the wound bed) pressure ulcer measuring 1.5 centimeters (cm) by 2 cm with a red eschar/wound bed. The resident required (dependent) of one staff for bed mobility. Physician orders included a 02/15/24 order to wear heel protectors while in bed as tolerated every shift for pressure wound and cleanse right heel with normal saline, apply betadine, cover with a ABD and cover with Kerlix. Review of a 02/20/24 Pressure Skin Grid revealed a right heel deep tissue injury (persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters )pressure ulcer measuring 1.8 centimeters (cm) by 1.9 cm with a 100% purple wound bed and fleshtone periwound. Observation on 02/26/24 at 1:35 P.M. revealed Resident #4 was in bed without heel bows. There was a pillow under his calves but his heels were resting on the bed. Observation on 02/26/24 at 3:06 P.M. of a dressing change to the right heel revealed the resident did not have heel bows on. After the dressing change, Registered Nurse (RN) #95 and Licensed Practical Nurse (LPN) #96 did not apply heel bows. Interview on 02/26/24 at 6:05 P.M. with State tested Nurse Aide (STNA) #84 revealed she never had seen heel bows on Resident #4. She looked in his room and could not find any heel bows. Review of the February 2024 treatment administration record (TAR) revealed Resident #4 was to wear heel protectors while in bed as tolerated every shift for pressure wound. This treatment was signed daily as completed. The TAR was signed 02/26/24 as being applied when they were not. Interview on 02/26/24 at 6:10 P.M. with Licensed Practical Nurse (LPN) #96 verified the resident did not have heel bows in place as ordered. 2. Record review of Resident #15 revealed a 07/01/18 admission with diagnoses including type two diabetes mellitus without complications, chronic obstructive pulmonary disease, unspecified, diastolic congestive heart failure, atherosclerotic heart disease, essential primary hypertension, rheumatoid arthritis, hyperlipidemia, arthritis, iron deficiency anemia, morbid severe obesity, hypokalemia, Gastroesophageal reflux disease without esophagitis,allergic rhinitis, adjustment disorders with depressed mood, vitamin D deficiency, encounter for orthopedic aftercare following a surgical amputation, muscle weakness, and a personal history of Covid. Review of a 01/09/24 quarterly MDS revealed the resident was independent for daily decision making, had lower extremity impairment on one side, and required touch assist for turning and rolling in bed. Review revealed a pressure skin grid dated 09/08/23 revealed 3.5 cm by 3.0 cm deep tissue injury (persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues with a dark purple wound bed) to left heel. Record review revealed a 09/08/23 order for a heel boot to left foot when up in wheelchair and in bed every shift for protection. Review of a pressure ulcer skin grid revealed the left heel on 02/20/24 was unstageable, 0.8 cm by 0.5 cm with 100% thin dry scab. Observation on 02/26/24 at 11:22 A.M. revealed the resident was sitting up in her wheelchair without a boot on as ordered. Interview on 02/26/24 at 11:25 A.M. with STNA #82 revealed she did not know the resident was to wear a boot. She indicated she had not seen the boot for months. Review of the February 2024 TAR revealed the boot was signed off as applied for 02/26/24 and signed off for all the days of February 2024 up to this point. Interview on 02/26/24 at 3:26 P.M. with Registered Nurse (RN) #72 verified the boot was ordered and should be on and not marked as on when it is not. Interview on 02/26/24 at 3:32 P.M. with LPN #97 revealed she doesn't know when the last time was she saw the boot on the resident. She verified the boot was not on as ordered. This deficiency represents non-compliance investigated under Master Complaint Number OH00151400.

Based on interview and record review, the facility failed to ensure bathing and showers were provided as requested. This affected one resident (#14) of three residents reviewed for showers. The census was 58. Findings include: Review of Resident #14's record revealed a 10/29/20 admission with diagnoses including Alzheimer's disease, hypertension, gastroesophageal reflux disease, depressive disorder, vitamin D deficiency, pruritus, chronic pain syndrome, peripheral vascular disease, anxiety disorder, dementia, and cough. Review of the 01/04/24 quarterly Minimum Data Set Assessment revealed the resident was independent for daily decision making, dependent of two or more for shower/bathing, and resident does none of the effort to complete activity. Interview on 02/26/24 at 1:35 P.M. with Resident #14 revealed she was to get a shower every Monday. She said it has been two weeks and they have not asked her if she wanted a shower. Review of shower sheets included the resident received one shower in January 2024 on 01/24/24, with no refusals noted. In February 2024 the resident had a shower on 02/06/24, 02/07/24 and 02/10/24. Refused all bathing 02/13/24, refused a shower on 02/20/24 and had a bed bath on 02/24/24. There was no evidence of the resident having a shower in the last two weeks as the resident stated. Review of the shower schedule revealed the resident was to receive a bed bath daily. Review of the bathing documentation in the electronic TASK record and the paper shower sheets revealed the resident was bathed ten (10) of 31 days in January 2024 and ten (10) of 26 days in February 2024, not daily as requested. Interview on 02/26/24 at 6:57 P.M. with the Director of Nursing and Administrator revealed they had no evidence of the resident being interviewed for personal preference. The Administrator included the staff asked each resident in October (2023) what their preferences were and they documented preferences on a shower schedule. The shower schedule was not part of the permanent record. The resident did not receive daily bed baths as scheduled or a shower in the last two weeks, The Director of Nursing indicated she believed showers were being provided as requested since they had a shower aide. This deficiency represents non-compliance investigated under Master Complaint Number OH00151400.

Based on record review, policy review, and interview, the facility failed to ensure resident representatives and physician were notified of changes in treatment and condition. This affected two residents (#59, #61) of three residents reviewed for notification. The census was 58. Findings include: 1. Record review of Residents #61 revealed a 09/09/22 admission with diagnoses including unspecified dementia, proximal atrial fibrillation, atherosclerotic heart disease, sick sinus syndrome, chronic kidney disease stage four, psoriasis, hypertension, hyperlipidemia, aortic aneurysm, peripheral vascular disease, anemia in chronic kidney disease, major depressive disorder, Anxiety, Gastroesophageal reflux disease, hemiplegia, gout, constipation, angina pectoris, overactive bladder, insomnia, Hydronephrosis, chronic pain syndrome, vitamin D deficiency, macular degeneration, cough, puritis, shortness of breath, hyperglycemia, old myocardial infarction, personal history of neoplasm with the breast, personal history of pulmonary embolism and dry eye syndrome. Review of the quarterly 01/15/24 Minimum Data Set Assessment included the resident was independent for daily decision making, had functional impairment of bilateral lower extremities, and needed maximal assist for toileting. Record review revealed on 01/12/24 at 3:47 P.M. Resident #61 reported she did not feel well. The resident reported having a cough that has become increasingly worse. Resident #61 felt warm to touch. Noted forehead temperature of 103.5 degrees Fahrenheit, blood pressure 170/72, pulse 83 beats per minute and respirations 22 breaths per minute and requested to be sent to the emergency room . The resident returned with a diagnosis of Influenza A on supplemental oxygen. Record review revealed on 01/15/24 the nephrologist was notified of a 01/12/24 urinalysis that was positive for escherichia coli. The resident was started on Cipro, an antibiotic, 250 milligrams (mg) twice a day for seven days. Review of physician orders revealed the antibiotic (Cipro) was to be administered until 12:00 P.M. on 01/22/24. Record review revealed on 01/15/24 the dietician note indicated resident may benefit from supplement usage at present (Influenza A) diagnosis. Interventions included a recommendation for the resident to receive 120 milliliters (ml) of House Supplement at bedtime. A physician order was written 01/15/24 for 120 ml of house supplement at bedtime. Record review revealed on 01/21/24 at 6:30 P.M. a physician order was written for Immodium A-D Oral Tablet 2 MG (Loperamide HCl), antidiarrheal, give one tablet by mouth every six hours as needed for diarrhea. No more than four tablets in 24 hour period. Record review revealed at 6:39 P.M. on 01/21/24 Immodium 2 mg was administered for diarrhea. On 01/22/24 at 6:20 A.M. it was documented the Immodium was ineffective. On 01/22/24 at 6:36 A.M. Immodium was administered for diarrhea. At 1:53 P.M. the follow up note said the Immodium was effective. Record review revealed on 01/22/24 at 2:15 P.M. the physician was notified of the resident having multiple episodes of foul smelling diarrhea with mucous, and is currently on oral antibiotics. An order was received to collect specimen and send for testing for Clostridium difficile. Review of an occupational therapy treatment encounter note written on 01/23/24 at 9:02 A.M. included on 01/22/24 the resident was observed with loose stools, nausea and vomiting. Therapist notified nurse of reported symptoms for further assessment. Therapist provided education on use of call light to minimize fall risk and if symptoms worsen. Review of treatment sheets revealed the resident did not ever consume any of the house supplement ordered 01/15/24 for twice a day. Review of the meal percentages revealed there were no meals documented for 01/21/24. The resident consumed 50 percent of breakfast and refused lunch and supper on 01/22/24. On 01/23/24 the resident refused breakfast. The resident was sent to the emergency room at lunch time 01/23/24. Record review revealed on 01/23/24 at 12:04 P.M. there was a progress note for the resident to be sent out. Record review revealed on 01/23/24 at 12:08 A.M. a note that included resident noted with increased lethargy. No oral intake this shift. Dry mucous membranes. Skin turgor poor. Opens eyes slightly to verbal stimuli. Asked resident if she would like to go to the emergency room , shakes her head yes. Resident has had one incontinent episode of liquid stool this shift. Unable to obtain specimen for C-Diff due to brief absorbed all of the liquid. Will not drink fluids. The physician was updated. Record review revealed there was no evidence of the resident's emergency contact being notified of the urinary tract infection, start of antibiotics, diarrhea and medication order, order for laboratory test for stool, refusing meals, order for house supplement, refusing house supplement, and nausea and vomiting. There was no evidence of the physician being notified of refusal of house supplement, meal refusal or nausea and vomiting. Interview on 02/27/24 at 11:42 A.M. with the Director of Nursing verified there was no evidence of family notification related to the change in condition, urinary tract infection, start of antibiotics, diarrhea and medication order for diarrhea, order for laboratory test for stool, refusing meals, order for house supplement, refusing house supplement, and nausea and vomiting. Further, there was no evidence of the physician being notified of refusal of house supplement, meal refusal or nausea and vomiting. Review of the facility Change of Condition policy (revised 04/2013), which the facility indicated was also the physician notification policy, included a change in condition is defined as deterioration in the health, mental, or psychosocial status of a resident related to a life threatening condition, a significant alteration in treatment or a significant change in the resident's clinical condition or status. The unit supervisor or charge nurse will notify the resident, physician, guardian/interested family members of all changes as stated above and of any other situations requiring notification. The person doing the notification may document all notification. A competent resident may request that their family not be notified if they choose to exercise their right to privacy. If they do not choose the right to privacy the family must be notified. 2. Record review for Resident #59 revealed a 11/09/23 admission with diagnoses including pneumonia, acute respiratory failure with hypoxia, partial intestinal obstruction, diverticulosis, muscle wasting and atrophy, dysphasia, anxiety disorder, neuropathy, hypertension, protein calorie malnutrition, hyperlipidemia, depressed mood, chronic obstructive pulmonary disease, atrial fibrillation, hypocalcemia, osteoarthritis, retention of urine, myocardial infarction, anemia, dementia, constipation, and vitamin D deficiency. Review of a 11/16/23 Admission MDS revealed the resident was moderately impaired for daily decision making. Review revealed on 01/31/24 the resident returned from the pulmonologist with orders for nebulizer treatments, albuterol 2.5 milligrams (mg) four times a day and as needed. There was no evidence of the family representative being notified of the new order. The surveyor was provided an undated handwritten note from Transport #80 noting the resident's son would not be able to go with the resident to the doctor appointment. The surveyor was provided an undated handwritten note from Registered Nurse #93 that he informed the son about choosing a nephrologist because the resident had been refusing appointments. During the conversation he indicated he updated the son on the resident's current condition and new orders received for breathing treatments. Interview on 02/27/24 at 11:42 A.M. with the Director of Nursing verified there was no evidence of family notification related to the new breathing treatment being added to the resident's plan of care. This deficiency represents non-compliance investigated under Complaint Number OH00150989.

Based on record review and interview, the facility failed to ensure a plan of care was in place related to a blister from spilled coffee. This affected one resident (#15) of three residents reviewed for skin conditions. The census was 58. Findings include: Review of Resident #15's medical record revealed a 07/01/18 admission with diagnoses including type two diabetes mellitus without complications, chronic obstructive pulmonary disease, unspecified, diastolic congestive heart failure, atherosclerotic heart disease, essential primary hypertension, rheumatoid arthritis, hyperlipidemia, arthritis, iron deficiency anemia, morbid severe obesity, hypokalemia, Gastroesophageal reflux disease without esophagitis,allergic rhinitis, adjustment disorders with depressed mood, vitamin D deficiency, encounter for orthopedic aftercare following a surgical amputation, muscle weakness, and a personal history of Covid. Review of a quarterly 01/09/24 Minimum Data Set Assessment indicated the resident was independent for daily decision making, with lower extremity impairment on one side, Interview on 02/26/24 at 11:22 A.M. with Resident #15 revealed she spilled coffee on herself twice and had red areas and a blister. She stated the kitchen ran out of lids for the coffee. One day her coffee cup was covered with saran wrap. When she took the saran wrap off the coffee cup she spilled the coffee on her stomach. Another day her coffee was covered with aluminum foil. She also spilled her coffee on her stomach. Both times she burned herself. Resident #15 indicated after she has her breakfast she gets a bath. She included she told the aides both times when they came in to give her a bath. She lifted her shirt to reveal several red areas nickel to quarter size remaining from the spills. Review of a 01/09/24 Skin Grid Non -Pressure included a new skin problem, a left upper quadrant blister 1.0 centimeter (cm) by 3.0 cm unable to determine depth, with a red dry periwound. Resident states she spilled coffee on herself. Order received to cleanse with normal saline and leave open to air until healed. Review of a 01/09/24 Skin Grid Non -Pressure included a right upper quadrant burn. It was 1.5 cm length by 2.5 cm width unable to determine depth. No drainage. No odor, no tunneling, no undermining and had no prior assessment. It was red and dry. Review of a Health Status Note dated 01/09/24 included resident has a reddened, dry area on right and left upper quadrants. Right area is 1.5 cm X 2.5 cm and left area is 1.0 cm X 3.0 cm. Resident said I spilled coffee on myself a couple weeks ago. Area assessed and cleansed with normal saline. Interview on 02/26/24 at 3:41 P.M. with Dietary Manager #79 revealed the coffee comes out of the kitchen between 140-150 degrees Fahrenheit. Review of the temperature logs revealed the coffee temperatures ranged from 135-161 degrees Fahrenheit. Record review revealed on 01/29/24 an Occupational Therapy referral was made to assess self feeding. On 02/16/24 restorative nursing assessment included active range of motion exercises and bilateral hand/wrist splints. Review of the current comprehensive plans of care revealed none of the plans identified the resident had a history of burning herself with spilled coffee to alert the staff of the potential for reoccurrence. Interview on 03/04/24 at 3:12 P.M. with the Director of Nursing revealed she found a discontinues plan of care for the blister. There was not an active plan of care to remind staff the resident had a blister from spilling coffee on herself. This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number OH00151400.

Based on record review and interview, the facility failed to ensure timely intervention for a resident with nausea and vomiting. This affected one resident (#61) of three residents reviewed for change in condition. The census was 58. Findings include: Record review of Residents #61 revealed a 09/09/22 admission with diagnoses including unspecified dementia, proximal atrial fibrillation, atherosclerotic heart disease, sick sinus syndrome, chronic kidney disease stage four, psoriasis, hypertension, hyperlipidemia, aortic aneurysm, peripheral vascular disease, anemia in chronic kidney disease, major depressive disorder, Anxiety, Gastroesophageal reflux disease, hemiplegia, gout, constipation, angina pectoris, overactive bladder, insomnia, Hydronephrosis, chronic pain syndrome, vitamin D deficiency, macular degeneration, cough, puritis, shortness of breath, hyperglycemia, old myocardial infarction, personal history of neoplasm with the breast, personal history of pulmonary embolism and dry eye syndrome. Review of the quarterly 01/15/24 Minimum Data Set Assessment included the resident was independent for daily decision making, had functional impairment of bilateral lower extremities, and needed maximal assist for toileting. Record review revealed on 01/12/24 at 3:47 P.M. Resident #61 reported she did not feel well. The resident reported having a cough that has become increasingly worse. Resident #61 felt warm to touch. Noted forehead temperature of 103.5 degrees Fahrenheit, blood pressure 170/72, pulse 83 beats per minute and respirations 22 breaths per minute and requested to be sent to the emergency room . The resident returned with a diagnosis of Influenza A on supplemental oxygen. Record review revealed on 01/15/24 the dietician note indicated resident may benefit from supplement usage at present (Influenza A) diagnosis. Interventions included a recommendation for the resident to receive 120 milliliters (ml) of House Supplement at bedtime. A physician order was written 01/15/24 for 120 ml of house supplement at bedtime. Record review revealed on 01/21/24 at 6:30 P.M. a physician order was written for Immodium A-D Oral Tablet 2 MG (Loperamide HCl), antidiarrheal, give one tablet by mouth every six hours as needed for diarrhea. No more than four tablets in 24 hour period. Record review revealed at 6:39 P.M. on 01/21/24 Immodium 2 mg was administered for diarrhea. On 01/22/24 at 6:20 A.M. it was documented the Immodium was ineffective. On 01/22/24 at 6:36 A.M. Immodium was administered for diarrhea. At 1:53 P.M. the follow up note said the Immodium was effective. Record review revealed on 01/22/24 at 2:15 P.M. the physician was notified of the resident having multiple episodes of foul smelling diarrhea with mucous, and is currently on oral antibiotics. An order was received to collect specimen and send for testing for Clostridium difficile. Review of an occupational therapy treatment encounter note written on 01/23/24 at 9:02 A.M. included on 01/22/24 the resident was observed with loose stools, nausea and vomiting. Therapist notified nurse of reported symptoms for further assessment. Therapist provided education on use of call light to minimize fall risk and if symptoms worsen. Review of treatment sheets revealed the resident did not consume any of the house supplement ordered 01/15/24 for twice a day. Review of the meal percentages revealed there were no meals documented for 01/21/24. The resident consumed 50 percent of breakfast and refused lunch and supper on 01/22/24. On 01/23/24 the resident refused breakfast. The resident was sent to the emergency room at lunch time 01/23/24. Record review revealed on 01/23/24 at 12:04 P.M. there was a progress note for the resident to be sent out. Record review revealed on 01/23/24 at 12:08 P.M. a note that included resident noted with increased lethargy. No oral intake this shift. Dry mucous membranes. Skin turgor poor. Opens eyes slightly to verbal stimuli. Asked resident if she would like to go to the emergency room , shakes her head yes. Resident has had one incontinent episode of liquid stool this shift. Unable to obtain specimen for C-Diff due to brief absorbed all of the liquid. Will not drink fluids. The physician was updated. Record review revealed a 01/23/24 note the facility received a call from the hospital stating the resident passed away at 10:26 P.M. The facility conducted an investigation after the death and determined on 01/21/24 no meal percentages were documented. An undated handwritten interview of State tested Nurse Aide (STNA) #83 included she ate better Sunday than on Saturday. For breakfast she ate 25%, lunch 60% and supper she did not eat. A statement included on 01/20/24 the resident was tired. On 01/21/24 she was doing a lot better. Her mood improved and she had more pep. She had a bedbath 01/21/24. She did not want a shower. She was drinking and her bowels moved once. A statement written and dated 01/25/24 by Licensed Practical Nurse (LPN) #96 who worked 7:00 A.M.-7:00 P.M. on 01/20/24 and 01/21/24 included the resident was not her usual self. She was recovering from the flu but said she was feeling better. She was having diarrhea, she got an order for Immodium which seemed to help. The resident said they told her she had diarrhea. She said she was eating and drinking fluids. The resident said she was not coughing as bad. A written statement dated 01/24/24 by Registered Nurse (RN)#93 who worked 7:00 A.M. to 7:00 P.M. on 01/22/24 included the resident was feeling better. He sat her up and she took her medicine. The STNA reported diarrhea, mucous and foul smelling. He received an order for a stool for c-diff and told the aide to get him the next time she went. RN #93 told staff to push fluids. The resident's lips were moist and she drank two cups of water with each medication pass. A written statement dated 01/24/24 by LPN #105 who worked 7:00 P.M.-7:00 A.M. 01/22/24 included the resident was her usual talkative self and coughing. She did not have diarrhea that shift. A written statement dated 01/25/24 by LPN #97 who worked 7:00 A.M. to 7:00 P.M. on 01/23/24 included night shift staff gave the medication. The resident was sleeping when she peeked in. No reports from anyone of any problems. There was nothing in report about a change of condition. The STNA reported she was not acting right. She (LPN #97) assessed and asked the resident if she wanted to go to the emergency room and she shook her head yes. The STNA reported diarrhea times one. She told the STNA she needed a stool specimen. The facility did not interview the STNA's who worked 01/22/24 or 01/23/24. Interview on 02/27/24 at 11:03 A.M. with STNA #81 revealed Resident #61 wanted to stay at the hospital when she was diagnosed with Influenza A but they told her there was nothing they could do for her that was not being done at the nursing home. Resident #61 told her she had a urinary tract infection and was on antibiotics. She was short of breath from the flu. The resident was a very picky eater. They knew she would eat a bacon cheeseburger, hot dog, grilled cheese. For breakfast the resident ate toast, little Debbie's, cereals, and juice. She was eating less when she had the flu, just the cereal,and half her juice. We were constantly filling up her water glass. We would fill up the four ounce water glasses, and she was drinking tons of water and apple juice. She was saying her tongue was dry from oxygen. She noted when passing trays the resident had diarrhea. A few days before she was sent out she was coughing. On 01/20/24 she seemed like she was feeling better. She was coughing up mucus on 01/21/24 and spitting into tissues. Interview on 02/27/24 at 11:42 A.M. with the Director of Nursing revealed she did not know there was a therapy note indicating the therapist reported Resident #61 had nausea and vomiting. She indicated she interviewed the nurses and no one reported nausea but acknowledged the therapist wrote she notified the nurse of nausea, vomiting and diarrhea. She verified if the nurse was aware of vomiting he/she should have requested medication for nausea. Interview on 02/27/24 at 1:06 P.M. with Occupational Therapist #146 included when she went into the resident's room on 01/22/24 for therapy the resident had a basin in front of her and was vomiting. She told the nurse the resident was vomiting as she had documented. Interview on 02/27/24 at 1:41 P.M. with STNA #84 revealed on 01/23/24 Resident #61 was still having diarrhea, weak, fatigued and vomited once. She told LPN #97 the resident was not acting right. LPN #97 did not go back to assess the resident. This deficiency represents non-compliance investigated under Complaint Number OH00150989.

Based on observation, record review, and interview, the facility failed to ensure accurate medical records. This affected two residents (#4, #15) of three residents reviewed for skin impairment. Findings include: 1. Record review of Resident #4 revealed a 01/24/24 admission with diagnoses including hemiplegia,hemiparesis following cerebral infarct affecting left non dominate side, protein calorie malnutrition, muscle weakness, dysphasia, muscle wasting and atrophy, proximal atrial fibrillation, tremor, hypercalcemia, gastrointestinal hemorrhage, pulmonary hypertension, major depressive disorder, hypertension, iron deficiency, anemia, hyperlipidemia, heart failure, pain, nausea and vomiting, urine retention, and benign prosthetic hyperplasia. Review of a 01/31/24 admission Minimum Data Set Assessment (MDS) revealed the resident was independent for daily decision making, had upper extremity impairment on one side, and required maximum assist for turning and rolling in bed. Review of a 02/15/24 Pressure Skin Grid revealed a right heel unstageable (full thickness tissue loss where the depth of the wound or bed sore is completely obscured by eschar in the wound bed) pressure ulcer measuring 1.5 centimeters (cm) by 2 cm with a red eschar/wound bed. The resident required (dependent) of one staff for bed mobility. Physician orders included a 02/15/24 order to wear heel protectors while in bed as tolerated every shift for pressure wound and cleanse right heel with normal saline, apply betadine, cover with a ABD and cover with Kerlix. Review of a 02/20/24 Pressure Skin Grid revealed a right heel deep tissue injury (persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters )pressure ulcer measuring 1.8 centimeters (cm) by 1.9 cm with a 100% purple wound bed and fleshtone periwound. Observation on 02/26/24 at 1:35 P.M. revealed Resident #4 was in bed without heel bows. There was a pillow under his calves but his heels were resting on the bed. Observation on 02/26/24 at 3:06 P.M. of a dressing change to the right heel revealed the resident did not have heel bows on. After the dressing change, Registered Nurse (RN) #95 and Licensed Practical Nurse (LPN) #96 did not apply heel bows. Interview on 02/26/24 at 6:05 P.M. with State tested Nurse Aide (STNA) #84 revealed she never had seen heel bows on Resident #4. She looked in his room and could not find any heel bows. Review of the February 2024 treatment administration record (TAR) revealed Resident #4 was to wear heel protectors while in bed as tolerated every shift for pressure wound. This treatment was signed daily as completed. The TAR was signed 02/26/24 as being applied when they were not. Interview on 02/26/24 at 6:10 P.M. with Licensed Practical Nurse (LPN) #96 verified the resident did not have heel bows in place as ordered. 2. Record review of Resident #15 revealed a 07/01/18 admission with diagnoses including type two diabetes mellitus without complications, chronic obstructive pulmonary disease, unspecified, diastolic congestive heart failure, atherosclerotic heart disease, essential primary hypertension, rheumatoid arthritis, hyperlipidemia, arthritis, iron deficiency anemia, morbid severe obesity, hypokalemia, Gastroesophageal reflux disease without esophagitis,allergic rhinitis, adjustment disorders with depressed mood, vitamin D deficiency, encounter for orthopedic aftercare following a surgical amputation, muscle weakness, and a personal history of Covid. Review of a 01/09/24 quarterly MDS revealed the resident was independent for daily decision making, had lower extremity impairment on one side, and required touch assist for turning and rolling in bed. Review revealed a pressure skin grid dated 09/08/23 revealed 3.5 cm by 3.0 cm deep tissue injury (persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues with a dark purple wound bed) to left heel. Record review revealed a 09/08/23 order for a heel boot to left foot when up in wheelchair and in bed every shift for protection. Review of a pressure ulcer skin grid revealed the left heel on 02/20/24 was unstageable, 0.8 cm by 0.5 cm with 100% thin dry scab. Observation on 02/26/24 at 11:22 A.M. revealed the resident was sitting up in her wheelchair without a boot on as ordered. Interview on 02/26/24 at 11:25 A.M. with STNA #82 revealed she did not know the resident was to wear a boot. She indicated she had not seen the boot for months. Review of the February 2024 TAR revealed the boot was signed off as applied for 02/26/24 and signed off for all the days of February 2024 up to this point. Interview on 02/26/24 at 3:26 P.M. with Registered Nurse (RN) #72 verified the boot was ordered and should be on and not marked as on when it is not. Interview on 02/26/24 at 3:32 P.M. with LPN #97 revealed she doesn't know when the last time was she saw the boot on the resident. She verified the boot was not on as ordered. This deficiency represents incidental findings of non-compliance investigated under Master Complaint Number OH00151400.

Based on record review, in room camera video review, resident interview, staff interview, and facility education review, the facility failed to ensure Resident #63 received a dignified experience during a meal service and during incontinence care. This affected one resident (#63) of three residents reviewed for dignity. Findings include: A review of Resident #63's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Down's Syndrome, senile degeneration of the brain, muscle weakness, depression, and anxiety disorder. A review of Resident #63's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had unclear speech and was sometimes able to make herself understood. She was sometimes able to understand others. Her vision was moderately impaired without the use of any corrective lenses. She had short and long term memory impairment and her cognitive skills for daily decision making was severely impaired. She was known to have hallucinations, physical behaviors directed at others, verbal behaviors directed at others, other behaviors not directed at others, and was known to reject care at times. The resident was indicated to be dependent on staff for eating. She required substantial/ maximal assistance with toileting. A review of Resident #63's care plans revealed she had a care plan in place for an altered cognitive function related to Down's Syndrome, senile degeneration of the brain, and anxiety. She was sometimes able to make simple needs known to the staff at times. Interventions included announcing self and all procedures prior to starting care, be patient with the resident, provide a calm and relaxing environment, use a calm and relaxed tone during conversations, and use simple direct statements during communication to ensure the resident understood. Her activities of daily living (ADL) care plan revealed she required total care for toileting and eating and was known to be incontinent of her bowel and bladder. 1 a.) A review of videos from an in room camera that was present in Resident #63's room during her stay in the facility and was provided as part of the complaint information revealed there were nine videos that lasted anywhere between 14 seconds and one minute and 27 seconds each and included audio. Six of the videos (videos #1, #2, #3, #4, #6, and #9) were of State tested Nursing Assistant (STNA #16) providing feeding assistance to Resident #63 during a meal. The video was not dated but all involved the same meal. In all, there was three minutes and 51 seconds of footage from the six videos of the meal process provided for review. Observations of those videos noted STNA #16 to not be engaging in conversation with Resident #63. She was also noted to be documenting on a work issued cell phone during the meal process with her head down. There was only a couple times STNA #16 was noted to provide feeding assistance to Resident #63 when she helped guide the resident's hand holding a sandwich to her mouth and to place a couple fries in the resident's mouth. STNA #63 was observed to remove the clothing protector from around Resident #63's neck in the last video and used it to wipe the resident's mouth without any verbal communication with the resident. She pulled the tray away while the resident continued to chew on a bite of food and continued doing so when the STNA was out of view of the camera. On 12/19/23 at 1:23 P.M., an interview with Resident #1 revealed she was the mother of Resident #63 and was the resident observed sitting in a recliner in Resident #63's room while the resident was being fed by STNA #16. She reported STNA #16 and other staff did not converse much with Resident #63 when they fed her. She stated the most she would hear them say would be to provide her instructions during the meal such as take a bite. She felt they could interact more with the resident while feeding her. She indicated the staff were always on their cell phones when she saw them. On 12/19/23 at 2:38 P.M., an interview with STNA #16 revealed she was the STNA in the videos that involved the feeding of Resident #63. She was asked to review the video that was from Resident #63's in room camera showing her providing feeding assistance to the resident. She agreed she was not engaged in conversation with the resident during the meal. She acknowledged the video showed her more focused on the cell phone with her head down than it did on providing feeding assistance to the resident. She reported the cell phone in most of the videos was what was provided to them by the facility and was what they used to do their charting. She confirmed in video #2 she did pull her personal cell phone out of her pocket and used it while Resident #63 was eating. She agreed it did not provide a dignified dining experience for Resident #63 when she was not interacting with her during the meal or when she was doing her charting when she should have been assisting the resident. 1 b.) A review of video #7 and #8 revealed they contained two minutes and 33 seconds of footage showing incontinence care being provided to Resident #63 by two STNA's. The two STNA's in the video were identified as STNA #45 and #68. The videos did not include a date but showed the STNA's transferring Resident #63 from her chair into bed and then the provision of incontinence care. Resident #1 (Resident #63's mother) was in the room at the time and was observed sitting in a recliner while the care was provided. STNA #45 and #68 was noted to be rushed during the care. Once the resident was laid down in bed, STNA #45 rapidly pulled her pants down to the resident's ankle area before completely removing them after taking off her shoes. They then removed her soiled brief and discarded it on the floor next to the bed. STNA #45 was heard in the video telling the resident sweetheart, if you cooperate, this could go a lot easier on her and the other aide. The aides did not provide care in a calm and relaxing tone, nor did they provide simple instructions to the resident explaining what they were doing before doing it. The resident was rapidly turned from side to side while the aides removed her soiled brief and applied a new one. The resident appeared startled with the rapid movements and was making ow sounds. The incontinence care was not provided in a dignified manner and the aides left the resident exposed in view of the in room camera and in the presence of Resident #1, who remained in the room while the care was being provided. On 12/19/23 at 3:05 P.M., the above videos from Resident #63's in room camera was reviewed with the Assistant Director of Nursing (ADON), Director of Nursing (DON) and the facility's Administrator. They acknowledged Resident #63 was not provided a dignified dining experience when STNA #16 was observed to feed her in six of the nine videos without engaging in any conversation with the resident and when using the cell phone for charting and personal reasons while the resident was eating. They also acknowledged Resident #63 was not provided incontinence care in a manner that promoted dignity for the resident as STNA #45 and #68 were rushed in their care and performed the incontinence care in a manner that was not dignified. They acknowledged Resident #63 was left exposed in view of her in room camera with no effort to provide privacy during the care by covering her private areas while changing her. They reported they were aware of the concerns with staff being rushed with the resident's care as one of the videos had been shared with one of their nurses prompting them to investigate. They reported they approached it as a customer service concern and provided education to the staff to address the concerns. A review of education that had been provided to the staff on 11/23/23 revealed it included helpful ways to supply a resident with good customer care. They were to treat them with respect, communicate clearly and concisely, and to focus on resident satisfaction to name a few. This deficiency represents non-compliance investigated under Complaint Number OH00149090.

Based on record review, review of hospital records and interview the facility failed to ensure Resident #16, who was cognitively impaired, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Actual harm occurred on 02/10/22 when Resident #16, who was exhibiting signs and symptoms of dehydration (general malaise, lower back pain, burning with urination and brown colored urine) was not adequately assessed, monitored or treated. On 02/11/22 Resident #16 sustained a fall with complaints of dizziness that resulted in multiple skin injuries. The family requested the resident be sent to the hospital for further evaluation. Hospital laboratory testing, dated 02/11/22 revealed the resident's sodium was critically high 161 (normal 137-145), blood urea nitrogen (BUN) was critically high 122 (normal 7-17) and creatinine was high 3.7 (normal 0.5-1.0), laboratory values consistent with dehydration. The resident was treated in the hospital for severe dehydration and returned to the facility with additional orders for intravenous (IV) hydration and laboratory monitoring for hydration. This affected one resident (#16) of one resident reviewed for hydration. Findings include: Record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #16's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/17/21 a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no note related to the reason for this change at this time. Review of [MEDICATION(S)] nutritional content revealed [MEDICATION(S)] contained 325 milligrams (mg) of sodium. Review of the administration records revealed the resident's enteral feeding flushes (150 cc's) were scheduled to be administered with medication administration for the resident. An admission nutritional assessment, dated 10/19/21 revealed Resident #16 received all nutrition and hydration via feeding tube. The resident's average fluid intake via tube was noted to be 501 cc's or more daily and the resident was NPO. The assessment documented the resident was receiving adequate hydration. The resident was receiving 150 cc water flushes four times daily and [MEDICATION(S)] 1.5 at 50 cc/hour (hr) for 22 hours a day. The resident's estimated fluid needs were calculated to be 1800 cc daily. The assessment revealed the resident's average fluid intake was 501 cc's or more but failed to determine the resident was being provided 1800 cc's of fluid per day. The assessment note did not break down the fluid sources being provided to the resident to ensure the resident was receiving the 1800 cc she was assessed to need. However, review of Resident #16's physician/provider notes, dated 11/18/21, 12/16/21, 01/13/22 and 02/10/22 indicated the resident was ordered [MEDICATION(S)] 1.2 Cal, one (1) eight ounce can via gastrostomy tube five times daily. The notes indicated may decrease bolus and increase frequency. The notes failed to accurately reflect the resident was receiving [MEDICATION(S)] and not [MEDICATION(S)] and that the enteral feeding was continuous and not bolus. Resident #16 had a current plan of care, initiated 10/27/21 for alteration in chewing/swallowing. Interventions included to monitor for dehydration and notify the physician of concerns/changes. The plan of care did not include specific ways to monitor for dehydration (i.e. less frequent urination, dark colored urine, fatigue, dizziness, confusion, tiredness, dry mouth, poor skin turgor) and did not include a plan for intake and output monitoring. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/20/22 revealed the resident had cognitive impairment. The MDS assessment revealed the resident had no episodes of rejection of care and no swallowing disorders identified, however had a feeding tube. The resident was assessed to require extensive assistance from staff for toilet use. The MDS assessment revealed Resident #16 was totally dependent on staff for eating. A quarterly nutritional assessment, dated 01/17/22 revealed Resident #16 received all nutrition and hydration via feeding tube. The resident's average fluid intake via tube was noted to be 501 cc's or more daily and the resident was NPO. The assessment documented the resident was receiving adequate hydration. The resident was receiving 150 cc water flushes four times daily and [MEDICATION(S)] 1.5 at 50 cc/hour (hr) for 22 hours a day. The resident's estimated fluid needs were calculated to be 1800 cc daily. The assessment revealed the resident's average fluid intake was 501 cc's or more but failed to determine the resident was being provided 1800 cc's of fluid per day. The assessment note did not break down the fluid sources being provided to the resident to ensure the resident was receiving the 1800 cc she was assessed to need. Review of Resident #16's laboratory testing results, from admission 10/16/21 to 02/10/22 revealed no evidence of laboratory testing to monitor the resident's electrolytes during this time period. Review of Resident #16's fluid intake revealed there was no written evidence the facility was tracking the resident's total daily fluid intake to ensure she was receiving 1800 cc's of fluid (her estimated needs). Review of Resident #16's bladder elimination records from 01/26/22 to 02/24/22 revealed the resident had episodes of continence and incontinence. The number of times the resident eliminated was not completed except for on 01/27/22, 02/05/22, 02/11/22, 02/14/22, 02/19/22, 02/22/22 and on 02/23/22 the resident had urinated one time the entire day and on 02/13/22 she had urinated five times the entire day. The amount of urine output was not being monitored for the resident (who was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Further review of the nursing progress notes from admission through 02/09/22 revealed no evidence the resident was being routinely assessed/monitored for dehydration. On 02/10/22 at 7:44 A.M. the resident complained of general malaise, lower back pain and burning with urination. The resident's urine was assessed to be brown in color. New orders were received to obtain a urinalysis. No additional assessment for dehydration was completed at that time. On 02/11/22 at 10:45 A.M. the nurse was summoned to the resident's room. The resident was noted on the floor on her right side, parallel to bed with her head resting on the tube feed pole. The resident reported she was trying to move herself up in bed and rolled out accidentally. Staff were present in room during incident. The resident complained of feeling dizzy. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's son was notified, and he requested resident to be sent to emergency room . The resident was transferred to the hospital. On 02/11/22 at 3:18 P.M. the emergency room reported the resident was severely dehydrated with a critically high sodium level. At 7:15 P.M. the resident returned from emergency room with new orders for intravenous (IV) fluids and laboratory monitoring. Review of Resident #16's hospital records, dated 02/11/22 revealed the resident was sent to emergency room for an evaluation after falling and hitting her head. The resident was diagnosed with dehydration and acute renal failure. Hospital records assessed the resident to be week and laboratory testing at 12:24 P.M. noted the resident had a critical sodium level of 161 (normal 135 to 145) and elevated blood urea nitrogen (BUN) of 122 (normal 6 to 24) reflective of dehydration and acute renal failure. The resident was given intravenous fluid and then returned to the nursing home with new orders to double (water) flushes, give one liter of intravenous fluid (D5W) on Saturday and Sunday and to recheck a basic metabolic panel (BMP) on 02/14/22 and 02/21/22. On 02/11/22 the resident's water flushes were increased to 300 cc's four times daily. The resident was ordered D5W one liter intravenously on 02/12/22 and 02/13/22 and ordered a basic metabolic panel (BMP) to be completed on 02/14/22 and 02/21/22 On 02/14/22 at 10:28 A.M. review of the BMP lab results revealed a critically high BUN of 124. The physician was notified but no new orders were obtained as the resident was ordered double water flushes. Review of Resident #16's medication administration records (MAR) for February 2022 revealed D5W at 125 cc/hour was administered on 02/11/22 (Friday) at 9:45 P.M., 02/12/22 (Saturday) at 9:22 P.M. and 02/14/22 (Monday) at 11:30 A.M. The resident water flushes were set up the same time as medication administration. However, there was no evidence the resident's total intake of fluids via gastrostomy tube and IV or outputs were documented/monitored during this time period. Resident #16's plan of care was revised 02/21/22 for potential for alteration in nutrition and hydration related to alternative nutrition via feeding tube, nutritional risk with NPO status related to swallowing impairment, upper dentures, history of [CONDITION(S)], dysphagia, high blood pressure, [CONDITION(S)], mild protein-calorie malnutrition, [CONDITION(S)], rheumatic arthritis, adult failure to thrive, B-cell [CONDITION(S)] and [CONDITION(S)]. Goals included no signs and symptoms of dehydration/electrolyte imbalance fluid overload. Interventions included to monitor of signs and symptoms of dehydration, monitor labs and intake and output as ordered, record intake and output as needed, and snacks and tube feed as ordered. On 02/24/22 at 3:31 P.M. interview with Dietician #300 revealed Resident #16 was NPO and had been NPO since admission. The dietician confirmed the facility was not monitoring the accumulative daily amount of urinary output or intake for Resident #16. The dietician revealed assumed since the nurses were signing off the flushes and tube feeding the resident was at least receiving 836 cc of free fluid from the enteral feeding and 600 cc's of fluid from the water flushes which equaled 1536 cc's of fluid per day. The dietician indicated nursing staff should also have been flushing the resident's gastrostomy tube with 30 cc of water before and after each medication administration which would provide the remaining 264 cc's of fluid to equal 1800 cc of fluid per day. Dietician #300 confirmed there was no evidence nursing staff were flushing the gastrostomy tube with this additional water as opposed to using the water from the 150 cc flush order with medications. The dietician verified the lack of documentation of the resident's skin turgor and mucous membranes in the medical record and also acknowledged the resident's gastrostomy tube had been clogged and nonfunctional several times throughout her staff which decreased the amount of fluid she might have received. Dietician #300 reported the resident's hydration status should be monitored by assessing the resident's skin turgor, [MEDICATION(S)] membranes, labs, intake and tolerance of tube feeding. If a resident was stable, laboratory testing should be obtained every three to six months. On 02/25/22 at 9:00 A.M. interview with Physician #301 revealed Resident #16's dehydration was caused by inadequate free fluids with tube feedings. The physician indicated the resident's sodium was still critical, however the creatinine level was coming down slowly. During the interview, the physician was asked if one enteral feeding product versus another might be beneficial to the resident (resident was admitted with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician revealed the facility had not changed the tube feeding to something with less sodium, however, he was considering diluting the enteral feeding product at this time. Review of Resident #16's progress note, dated 02/25/22 at 1:13 P.M. revealed the physician was notified of Resident #16's lab results. The physician reported considering changing the enteral feeding to something with less sodium and protein and the resident was restarted on IV fluids. On 02/26/22 the dietician changed the resident's enteral feeding to Renalcal. On 02/28/22 at 5:28 P.M. interview with Resident #16's son revealed Resident #16 was exhibiting signs and symptoms of dehydration prior to her emergency room visit on 02/11/22. The son reported the resident's lips and mouth were so dry her skin was peeling off her lips and she was more confused. The son confirmed he had requested the resident be transferred to the hospital on 02/11/22 for evaluation and treatment. On 02/28/22 at 5:44 A.M. interview with the Director of Nursing (DON) revealed the resident was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence the resident's electrolytes had been checked from admission until she was sent to the hospital on 02/11/22 after sustaining a fall with injuries. On 02/28/22 at 6:01 P.M. interview with Registered Nurse (RN) #102 revealed she had spoken the dietician to determine why the resident's admission order for [MEDICATION(S)] was changed to [MEDICATION(S)]. The dietician reported the facility did not carry the [MEDICATION(S)]. This deficiency is an incidental finding to Complaint Number OH 124.

Based on record review, review of hospital records and interview the facility failed to ensure Resident #16, who was cognitively impaired, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Actual harm occurred on 02/10/22 when Resident #16, who was exhibiting signs and symptoms of dehydration (general malaise, lower back pain, burning with urination and brown colored urine) was not adequately assessed, monitored or treated. On 02/11/22 Resident #16 sustained a fall with complaints of dizziness that resulted in multiple skin injuries. The family requested the resident be sent to the hospital for further evaluation. Hospital laboratory testing, dated 02/11/22 revealed the resident's sodium was critically high 161 (normal 137-145), blood urea nitrogen (BUN) was critically high 122 (normal 7-17) and creatinine was high 3.7 (normal 0.5-1.0), laboratory values consistent with dehydration. The resident was treated in the hospital for severe dehydration and returned to the facility with additional orders for intravenous (IV) hydration and laboratory monitoring for hydration. This affected one resident (#16) of one resident reviewed for hydration. Findings include: Record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #16's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/17/21 a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no note related to the reason for this change at this time. Review of [MEDICATION(S)] nutritional content revealed [MEDICATION(S)] contained 325 milligrams (mg) of sodium. Review of the administration records revealed the resident's enteral feeding flushes (150 cc's) were scheduled to be administered with medication administration for the resident. An admission nutritional assessment, dated 10/19/21 revealed Resident #16 received all nutrition and hydration via feeding tube. The resident's average fluid intake via tube was noted to be 501 cc's or more daily and the resident was NPO. The assessment documented the resident was receiving adequate hydration. The resident was receiving 150 cc water flushes four times daily and [MEDICATION(S)] 1.5 at 50 cc/hour (hr) for 22 hours a day. The resident's estimated fluid needs were calculated to be 1800 cc daily. The assessment revealed the resident's average fluid intake was 501 cc's or more but failed to determine the resident was being provided 1800 cc's of fluid per day. The assessment note did not break down the fluid sources being provided to the resident to ensure the resident was receiving the 1800 cc she was assessed to need. However, review of Resident #16's physician/provider notes, dated 11/18/21, 12/16/21, 01/13/22 and 02/10/22 indicated the resident was ordered [MEDICATION(S)] 1.2 Cal, one (1) eight ounce can via gastrostomy tube five times daily. The notes indicated may decrease bolus and increase frequency. The notes failed to accurately reflect the resident was receiving [MEDICATION(S)] and not [MEDICATION(S)] and that the enteral feeding was continuous and not bolus. Resident #16 had a current plan of care, initiated 10/27/21 for alteration in chewing/swallowing. Interventions included to monitor for dehydration and notify the physician of concerns/changes. The plan of care did not include specific ways to monitor for dehydration (i.e. less frequent urination, dark colored urine, fatigue, dizziness, confusion, tiredness, dry mouth, poor skin turgor) and did not include a plan for intake and output monitoring. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 01/20/22 revealed the resident had cognitive impairment. The MDS assessment revealed the resident had no episodes of rejection of care and no swallowing disorders identified, however had a feeding tube. The resident was assessed to require extensive assistance from staff for toilet use. The MDS assessment revealed Resident #16 was totally dependent on staff for eating. A quarterly nutritional assessment, dated 01/17/22 revealed Resident #16 received all nutrition and hydration via feeding tube. The resident's average fluid intake via tube was noted to be 501 cc's or more daily and the resident was NPO. The assessment documented the resident was receiving adequate hydration. The resident was receiving 150 cc water flushes four times daily and [MEDICATION(S)] 1.5 at 50 cc/hour (hr) for 22 hours a day. The resident's estimated fluid needs were calculated to be 1800 cc daily. The assessment revealed the resident's average fluid intake was 501 cc's or more but failed to determine the resident was being provided 1800 cc's of fluid per day. The assessment note did not break down the fluid sources being provided to the resident to ensure the resident was receiving the 1800 cc she was assessed to need. Review of Resident #16's laboratory testing results, from admission 10/16/21 to 02/10/22 revealed no evidence of laboratory testing to monitor the resident's electrolytes during this time period. Review of Resident #16's fluid intake revealed there was no written evidence the facility was tracking the resident's total daily fluid intake to ensure she was receiving 1800 cc's of fluid (her estimated needs). Review of Resident #16's bladder elimination records from 01/26/22 to 02/24/22 revealed the resident had episodes of continence and incontinence. The number of times the resident eliminated was not completed except for on 01/27/22, 02/05/22, 02/11/22, 02/14/22, 02/19/22, 02/22/22 and on 02/23/22 the resident had urinated one time the entire day and on 02/13/22 she had urinated five times the entire day. The amount of urine output was not being monitored for the resident (who was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Further review of the nursing progress notes from admission through 02/09/22 revealed no evidence the resident was being routinely assessed/monitored for dehydration. On 02/10/22 at 7:44 A.M. the resident complained of general malaise, lower back pain and burning with urination. The resident's urine was assessed to be brown in color. New orders were received to obtain a urinalysis. No additional assessment for dehydration was completed at that time. On 02/11/22 at 10:45 A.M. the nurse was summoned to the resident's room. The resident was noted on the floor on her right side, parallel to bed with her head resting on the tube feed pole. The resident reported she was trying to move herself up in bed and rolled out accidentally. Staff were present in room during incident. The resident complained of feeling dizzy. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's son was notified, and he requested resident to be sent to emergency room . The resident was transferred to the hospital. On 02/11/22 at 3:18 P.M. the emergency room reported the resident was severely dehydrated with a critically high sodium level. At 7:15 P.M. the resident returned from emergency room with new orders for intravenous (IV) fluids and laboratory monitoring. Review of Resident #16's hospital records, dated 02/11/22 revealed the resident was sent to emergency room for an evaluation after falling and hitting her head. The resident was diagnosed with dehydration and acute renal failure. Hospital records assessed the resident to be week and laboratory testing at 12:24 P.M. noted the resident had a critical sodium level of 161 (normal 135 to 145) and elevated blood urea nitrogen (BUN) of 122 (normal 6 to 24) reflective of dehydration and acute renal failure. The resident was given intravenous fluid and then returned to the nursing home with new orders to double (water) flushes, give one liter of intravenous fluid (D5W) on Saturday and Sunday and to recheck a basic metabolic panel (BMP) on 02/14/22 and 02/21/22. On 02/11/22 the resident's water flushes were increased to 300 cc's four times daily. The resident was ordered D5W one liter intravenously on 02/12/22 and 02/13/22 and ordered a basic metabolic panel (BMP) to be completed on 02/14/22 and 02/21/22 On 02/14/22 at 10:28 A.M. review of the BMP lab results revealed a critically high BUN of 124. The physician was notified but no new orders were obtained as the resident was ordered double water flushes. Review of Resident #16's medication administration records (MAR) for February 2022 revealed D5W at 125 cc/hour was administered on 02/11/22 (Friday) at 9:45 P.M., 02/12/22 (Saturday) at 9:22 P.M. and 02/14/22 (Monday) at 11:30 A.M. The resident water flushes were set up the same time as medication administration. However, there was no evidence the resident's total intake of fluids via gastrostomy tube and IV or outputs were documented/monitored during this time period. Resident #16's plan of care was revised 02/21/22 for potential for alteration in nutrition and hydration related to alternative nutrition via feeding tube, nutritional risk with NPO status related to swallowing impairment, upper dentures, history of [CONDITION(S)], dysphagia, high blood pressure, [CONDITION(S)], mild protein-calorie malnutrition, [CONDITION(S)], rheumatic arthritis, adult failure to thrive, B-cell [CONDITION(S)] and [CONDITION(S)]. Goals included no signs and symptoms of dehydration/electrolyte imbalance fluid overload. Interventions included to monitor of signs and symptoms of dehydration, monitor labs and intake and output as ordered, record intake and output as needed, and snacks and tube feed as ordered. On 02/24/22 at 3:31 P.M. interview with Dietician #300 revealed Resident #16 was NPO and had been NPO since admission. The dietician confirmed the facility was not monitoring the accumulative daily amount of urinary output or intake for Resident #16. The dietician revealed assumed since the nurses were signing off the flushes and tube feeding the resident was at least receiving 836 cc of free fluid from the enteral feeding and 600 cc's of fluid from the water flushes which equaled 1536 cc's of fluid per day. The dietician indicated nursing staff should also have been flushing the resident's gastrostomy tube with 30 cc of water before and after each medication administration which would provide the remaining 264 cc's of fluid to equal 1800 cc of fluid per day. Dietician #300 confirmed there was no evidence nursing staff were flushing the gastrostomy tube with this additional water as opposed to using the water from the 150 cc flush order with medications. The dietician verified the lack of documentation of the resident's skin turgor and mucous membranes in the medical record and also acknowledged the resident's gastrostomy tube had been clogged and nonfunctional several times throughout her staff which decreased the amount of fluid she might have received. Dietician #300 reported the resident's hydration status should be monitored by assessing the resident's skin turgor, [MEDICATION(S)] membranes, labs, intake and tolerance of tube feeding. If a resident was stable, laboratory testing should be obtained every three to six months. On 02/25/22 at 9:00 A.M. interview with Physician #301 revealed Resident #16's dehydration was caused by inadequate free fluids with tube feedings. The physician indicated the resident's sodium was still critical, however the creatinine level was coming down slowly. During the interview, the physician was asked if one enteral feeding product versus another might be beneficial to the resident (resident was admitted with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician revealed the facility had not changed the tube feeding to something with less sodium, however, he was considering diluting the enteral feeding product at this time. Review of Resident #16's progress note, dated 02/25/22 at 1:13 P.M. revealed the physician was notified of Resident #16's lab results. The physician reported considering changing the enteral feeding to something with less sodium and protein and the resident was restarted on IV fluids. On 02/26/22 the dietician changed the resident's enteral feeding to Renalcal. On 02/28/22 at 5:28 P.M. interview with Resident #16's son revealed Resident #16 was exhibiting signs and symptoms of dehydration prior to her emergency room visit on 02/11/22. The son reported the resident's lips and mouth were so dry her skin was peeling off her lips and she was more confused. The son confirmed he had requested the resident be transferred to the hospital on 02/11/22 for evaluation and treatment. On 02/28/22 at 5:44 A.M. interview with the Director of Nursing (DON) revealed the resident was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence the resident's electrolytes had been checked from admission until she was sent to the hospital on 02/11/22 after sustaining a fall with injuries. On 02/28/22 at 6:01 P.M. interview with Registered Nurse (RN) #102 revealed she had spoken the dietician to determine why the resident's admission order for [MEDICATION(S)] was changed to [MEDICATION(S)]. The dietician reported the facility did not carry the [MEDICATION(S)]. This deficiency is an incidental finding to Complaint Number OH 124.

Based on observation, record review, review of hospital records and interview the facility failed to ensure Resident #40 received timely and proper treatment to prevent dehydration. This affected one resident (#40) of three residents reviewed for dehydration. Actual harm occurred on 03/05/21 when Resident #40, who was exhibiting signs and symptoms of dehydration was not provided timely intervention including physician ordered intravenous (IV) fluids. Laboratory testing dated 03/06/21 revealed the resident's sodium was low 133 (normal 137-145), potassium was high 5.5 (normal 3.5-5.0), blood urea nitrogen (BUN) was critically high 117 (normal 7-17) and creatinine was high 39 (normal 0.5-1.0), laboratory values consistent with dehydration. The resident was subsequently hospitalized with admitting [DIAGNOSES REDACTED]. The resident was hospitalized for [REDACTED]. Findings include: Record review revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #40's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/19/21 revealed the resident had cognitive impairment. The MDS assessment revealed the resident had no episodes of rejection of care and no swallowing disorders identified. The resident was assessed to require extensive assistance from staff for bed mobility, transfers and toilet use. The MDS assessment revealed Resident #40 was independent with eating. A quarterly nutritional assessment, dated 01/19/21 revealed Resident #40 received a nutritional supplement with intakes of 25-50%. The resident did not have any oral status abnormalities (holding or losing liquids/solids form mouth, coughing, or choking or complaints of pain). Resident #40 was at risk for dehydration related to urinary tract infections, diuretics and infections. The resident's estimated fluid needs were 1300 milliliters (ml's) per day. The assessment revealed the resident fed herself with set-up assistance and a scoop plate. The resident was at high risk for decline and had a nutritional [DIAGNOSES REDACTED]. Resident #40 had a current plan of care, most recently updated on 03/03/21 for the Potential for Alternation in Nutrition and Hydration. The goal of the plan of care included the resident would not have signs or symptoms of dehydration. Interventions included monitoring for signs and symptoms of dehydration, offer alternative fluid options and assist with meals as needed. Review of Resident #40's physician orders, for 03/2021 revealed the resident had an order for [REDACTED]. Review of Resident #40's fluid intake, dated 02/04/21 to 03/05/21 revealed the resident averaged 120-240 milliliters (ml) of fluid with each meal. On 03/01/21 her documented fluid intake was 600 ml, on 03/02/21 840 ml, on 03/03/21 240 ml and on 03/04/21 360 ml. There was no written evidence of fluid intake amounts documented outside of the meals intake documentation. On 03/05/21 from 9:21 A.M. to 9:30 A.M. Resident #40 was observed lying in bed. During the observation, the resident verbally made requests for water several times. There were two sippy cups observed on the dresser beside the resident's bed. Both cups were observed to be three-quarters (3/4) full with warm water. The sippy cups had dried food particles around the tops and on the mouthpiece of them. Due to the resident's requests for water, the surveyor activated the resident's call light. The call light was activated at 9:21 A.M. At 9:30 A.M. State tested Nursing Assistant (STNA) #46 answered the call light. The STNA verified the resident was requesting water to drink at that time and confirmed she was not able to independently reach the sippy cups. STNA #46 revealed the resident would need assistance with fluids. The STNA also confirmed the sippy cups were dirty and should have been sent to the kitchen to be cleaned. On 03/05/21 the resident's fluid intake, documented at 1:32 P.M. was 240 ml. Review of Resident #40's nursing progress note, dated 03/05/21 at 6:24 P.M. revealed nursing staff noted the resident had a decline in condition. The note indicated the resident had a 20 pound weight loss (timeframe not noted), a decrease in range of motion (ROM) and increased weakness. The resident's voice was shallow and quiet and she had increased anxiety. The nursing progress note revealed the physician was notified and a new order was obtained for IV fluids to begin in A.M. at 80 ml/hr for 24 hours. An order was also obtained for laboratory testing including a complete blood count (CBC) and basic metabolic panel (BMP), which were also documented to be ordered for in the A.M. Further review of Resident #40's progress notes revealed a note, dated 03/06/21 at 8:00 A.M. that indicated the nurse was not able to obtain IV access to start the resident's IV fluids. There was no evidence the physician was notified until 03/06/21 at 2:35 P.M. The note revealed the physician instructed the facility to send the resident to the emergency room for evaluation. Review of Resident #40's laboratory results dated [DATE] revealed the resident's sodium was low 133 (normal range 137-145), potassium was high 5.5 (normal range 3.5-5.0), BUN was critically high 117 (normal range 7-17), and creatinine was high 39 (normal 0.5-1.0). The laboratory results were indicative of dehydration. Review of Resident #40's progress notes revealed on 03/06/21 at 3:05 P.M. the resident was transferred via squad to the local hospital. Review of Resident #40's hospital record documentation revealed the resident was admitted with acute kidney injury, dehydration, [MEDICAL CONDITION] due to dehydration, probably due to poor oral intakes and use of diuretics and urinary tract infection [MEDICAL CONDITION]. The resident was admitted and was receiving IV fluids. Her blood pressure had improved to the 90's and her BUN and creatinine had improved (BUN was 84 and the creatinine was 0.8). A plan for IV fluids to continue, the resident's [MEDICATION NAME], Potassium and anti-hypertension medications were held, and the resident was started on the antibiotic medication,[MEDICATION NAME] milligrams (mg) IV for a urinary tract infection. The resident returned to the facility on [DATE]. On 03/08/21 at 11:42 A.M. interview with Resident #40's daughters revealed concerns the facility did not have enough staff to provide basic care to their mother. The daughters stated the resident was currently unable to feed herself or drink without staff assistance. The daughters reported their brother, who was a physician had called the resident's physician to voice concerns about their mother's care. The physician had told the family he was going to order IV fluids and obtain laboratory testing. The daughters indicated family had visited Friday (03/05/21) afternoon and Saturday (03/06/21) morning and noticed there had been no IV started as planned. The daughters revealed the nurse reported to them she had tried three times to start the IV but was not able to. The daughters also revealed the nurse had confirmed to them that she had not notified the doctor but rather was waiting for the laboratory testing to return before she called him. The daughter reported she left the facility around 3:00 P.M. on Saturday 03/06/21 and before she made it home the nurse had called her and reported the doctor wanted the resident to go to the hospital for IV fluids due to her BUN being elevated. The resident's family was concerned the facility had not been accurately monitoring the resident or adjusting her medication based on her decline in condition. The family revealed they felt the resident was on high doses of [MEDICATION NAME] (diuretics) and was not drinking enough fluids, however the facility never decreased her [MEDICATION NAME]. On 03/08/21 at 1:35 P.M. interview with Registered Nurse (RN) #39 revealed Resident #40 had declined and required staff to assist with meals due her hands being shaky and her anxiety. RN #39 revealed the resident was able to make her needs known, however she was not able to ambulate on her own. On 03/08/21 at 3:51 P.M. interview with STNA #46 revealed Resident #40 was dependent on staff for feedings and required assistance with fluids. During the interview, STNA #46 revealed she had observed mold in the resident's sippy cups. On 03/08/21 at 3:52 P.M. and 03/10/21 at 8:18 A.M. interview with the Director of Nursing (DON) and Registered Nurse (RN) #8 verified on 03/05/21 at 6:24 P.M., the nurse called the resident's physician due to a decline in the resident's condition. The DON and RN indicated new orders were received for IV fluids at 80 ml/hr for 24 hours and acknowledged the note indicated the IV was to be started in A.M. The DON and RN also verified additional orders were received for a laboratory testing including a CBC and BMP with results to be called to the physician. The DON and RN #8 verified on 03/06/21 at 8:00 A.M., the nurse tried three times to access an IV line but was unsuccessful. However, the nurse did not notify the physician until 2:35 P.M. when the laboratory results returned that she was not able to start the IV. During the interview, RN #8 reported she had questioned the resident's nurse (on 03/05/21) to ensure the physician wanted to wait until morning to start the IV, however neither she nor the nurse called the physician on 03/05/21 to verify the IV order. On 03/08/21 at 3:50 P.M. interview with Resident #40's physician, the DON and RN #8 via telephone revealed the physician indicated he wanted the IV started on Friday 03/05/21 at the time the order was given. The physician indicated he was not aware the IV was not started at that time and was not notified in the morning of 03/06/21 when staff could not start the IV. The physician revealed he was contacted by the resident's family (on 03/06/21) and he then called the facility to see why the IV had not been started. During the interview, the DON verified there was a delay in the IV fluid treatment which contributed to the resident's hospitalization for dehydration. Between 03/08/21 and 03/10/21 additional interviews with three anonymous facility staff revealed concerns related to staffing resulted in staff not being able to assist with providing adequate fluids throughout the day for dependent residents. This deficiency substantiates Complaint Number OH 549.

Based on medical record review, observation and staff interview, the facility failed to ensure a resident without functional limitations was provided preventative measures to prevent a decline in range in motion (ROM). This affected one of one resident reviewed for contracture's (Resident #10). The facility identified seven residents with contractures. The census was 49. Harm resulted when Resident #10 experienced avoidable limitations in ROM of the right upper extremity without intervention or preventative measures implemented to prevent the decline. Findings include: Medical record review revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Baseline Joint Mobility assessment dated [DATE] revealed Resident #10's right upper extremity ROM was within functional limits. Review of the medical record revealed no assessment of Resident #10's joint mobility between 05/04/10 and 12/01/11. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 was severely impaired for daily decision making, required total assistance of two staff for bed mobility and transfers, and had no functional limitations in ROM of the upper or lower extremities. Review of the annual MDS assessment dated [DATE] revealed Resident #10 had functional limitation in ROM on one side of the upper extremities and no functional limitations in ROM of the lower extremities. The resident was not receiving occupational therapy, physical therapy or restorative nursing. Review of the quarterly MDS assessment (dated 07/26/11) revealed Resident #10 had functional limitation in ROM on both sides of upper and lower extremities. The resident was not receiving occupational therapy, physical therapy or restorative nursing. Review of the quarterly Physical Function Assessments revealed: On 02/17/11, Resident #10 had no functional limitations in ROM of the upper or lower extremities. On 04/20/11, Resident #10 had functional limitations in ROM of bilateral upper extremities and no functional limitations of the lower extremities. Review of the assessment revealed no percentage of available ROM. On 07/20/11, Resident #10 had functional limitations in ROM of bilateral upper and lower extremities that included moderate (50% to 75% limitation) involving neck rotation, the right and left dorsal ankle, and left hand/fingers. Resident #10 had moderate to severe limitation (25% to 50% limitation) of the right and left plantar ankle. The assessment identified the assessment reflected a more accurate assessment of the resident. On 10/20/11, Resident #10 had functional limitations in ROM of bilateral upper and lower extremities. Review of the assessment revealed no percentage of available ROM. Review of the medical record revealed no documented evidence Resident #10 received physical therapy or restorative nursing to prevent a decline in ROM of the lower extremities between 08/03/09 and 12/01/11. Review of the medical record revealed no documented evidence Resident #10 received occupational therapy or restorative nursing to prevent a decline in ROM of the upper extremities between 06/23/09 and 12/01/11. Review of the medical record revealed no documented evidence Resident #10's physician was notified of the resident's decline in ROM between 04/20/11 and 10/20/11. Review of the medical record revealed no documented evidence Resident #10 received ROM, restorative nursing or therapy to prevent a decline in ROM of the upper and lower extremities. Review of the medical record revealed no documented evidence Resident #10 had a care plan addressing the functional limitations in ROM or preventative measures. On 12/01/11 at 9:45 A.M., observation of Resident #10 revealed contracture's were present to both lower legs, feet and hands. At the time of the observation, interview with Licensed Practical Nurse (LPN) #12 verified the resident had contracture's of both lower legs, feet and hands. On 11/30/11 at 3:09 P.M., interview with Occupational Therapist (OT) #14 and Physical Therapist (PT) #15 stated the therapy department was not notified by nursing of Resident #10's decline in ROM and the resident had not been evaluated by occupational or physical therapy for a decline in ROM. OT #14 and PT #15 also stated therapy does not screen or evaluate residents unless notified by nursing regarding a decline in function. On 11/30/11 at 4:10 P.M., interview with Registered Nurse (RN) #2 verified the MDS assessments dated 07/20/11 and 07/26/11 revealed a decline in ROM, the medical record revealed no documented evidence of interventions therapy, or restorative nursing and there was no documented evidence Resident #10's physician was notified of the decline in ROM. On 11/30/11 at 4:30 P.M., interview with RN #2 verified there was no documented evidence in the medical record of the residents ROM since 05/04/10. On 12/01/11 at 9:35 A.M., interview with State tested Nurse Aide #13 verified Resident #10 does not receive ROM.

Based on medical record review, observation, policy review and staff interview, the facility failed to adequately assess, implement pain interventions and address non-verbal and verbal complaints of pain for a resident with a Stage III (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed) pressure ulcer. This affected one of two residents reviewed for pressure ulcers (Resident #74). The facility identified four residents with pressure ulcers and no residents on a pain management program. The facility census was 49. Harm occurred when Resident #74 voiced a pain level of seven of ten and the staff member proceeded to complete a dressing change to a Stage III pressure ulcer without medicating the resident prior to the procedure. Findings include: Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #74 was severely impaired for daily decision making, was not at risk for developing pressure ulcers, and had a Stage III pressure ulcer. Review of Resident #74's weekly pain assessments dated 09/01/11 through 11/27/11 revealed the resident had no complaints of pain. The resident's pain assessments were completed on the night shift. Review of the monthly November 2011 physician orders [REDACTED]. Review of the Treatment Administration Record (TAR) dated September, October and November 2011 revealed Resident #74's left heel pressure ulcer dressing change was changed three times a week. Review of the medical record revealed no documented evidence Resident #74's pain was assessed prior to the left heel pressure ulcer dressing change on 09/03/11, 09/10/11, 09/17/11, 09/24/11, 10/01/11, 10/08/11, 10/15/11, 10/22/11, 10/29/11, 11/05/11, 11/12/11, 11/19/11, 11/25/11 and 11/27/11. Review of the At Risk for Pain care plan (dated 08/31/11) revealed pain assessments were to be completed per facility policy. On 11/30/11 at 9:25 A.M., observation of Resident #74's left heel pressure ulcer dressing change revealed the resident grimaced and winced when Licensed Practical Nurse (LPN) #12 lifted the resident's left ankle prior to the dressing change. Resident #74 complained the left heel was "sore" and rated his pain a seven of 10 on a scale of zero to 10. No pain management interventions or non-pharmacological interventions were attempted and LPN #10 changed the resident's Stage III pressure ulcer dressing. Review of the Skin Assessment-Monitor of Healing Process policy (revised November 2006) included pain was to be assessed daily for adequate pain control, weekly, and with wound changes. Review of the Management of the Resident in Pain policy (revised March 2011) revealed assessments of verbal complaints and non-verbal signs or symptoms of pain was to be completed. Assessments, interventions, evaluations and resident care was to be documented. On 11/30/11 at 9:25 A.M., interview with LPN #12 verified the resident's complaints of pain at the time of the observation. On 11/30/11 at 10:15 A.M., interview with LPN #10 verified no pain assessment or pain interventions were implemented when the resident complained of pain prior to the Stage III pressure dressing change. LPN #10 verified she does not assess the resident's pain daily or before dressing changes and that pain assessments were completed on the night shift. LPN #10 also verified Resident #74's plan of care did not address the resident had a left heel pressure ulcer.

Based on medical record review, policy review, and staff interview, the facility failed to provide adequate care and services to promote healing of Resident #74's left heel Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed). This affected one of two residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. The facility census was 49. Harm resulted to Resident #74 when the resident developed a nosocomial (facility acquired) Stage III pressure ulcer wound infection and failed to timely treat the wound infection. The physician was not notified of changes in the resident's pressure ulcer and the Stage III pressure ulcer deteriorated to an unstageable pressure ulcer. Findings include: Medical record review revealed Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #74 was severely impaired for daily decision making, was not at risk for developing pressure ulcers, and had a Stage III pressure ulcer. Review of the Pressure Ulcer Risk assessment dated [DATE] revealed Resident #74 was at low risk for development of pressure ulcers and did not have a history of a Stage III pressure ulcer. Review of the physician Admission History and Physical dated 09/01/11 revealed Resident #74 had "some soreness on the left heel". Review of the physical examination revealed no documented evidence Resident #74 had a Stage III left heel pressure ulcer. Review of the Skin Admit assessment dated [DATE] revealed Resident #74 had a left heel Stage II pressure ulcer with no documented evidence of the pressure ulcer's wound bed, presence of drainage or odor, wound edges, surrounding tissue or presence of pain. Review of Resident #74's Skin Grid-Pressure assessments revealed on 09/01/11, the pressure ulcer was macerated (softening and breakdown of the wound tissue resulting from prolonged exposure to moisture) and had scant drainage, slough, and no odor. There was no documented assessment of the drainage, percent of slough present in wound or presence of pain. On 09/08/11, the Stage III pressure ulcer was macerated, had moderate, serous drainage (watery, clear or slightly yellow/tan/pink fluid) and a foul odor. The wound was documented as unchanged from the previous assessment on 09/06/11. On 10/06/11, the pressure ulcer was assessed as a Stage II pressure ulcer with a small amount of yellow drainage. On 10/11/11, the pressure ulcer was assessed as a Stage III pressure ulcer with a moderate amount of clear drainage. On 11/30/11, the pressure ulcer was assessed as unstageable. Review of the Skin Grid-Pressure Assessments revealed Resident #74's left heel pressure ulcer declined from a Stage II pressure ulcer to a Stage III pressure ulcer on 09/01/11, 09/30/11 and 10/11/11, and deteriorated from a Stage III pressure ulcer to an unstageable pressure ulcer (staging could not be determined due to black, dead tissue was covering the wound bed) on 11/30/11. Review of the medical record revealed no documented evidence the physician was notified Resident #74's pressure ulcer declined from a Stage II pressure ulcer to a Stage III pressure ulcer between 10/06/11 and 10/11/11. Review of the Laboratory Specimen Inquiry wound culture report dated 10/07/11 revealed moderate growth of [MEDICATION NAME] Faecalis (infection). An entry (unsigned and undated) stated the physician and wound clinic was notified, the open wound would always have bacteria and no treatment was ordered. Review of Resident #74's physician orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the medical record revealed no documented evidence Resident #74's was monitored by the wound nurse or wound clinic between 10/11/11 and 11/07/11. Resident #74 was not evaluated by the wound clinic until 11/07/11. On 11/30/11 at 9:25 A.M., observation of Resident #74's left heel pressure ulcer revealed an unstageable pressure ulcer that measured 4.5 cm (l) by 3.0 cm (w) by 0.2 cm (d). The pressure ulcer was 50 percent covered with black eschar, 50 percent hard yellow-tan tissue and the wound edges were white and calloused. Review of the At Risk for Impaired Skin Integrity care plan (revised 08/31/11) revealed Resident #74 had a left heel pressure ulcer and at times removed the specialty boot on his own. Interventions included to wear a specialty boot on the left foot, to complete skin assessments as ordered, and the wound clinic specialist was to monitor the resident's left heel pressure ulcer. Review of the Skin Assessment-Monitoring of Healing Process policy (revised November 2006) revealed assessments were to be completed weekly, with complications or wound changes. Documentation was to include the presence of pain. The nurse was to report signs and symptoms of infection in the wounds, changes in the wound characteristics, failure of the wound to respond to the current treatment after two weeks and any other symptom that may indicate complications or delayed wound healing. On 11/29/11 at 4:15 P.M., interview with the Director of Nursing (DON) verified the admission pressure ulcer assessment revealed the residents pressure ulcer was a Stage II and stated the assessment was not correct. The DON verified there was no documented evidence in the medical record indicating the assessment was incorrect. On 11/29/11 at 5:03 P.M., interview with Registered Nurse #2 verified Resident #74 was assessed at low risk for pressure ulcers. On 11/30/11 at 12:45 P.M., interview with RN #1 verified Resident #74 had a left heel nosocomial (infection acquired at the facility) pressure ulcer infection during September 2011 and October 2011. On 11/30/11 at 4:21 P.M., interview with RN #2 verified Resident #74's physician was not notified of weekly changes in the residents pressure ulcer. On 11/30/11 at 5:45 P.M., interview with the DON verified the medical record revealed no documented evidence the resident's physician was notified of the wound culture results on 10/07/11. The DON verified the copy of the wound culture result dated 10/07/11 had no faxed date or time from the laboratory, and the documentation of notification to the physician and wound clinic did not include a date or time. The DON verified Resident #74's physician ordered [MEDICATION NAME] to be administrated on 10/11/11 and the MAR (dated October 2011) revealed [MEDICATION NAME] was not administered until 10/12/11. On 11/30/11 at 6:05 P.M., interview with Licensed Practical Nurse (LPN) #11 verified Resident # 74's wound culture results were faxed to the physician on 10/07/11 and the physician was not called with the wound culture results. On 11/30/11 at 6:09 P.M., interview with RN #2 verified no documented evidence the resident's physician was notified of the wound culture results (dated 10/07/11) that indicated a Stage III pressure ulcer wound infection until 10/11/11 and an antibiotic was not started until 10/12/11. RN #2 verified the only documentation from the wound clinic was on 11/07/11. On 12/01/11 at 9:08 A.M., interview with RN #1 verified the MDS dated [DATE] was coded incorrectly for a healed Stage III pressure ulcer. RN #1 stated she does not assess a resident's pressure ulcer prior to coding the MDS, but codes the MDS from documentation from the resident's pressure ulcer skin grids. On 12/01/11 at 10:55 A.M., interview with the DON verified Resident #74's laboratory result had handwriting which directed the wound clinic did not want any treatment. However, the resident was not seen by the wound clinic until 11/07/11. The physician ordered [MEDICATION NAME] to be started on 10/11/11 and the antibiotic was not administered until 10/12/11. The DON verified the resident's left heel declined from a Stage II pressure ulcer on 10/06/11 to a Stage III pressure ulcer on 10/11/11.